Peds ward rounds
My hut and snazzy rental car
View of part of the hospital.
Saturday, December 19, 2009
Some pics. slooooowwww uploooaaaddding
My little fracture kid, placed is backslab.
Peds ward rounds
My hut and snazzy rental car
View of part of the hospital.
Peds ward rounds
My hut and snazzy rental car
View of part of the hospital.
Zithulele Week 2
Putting in a early post for my second week. I’m having a great time here at Zithulele. Its such a gem of a hospital given its location, and service to community.
Bit of some drama over the weekend. I went to Bulungula lodge to meet up with Graem and some other Jo-berg medical students. It is about a 45min-1hr drive on a rough dirt road, then a 45 minute walk unless you have a 4x4 vehicle. The website is: www.bulungula.com. I had a great time, experienced the culture, hung out with locals. I stayed in a rondavel dorm room… which is amusing since I went from a rondavel with electricity and tiled floors, to one with a cow dung floor and only candle lit. The lodge is partially owned by the community, so many of the activities are run by locals, and anyone can hang out there. So lots of little black kids come to drum around the fire at night, and you can go on a tour with local women to see what a typical day is for them. I left Sunday afternoon looking forward to a nice walk and saying hello to the cows and sheep. The weather rapidly changed, and I was drenched with rain. Wearing only shorts and t-shirt, I managed to wrap my waist in a towel, and my rain coat over my bag. I arrived at my car covered in mud, soaked, and shivering. Even the locals at the shop gave me a look of, (what happened to that guy). I start my drive, and within 10 minutes went over a hidded eroded area of road, the front of the car dipped producing a loud “thud.” I stop the car and heard “pssssssss” and my front right tire deflated within a minute! Haha. Bear in mind its raining and no cell phone coverage. Luckily I am not an idiot and was able to sort out putting the spare tire on. Even had a little kid ask me for “sweets,” geez, bad timing kid, I asked him for a new tire. Strangely he just stood with me watching for like 20 minutes. I gave him a cookie for keeping me company. About an hour later I arrived at our rondavel, somehow, and in one piece. What a wild adventure, on the wild coast.
Graem left last week, but a new pre-medical student named Rachel arrived from Cape Town. This week I am on Male ward with Dr. Carl Le Roux, with OPD in the afternoon. Already have a few stories to tell:
I have had a number of patients with the ends of their pinky missing. Confused and curious I asked one of the nurses… apparently for some tribes it is done to ward off evil. Eeks, that must hurt. I guess I don’t use my pinky that much, it would make typing a bit awkward.
---
Lots more boys have come in with infections from community circumcisions. They are in good spirits, and healing well. There is actually a specialized male nurse that wears a jacket with says “Traditional Health Services,” and he specializes in circumcision wound care and other medical problems related to traditional practices. Don’t think we have those in the US…
---
HIV and TB everywhere! Geez. It totally messes up every differential diagnosis. Stroke? HIV. Skin bumps… TB of skin. Craziness. Then there are all the problems from the TB and HIV drugs. It is such a different type of medicine here by virtue of the disease landscape. Its funny because if you had a patient with HIV at a major hospital, that is a direct referral to an infectious disease specialist. Here everyone just has to learn how to manage.
---
In the high care room there is a 14 yo boy with severe full thickness burns to the majority of his left side after his families rondavel was struck by lightning and started on fire. Craziness. Apparantly it is not uncommon because huts are on top of hills and there are few trees. In the US, this kid would be sent immediately to the specialized burn center. The referral hospital in Mthata does not have a burn center! So there is nowhere to send this kid. Well he was sent to Mthata then transferred back to zithulele. So every morning this guy gets diazepam and ketamine to keep him calm during dressing changes. It is such a serious burn, I’m not sure he fully grasps the gravity of the situation. There is no other option, so they are doing the best they can with the resources available... so PT/OT helping out with the dressing and keeping his morale up. He has his own room and has been having nightmares and been really lonely. So one of the physios suggested moving one of the other long term young male patients into the burn kids room. What a cool idea! Even though it’s a hospital, many patients are there a long term so patients often get close with their ward mates. Privacy in US hospitals may be over rated…
---
Continue to have issues getting transport from the state ambulance service. Many times no one picks up at the other line, so doctors are forced to waste a lot of time tracking down a responsible party. I imagine it is a tricky drive for a big ambulance along that dirt road. Still not sure what to make of the problem. I’m so used to immediate response of all medical services, from ambulances, to getting into specialisits…
Oh dear, there are too many stories to tell. Well I’ll leave it at that for now. Obviously you can see that I am pointing out interesting differences and things that I didn’t expect. All in all this hospital is providing really great care given the limits of staffing, resources, and referring. Patients are generally happy despite a sometimes excessively long cue. I am slowly running out of food supplies, so will be heading to east London to raid the new love of my life, Woolworths foods. It is a up-market place that somehow produces products that are amazingly good, by products I mean, if it has Woolworths on it, it is always spectacular. No equivalent in the US. Ok, I’ll try to post pictures of my hut sometime soon.
Bit of some drama over the weekend. I went to Bulungula lodge to meet up with Graem and some other Jo-berg medical students. It is about a 45min-1hr drive on a rough dirt road, then a 45 minute walk unless you have a 4x4 vehicle. The website is: www.bulungula.com. I had a great time, experienced the culture, hung out with locals. I stayed in a rondavel dorm room… which is amusing since I went from a rondavel with electricity and tiled floors, to one with a cow dung floor and only candle lit. The lodge is partially owned by the community, so many of the activities are run by locals, and anyone can hang out there. So lots of little black kids come to drum around the fire at night, and you can go on a tour with local women to see what a typical day is for them. I left Sunday afternoon looking forward to a nice walk and saying hello to the cows and sheep. The weather rapidly changed, and I was drenched with rain. Wearing only shorts and t-shirt, I managed to wrap my waist in a towel, and my rain coat over my bag. I arrived at my car covered in mud, soaked, and shivering. Even the locals at the shop gave me a look of, (what happened to that guy). I start my drive, and within 10 minutes went over a hidded eroded area of road, the front of the car dipped producing a loud “thud.” I stop the car and heard “pssssssss” and my front right tire deflated within a minute! Haha. Bear in mind its raining and no cell phone coverage. Luckily I am not an idiot and was able to sort out putting the spare tire on. Even had a little kid ask me for “sweets,” geez, bad timing kid, I asked him for a new tire. Strangely he just stood with me watching for like 20 minutes. I gave him a cookie for keeping me company. About an hour later I arrived at our rondavel, somehow, and in one piece. What a wild adventure, on the wild coast.
Graem left last week, but a new pre-medical student named Rachel arrived from Cape Town. This week I am on Male ward with Dr. Carl Le Roux, with OPD in the afternoon. Already have a few stories to tell:
I have had a number of patients with the ends of their pinky missing. Confused and curious I asked one of the nurses… apparently for some tribes it is done to ward off evil. Eeks, that must hurt. I guess I don’t use my pinky that much, it would make typing a bit awkward.
---
Lots more boys have come in with infections from community circumcisions. They are in good spirits, and healing well. There is actually a specialized male nurse that wears a jacket with says “Traditional Health Services,” and he specializes in circumcision wound care and other medical problems related to traditional practices. Don’t think we have those in the US…
---
HIV and TB everywhere! Geez. It totally messes up every differential diagnosis. Stroke? HIV. Skin bumps… TB of skin. Craziness. Then there are all the problems from the TB and HIV drugs. It is such a different type of medicine here by virtue of the disease landscape. Its funny because if you had a patient with HIV at a major hospital, that is a direct referral to an infectious disease specialist. Here everyone just has to learn how to manage.
---
In the high care room there is a 14 yo boy with severe full thickness burns to the majority of his left side after his families rondavel was struck by lightning and started on fire. Craziness. Apparantly it is not uncommon because huts are on top of hills and there are few trees. In the US, this kid would be sent immediately to the specialized burn center. The referral hospital in Mthata does not have a burn center! So there is nowhere to send this kid. Well he was sent to Mthata then transferred back to zithulele. So every morning this guy gets diazepam and ketamine to keep him calm during dressing changes. It is such a serious burn, I’m not sure he fully grasps the gravity of the situation. There is no other option, so they are doing the best they can with the resources available... so PT/OT helping out with the dressing and keeping his morale up. He has his own room and has been having nightmares and been really lonely. So one of the physios suggested moving one of the other long term young male patients into the burn kids room. What a cool idea! Even though it’s a hospital, many patients are there a long term so patients often get close with their ward mates. Privacy in US hospitals may be over rated…
---
Continue to have issues getting transport from the state ambulance service. Many times no one picks up at the other line, so doctors are forced to waste a lot of time tracking down a responsible party. I imagine it is a tricky drive for a big ambulance along that dirt road. Still not sure what to make of the problem. I’m so used to immediate response of all medical services, from ambulances, to getting into specialisits…
Oh dear, there are too many stories to tell. Well I’ll leave it at that for now. Obviously you can see that I am pointing out interesting differences and things that I didn’t expect. All in all this hospital is providing really great care given the limits of staffing, resources, and referring. Patients are generally happy despite a sometimes excessively long cue. I am slowly running out of food supplies, so will be heading to east London to raid the new love of my life, Woolworths foods. It is a up-market place that somehow produces products that are amazingly good, by products I mean, if it has Woolworths on it, it is always spectacular. No equivalent in the US. Ok, I’ll try to post pictures of my hut sometime soon.
Wild Coast Adventures
Well I’m back again! Just posted my final entry from Somerset West. This week I made the multi-day driving journey to the Wild Coast of South Africa. I luckily have upgraded vehicles from my old 1983 leaded gas guzzler Mercedes Benz to a 2009 Honda Jazz 1.5L hatchback. My god, drives so well, tight steering. Good thing because the drive from Cape Town to the Wild coast has these windy, mountainous, awesome roads… it feels like you are in a video game. Its about 1300km, to the wild coast.
The drive from Cape Town to Port Elizabeth is called the garden route… must be because of how beautiful it is. Right along the coast, through small river port cities, large resort areas, various game reserves. As you keep driving things get more rural, mostly small towns between port Elizabeth and east London (two major cities). Many townships, with just corrugated steel homes.
On Sunday I left for Zithulele hospital. I had no idea the adventure that in store. I get off the major N2 highway toward the coast, which drives by the small town of Mqanduli, and on to Coffee Bay. I stopped at the Mqanduli Super Spar grocery store to buy my food supplies for two weeks! Not so easy to do. As I began the 70km drive to Zithulele white clouds turned dark, and a fog began to….
Holy crap, quick time out. A big rat just ran into our little hut. I tried to get it out and it jumped on my legg. Ahhhh. We cornered him and he politely left…
Ok, so yeah it was super foggy and the tar road had more potholes than functional road. My poor avis vehicle… After 50km of some amazing swerving and slowing down, I got off on the dirt road to Zithulele. Only issue is that the whole 17km is totally under construction, and it’s the rainy season. So it was so gnarwly, sliding all over, mud splashing everywhere, crazy lane changes, haha. I almost hit a cow. A dog. A horse. Some drunk guy with a walking stick… that was a close one. Tons of locals, dressed colorfully, all asking for a ride…
Finally I make it to the hospital, surrounded in small steel huts, wonderful African music playing from the funny little auto shop. I am directed to the student housing, which is a round hut (a traditional structure called a rondavel), with thatched roof, about 24 ft in diameter with a kitchen and bathroom off of it. I met Graem, a medical student from Johannesburg and Kathlene, another medical student from the UK. It is a sweet little place, kinda like being at summer camp, except I’m in Africa.
It is the rainy season so lots of low clouds, fog, thundershowers, with days of sunshine in between.
Day one at hospital. Surprisingly, the hospital has some wonderful facilities. Lots of new buildings, with big open wards, windows, covered walkways.
The language spoken by patients is primarily Xhosa, no Afrikaans or English unfortunately. Luckily there are lots of nurses who translate for the non-xhosa speaking doctors. In the out patient department every morning, the patients and staff all sing! Its really cool. Why not, they are waiting. Imagine a waiting room in the US belting out in song… meh, US is way to reserved.
Once again, my first day at a SA hospital began dramatically. We were doing rounds on the female ward, and we saw one severely ill 30yo HIV/TB patient. She was a bit confused, rapid breathing. We couldn’t get a good signal from the oxygen saturation monitor from her finger… As we moved to the next room the nurse grabbed us because the patient stopped breathing and had died.
30 yo mother just died. Nothing else to do, she was already on ARV and TB medications. I imagine this won’t be the first death like this.
In the OPD, we saw one patient who was assaulted. He needed a police report filled out, except he had lost his health history folder. To make things worse, the doctor who initially saw him and who needs to fill out the form was away in Mthata until tomorrow. We apologized, and he said he would stay overnight here.
Confused, I asked the Dr. where he would sleep? She replied, “likely on the beach.”
Transport is so difficult when the roads are wet, it is interesting how some patients just get stuck here without a formal place to stay.
---
Did my first lumbar puncture today. Not so difficult after all. The doctors here just grab you to do something, “hey you wanna do an LP?” The doctors say the locals are not like US or European patients that scream and yell. Patients here are very strong, and have high pain tolerance. I guess it’s a cultural thing. It makes being a student much easier, since you can be calm, the patient is calm, and you can get confident in your skills.
---
25 yo M was assaulted with a broken bottle and had a huge slice around his ear down to jaw angle. He came to clinic because even though the sutures put him back together, still had a facial nerve palsy. After some effort, we got ahold of a surgeon in Mthata (referral hospital in the region), would wait until January once the inflammation had calmed down.
Drunken violence, not fun.
---
Apparently every doctor in South Africa and even the international students use a book called Oxford handbook. There is like an emergency medicine and procedure one, medicine, surgical one. They are amazing! Its great because it has more than just clinical medicine, but like OB/Gyn, procedure, casting… it just a great book to have here since everything comes at you. I’m going to definitely buy one when I return.
---
One really cool thing is that patients all have their own health history book. Whether they go to a local clinic, hospital, ARV clinic, they bring it. So in addition to inpatient notes, doctors also fill out a summary in their book in case they leave the area or they show up in OPD (hospital charts are not readily accessible in clinics). The funny thing is that they are these colorful exercise notebooks. Some are small, some are large. Some have newspaper covers folded on. Regardless, these patients have a better record of the their health history than the majority of Americans! We have our electronic and paper records everywhere and we say, hey clinic/hospital, yeah you just keep track of it… I think we should definitely move toward patients keeping a electronic copy of all their records so no matter where they go, they have the info. Some books are really beaten up, but its obvious that the community has embraced the concept since everyone brings theirs.
---
During morning meeting, one of the doctors was concerned about the lack of open male ward beds. Turns out, some patients had been discharged but just never left! So some had been there for a like a week, kinda like a hospital motel. What a crazy place. Not sure who’s job it is to get them out. In the US, I guess most people run out of the hospital trying to reduce the damage to their wallets…
---
For patients who need more specialized care they are transferred to Mthatha. Transfer should be easy right? Well the road to the hospital is really bad, and for whatever reason their was an argument with the ambulance service so no one was being transferred. It is crazy because it’s not like you can just call another service, options are limited out here. One of the main docs ended up going to Mthatha to meet with the ambulance service to sort out the dispute.
---
Very interesting case showing interplay between culture, health and medicine:
16 yo boy, painted in colored mud and covered only in a traditional blanket. He was participating in his puberty rite of passage and last week had received a community circumcision. For a few days he has had pain and discomfort from his penis. Luckily his family was Ok with bringing him. Some families would disown a son who sought medical attention during this very important ritual. His penis was wrapped in a long dark cloth… when we exposed the head it was infected. He was in severe pain. His family consented to him being admitted, and we pumped him full of antibiotics and continuously cleaned the wound for a few days.
Apparently in the Eastern Cape about 55 young males per year are lost due to complications from circumcisions. Most are issues related to unsterile instruments, and not properly trained practitioners. Its easy to assume a judgmental stance, but I think its better to think about how to improve the problem. Some areas are bringing doctors and the community members who perform the surgeries to meet and discuss how to reduce the morbidity and mortality. One of the head doctors said some cases of septic penis are so bad that they can actually lose a part or all of their penis. It just become necrotic. And complicating the problem is that the boys typically are not allowed to drink fluids for many days, so they come in severely ill.
Definitely never learning anything like this in the US. I’m definitely in Africa…
----
Well that’s a bunch of random stuff. Its already my third day. The sun came out so I went to the beach for a few hours after work with the other students. By beach I mean, we drove 20 minutes on crazy, bumpy road past huts and over huge hills. Ending in this magnificent beach, with only us and some local kids playing soccer on the sand. Soon after we arrived the clouds rolled in… likely rain and t-storms again tonight.
The drive from Cape Town to Port Elizabeth is called the garden route… must be because of how beautiful it is. Right along the coast, through small river port cities, large resort areas, various game reserves. As you keep driving things get more rural, mostly small towns between port Elizabeth and east London (two major cities). Many townships, with just corrugated steel homes.
On Sunday I left for Zithulele hospital. I had no idea the adventure that in store. I get off the major N2 highway toward the coast, which drives by the small town of Mqanduli, and on to Coffee Bay. I stopped at the Mqanduli Super Spar grocery store to buy my food supplies for two weeks! Not so easy to do. As I began the 70km drive to Zithulele white clouds turned dark, and a fog began to….
Holy crap, quick time out. A big rat just ran into our little hut. I tried to get it out and it jumped on my legg. Ahhhh. We cornered him and he politely left…
Ok, so yeah it was super foggy and the tar road had more potholes than functional road. My poor avis vehicle… After 50km of some amazing swerving and slowing down, I got off on the dirt road to Zithulele. Only issue is that the whole 17km is totally under construction, and it’s the rainy season. So it was so gnarwly, sliding all over, mud splashing everywhere, crazy lane changes, haha. I almost hit a cow. A dog. A horse. Some drunk guy with a walking stick… that was a close one. Tons of locals, dressed colorfully, all asking for a ride…
Finally I make it to the hospital, surrounded in small steel huts, wonderful African music playing from the funny little auto shop. I am directed to the student housing, which is a round hut (a traditional structure called a rondavel), with thatched roof, about 24 ft in diameter with a kitchen and bathroom off of it. I met Graem, a medical student from Johannesburg and Kathlene, another medical student from the UK. It is a sweet little place, kinda like being at summer camp, except I’m in Africa.
It is the rainy season so lots of low clouds, fog, thundershowers, with days of sunshine in between.
Day one at hospital. Surprisingly, the hospital has some wonderful facilities. Lots of new buildings, with big open wards, windows, covered walkways.
The language spoken by patients is primarily Xhosa, no Afrikaans or English unfortunately. Luckily there are lots of nurses who translate for the non-xhosa speaking doctors. In the out patient department every morning, the patients and staff all sing! Its really cool. Why not, they are waiting. Imagine a waiting room in the US belting out in song… meh, US is way to reserved.
Once again, my first day at a SA hospital began dramatically. We were doing rounds on the female ward, and we saw one severely ill 30yo HIV/TB patient. She was a bit confused, rapid breathing. We couldn’t get a good signal from the oxygen saturation monitor from her finger… As we moved to the next room the nurse grabbed us because the patient stopped breathing and had died.
30 yo mother just died. Nothing else to do, she was already on ARV and TB medications. I imagine this won’t be the first death like this.
In the OPD, we saw one patient who was assaulted. He needed a police report filled out, except he had lost his health history folder. To make things worse, the doctor who initially saw him and who needs to fill out the form was away in Mthata until tomorrow. We apologized, and he said he would stay overnight here.
Confused, I asked the Dr. where he would sleep? She replied, “likely on the beach.”
Transport is so difficult when the roads are wet, it is interesting how some patients just get stuck here without a formal place to stay.
---
Did my first lumbar puncture today. Not so difficult after all. The doctors here just grab you to do something, “hey you wanna do an LP?” The doctors say the locals are not like US or European patients that scream and yell. Patients here are very strong, and have high pain tolerance. I guess it’s a cultural thing. It makes being a student much easier, since you can be calm, the patient is calm, and you can get confident in your skills.
---
25 yo M was assaulted with a broken bottle and had a huge slice around his ear down to jaw angle. He came to clinic because even though the sutures put him back together, still had a facial nerve palsy. After some effort, we got ahold of a surgeon in Mthata (referral hospital in the region), would wait until January once the inflammation had calmed down.
Drunken violence, not fun.
---
Apparently every doctor in South Africa and even the international students use a book called Oxford handbook. There is like an emergency medicine and procedure one, medicine, surgical one. They are amazing! Its great because it has more than just clinical medicine, but like OB/Gyn, procedure, casting… it just a great book to have here since everything comes at you. I’m going to definitely buy one when I return.
---
One really cool thing is that patients all have their own health history book. Whether they go to a local clinic, hospital, ARV clinic, they bring it. So in addition to inpatient notes, doctors also fill out a summary in their book in case they leave the area or they show up in OPD (hospital charts are not readily accessible in clinics). The funny thing is that they are these colorful exercise notebooks. Some are small, some are large. Some have newspaper covers folded on. Regardless, these patients have a better record of the their health history than the majority of Americans! We have our electronic and paper records everywhere and we say, hey clinic/hospital, yeah you just keep track of it… I think we should definitely move toward patients keeping a electronic copy of all their records so no matter where they go, they have the info. Some books are really beaten up, but its obvious that the community has embraced the concept since everyone brings theirs.
---
During morning meeting, one of the doctors was concerned about the lack of open male ward beds. Turns out, some patients had been discharged but just never left! So some had been there for a like a week, kinda like a hospital motel. What a crazy place. Not sure who’s job it is to get them out. In the US, I guess most people run out of the hospital trying to reduce the damage to their wallets…
---
For patients who need more specialized care they are transferred to Mthatha. Transfer should be easy right? Well the road to the hospital is really bad, and for whatever reason their was an argument with the ambulance service so no one was being transferred. It is crazy because it’s not like you can just call another service, options are limited out here. One of the main docs ended up going to Mthatha to meet with the ambulance service to sort out the dispute.
---
Very interesting case showing interplay between culture, health and medicine:
16 yo boy, painted in colored mud and covered only in a traditional blanket. He was participating in his puberty rite of passage and last week had received a community circumcision. For a few days he has had pain and discomfort from his penis. Luckily his family was Ok with bringing him. Some families would disown a son who sought medical attention during this very important ritual. His penis was wrapped in a long dark cloth… when we exposed the head it was infected. He was in severe pain. His family consented to him being admitted, and we pumped him full of antibiotics and continuously cleaned the wound for a few days.
Apparently in the Eastern Cape about 55 young males per year are lost due to complications from circumcisions. Most are issues related to unsterile instruments, and not properly trained practitioners. Its easy to assume a judgmental stance, but I think its better to think about how to improve the problem. Some areas are bringing doctors and the community members who perform the surgeries to meet and discuss how to reduce the morbidity and mortality. One of the head doctors said some cases of septic penis are so bad that they can actually lose a part or all of their penis. It just become necrotic. And complicating the problem is that the boys typically are not allowed to drink fluids for many days, so they come in severely ill.
Definitely never learning anything like this in the US. I’m definitely in Africa…
----
Well that’s a bunch of random stuff. Its already my third day. The sun came out so I went to the beach for a few hours after work with the other students. By beach I mean, we drove 20 minutes on crazy, bumpy road past huts and over huge hills. Ending in this magnificent beach, with only us and some local kids playing soccer on the sand. Soon after we arrived the clouds rolled in… likely rain and t-storms again tonight.
Final Week at Somerset West
It is already my final week. Crazy! I finally am feeling comfortable here. I’m still slightly under the weather. I think the flu or whatever it was knocked me down a bit, so I’m trying to sleep more.
Yesterday I assisted with a few surgeries, among other things. Today I went back to Gordon’s Bay clinic. The other Stellenbosch medcial students finished their family medicine elective so it was just me and one of the community service doctors (3rd year resident). What a fun time. A packed waiting room of patients, and two very young looking doctors, haha.
Once again I reminded of the violence that is occurring under most foreigners radar. One elderly patient was visiting Hermanus, a cute little beach town known for whale watching. Actually I was there just this past weekend with some of the international medical students. While walking home from a restaurant someone assaulted her, kicked her, and bashed her head into her car window. She showed me the pics. Unbelievable. I couldn’t believe that could happen in such a safe looking town. Well since the event she has had constant headaches, and was in tears when talking about her experience. Her private general practioner wanted her to get a CT scan, but she couldn’t afford it. So she was asking for a referral to tygerberg… In the states, she would have had one at the small hospital, or within a few days. Does she need one? Here is where clinical judgment must rule out, since there needs to be clear indications to scan. Things get interesting when resources are limited, and you can’t just do every test. We decided to refer her to the hospital outpatient department to re-assess her in a week.
I also saw a handful of patients with issues of high blood pressure. Many patients come just to get theirs checked, I’m not sure everyone understands the physiology or contributing factors. It is interesting how similar this is to the US primary care clinics. Many of the patients are overweight, low activity, and relatively young. Just like in the states, medications are prescribed easily and only little energy is given to education. I tried my best to encourage one patient to increase her vegetable intake, less on the rice, potatoes and meat. At only 34yo, she was on a scary path. The governmental system was created to provide medical care, but there are limited resources to encourage healthy living behaviors. Wouldn’t it be great if the government would pay for visiting healthy behavior counselor for those patients at high risk. They could come to your house and help cook a healthy meal, set-up goals, work with the family. There has to be a better way to encourage healthy living than leaving it for a few minutes at a primary care clinic. You’d think a governmental system so limited in funding would be much better at this than our bloated US system. I mean if ½ of their hypertensive patients with risk factors improved their diet, and got more active, imagine the money saved in hospital costs from downstream diseases.
I am heading back to Cape Town to stay with family before making the long drive to my next hospital. I hope I will be able to apply my new knowledge and skills. The cool thing is that the head doctor said any other medical students from UMN could come to the hospital. Thanks a great experience.
Yesterday I assisted with a few surgeries, among other things. Today I went back to Gordon’s Bay clinic. The other Stellenbosch medcial students finished their family medicine elective so it was just me and one of the community service doctors (3rd year resident). What a fun time. A packed waiting room of patients, and two very young looking doctors, haha.
Once again I reminded of the violence that is occurring under most foreigners radar. One elderly patient was visiting Hermanus, a cute little beach town known for whale watching. Actually I was there just this past weekend with some of the international medical students. While walking home from a restaurant someone assaulted her, kicked her, and bashed her head into her car window. She showed me the pics. Unbelievable. I couldn’t believe that could happen in such a safe looking town. Well since the event she has had constant headaches, and was in tears when talking about her experience. Her private general practioner wanted her to get a CT scan, but she couldn’t afford it. So she was asking for a referral to tygerberg… In the states, she would have had one at the small hospital, or within a few days. Does she need one? Here is where clinical judgment must rule out, since there needs to be clear indications to scan. Things get interesting when resources are limited, and you can’t just do every test. We decided to refer her to the hospital outpatient department to re-assess her in a week.
I also saw a handful of patients with issues of high blood pressure. Many patients come just to get theirs checked, I’m not sure everyone understands the physiology or contributing factors. It is interesting how similar this is to the US primary care clinics. Many of the patients are overweight, low activity, and relatively young. Just like in the states, medications are prescribed easily and only little energy is given to education. I tried my best to encourage one patient to increase her vegetable intake, less on the rice, potatoes and meat. At only 34yo, she was on a scary path. The governmental system was created to provide medical care, but there are limited resources to encourage healthy living behaviors. Wouldn’t it be great if the government would pay for visiting healthy behavior counselor for those patients at high risk. They could come to your house and help cook a healthy meal, set-up goals, work with the family. There has to be a better way to encourage healthy living than leaving it for a few minutes at a primary care clinic. You’d think a governmental system so limited in funding would be much better at this than our bloated US system. I mean if ½ of their hypertensive patients with risk factors improved their diet, and got more active, imagine the money saved in hospital costs from downstream diseases.
I am heading back to Cape Town to stay with family before making the long drive to my next hospital. I hope I will be able to apply my new knowledge and skills. The cool thing is that the head doctor said any other medical students from UMN could come to the hospital. Thanks a great experience.
Friday, November 13, 2009
FNAB'O'RAMA and more cloudy skies
Today is Wednesday. Last evening was very windy and rainy. By wind I mean like 50-60 mph gusts that shake the whole house! Weather patterns are crazy here. In the span of 5 minutes, the sun shined bright, then you’re hit by a gust of wind, then it starts raining.
Today I attended medicine rounds again. Some things:
- If you are wondering what is going on with the lymph or immune system, just FNAB it! (Fine needle aspiration biopsty). It is as routine as a blood draw here. I’m used to the whole u/s guided… usually with breast lumps. They do them with neck, axillary, and breasts… find the node, squeeze it, and stab it. Gets the job done, and no waiting!
- We had an older male patient, chronic alcoholic. Pt has a dilated cardiomyopathy, but its still functioning well. The attending asked the patient what kind of alcohol he drank… turns out, he drinks xhosa beer. This is a bootleg beer brewed in old iron barrels. So patients can develop hemosiderosis (iron overload)! Not thinking this is that, but he had a unique scaly skin pattern on his legs… pellagra? The differential diagnosis are so different here!
- I wandered into the orthopaedic ward for a bit. In there was an 83 yo elderly male laying still with a full metal neck immobilizer. The intern told me he had a C1/C2 spine fracture. Of course, I assumed this was a car accident or something. Turns out he was assaulted…, robbers broke into his house, then stepped on his neck. How absolutely horrible. I wonder if they found the criminals… if it made the local news… Hopefully he recovers. No surgery for now, likely would need a transfer to tygerberg.
The rest of the afternoon I hung out in casualty. At times it feels like good old United Hospital in Saint Paul. Patients with diabetes complications, minor injuries, syncope. I think I’m just getting used to the flow of things, so the differences are becoming more common.
I’m off to Stellenbosch tonight for dinner and then to meet up with Silvan and some other international medical students. The days are flying by so quickly it is almost scary. Luckily my cold/flu/whatever managed to infect me is improving, thanks to some help from my good old friend augmentin =).
Today I attended medicine rounds again. Some things:
- If you are wondering what is going on with the lymph or immune system, just FNAB it! (Fine needle aspiration biopsty). It is as routine as a blood draw here. I’m used to the whole u/s guided… usually with breast lumps. They do them with neck, axillary, and breasts… find the node, squeeze it, and stab it. Gets the job done, and no waiting!
- We had an older male patient, chronic alcoholic. Pt has a dilated cardiomyopathy, but its still functioning well. The attending asked the patient what kind of alcohol he drank… turns out, he drinks xhosa beer. This is a bootleg beer brewed in old iron barrels. So patients can develop hemosiderosis (iron overload)! Not thinking this is that, but he had a unique scaly skin pattern on his legs… pellagra? The differential diagnosis are so different here!
- I wandered into the orthopaedic ward for a bit. In there was an 83 yo elderly male laying still with a full metal neck immobilizer. The intern told me he had a C1/C2 spine fracture. Of course, I assumed this was a car accident or something. Turns out he was assaulted…, robbers broke into his house, then stepped on his neck. How absolutely horrible. I wonder if they found the criminals… if it made the local news… Hopefully he recovers. No surgery for now, likely would need a transfer to tygerberg.
The rest of the afternoon I hung out in casualty. At times it feels like good old United Hospital in Saint Paul. Patients with diabetes complications, minor injuries, syncope. I think I’m just getting used to the flow of things, so the differences are becoming more common.
I’m off to Stellenbosch tonight for dinner and then to meet up with Silvan and some other international medical students. The days are flying by so quickly it is almost scary. Luckily my cold/flu/whatever managed to infect me is improving, thanks to some help from my good old friend augmentin =).
Grant day, and TB madness
Here is the "tearoom", AKA doctors lounge. Female doctors won't let you take pictures of their faces...
Rainer, another medical student from Germany who is doing surgery
Post-op recovery, nice and warm.
"DOKTER" the doctors tearoom sign
Sebastian from Namibia, specializing in family medicine. Interesting scrubs here!
Today at the hospital I wandered into the high risk pregnancy clinic. I found a flustered doctor with a huge pile of files. I tried to help out by taking blood for those being admitted. Luckily some interns wandered in… Haha. This hospital is so random. We saw all different kinds of mothers, white Afrikaans, xhosa speakers, teens to older moms, fancy dressed and some with holes in their shirts. Everyone gets the same care. If you speak Afrikaans or English, it definitely makes things easier to sort out… Here, the interns kinda run their own show. If they have questions they ask, otherwise they just decide the plan… follow up, admit, transfer to tygerberg.
Went around with the Sanet, a senior medical officer, for afternoon rounds. There were some interesting cases (speaking from a pathology perspective), and some interesting people (speaking from a human perspective). Tomorrow is disability grant day, but in order to collect you have to be home with your family. So many patients were feeling much better today =).
-One guy in his 40s presented with delirium and headaches. Dx with TB meningitis. But when he became lucid they discovered his legs were paralyzed. Spinal shock from TB tubuculoma compromising his lower spinal cord. His wheelchair was next to his bed. We updated his medications, and moved to the next patient. He did not say very much, just that he felt “fine” when asked. I can’t help but wonder how he was coping with his new paralysis and dependency on a wheelchair… Emotions are not frequently addressed or brought to the surface in the hospital. This is sad, because some of the most powerful experiences I have had with patients is when we talk about how one copes and processes being in a sick role. I still need to process this a bit more. Internal medicine in the states frequently only focuses on physical disease… To be continues.
- Few stroke patients. One patient does not communicate, can’t move arms or legs. Whenever we say hello to her she just smiles, eyes closed. Patient was not a candidate for a MRI or CT scan (which involves a transfer to tygerberg). No neurology consult... not sure if its needed. They think she had a intracerebral bleed. The most important thing is planning where to transfer her. Plan is to transfer her to Helderberg Hospice, a community supported facility. Usually people go there for about 2 weeks, either for hospice to die, or in transitioning to home. They work with families to train them how to be caregivers. Interesting how this is community and not governmentally funded… This patient has family that are going to take her, otherwise she could be stuck in the hospital for a long time waiting for a rehab center bed.
That’s all for now. I’ll do my best to get more pictures. Time to recover in bed. Cough cough sputter.
Cape town, Braai's, woodstock, and miller beer
Hello again. It is Monday again… weeks are already flying by. This is my third week at the hospital. Last week I developed a sore throat, then some laryngitis, big honkin lymph nodes. Well by the weekend it turned into a barking cough, and sinus congestion headache. Not fun at all. Many of the other staff have similar symptoms. Yet, that does not stop them from trying to scare me into thinking I have TB or am seroconverting. Very funny… not! On a positive note, atleast its not diarrheal disease….
Last weekend I went into Cape Town again to stay with relatives. No night casualty shifts for now due to my health. My friend Silvan, the swiss medical student, moved to Tygerberg hospital for the month. That is the tertiary care center where we transfer our complicated patients. He is staying at an international dorm, which has medical students from Germany, Netherlands, Switzerland, US (Illinois) and others. It is so much fun to meet other students in the same field but from such different places.
Last night I went for a Sunday evening Braai (aka BBQ), a local end of the week festivity. I actually went with a local colored guy named Donnovan (this is a politically correct adjuctive in SA) who I met on a taxi ride home. After just meeting him he invited me to come… why not? This seems to be another common theme here. One of inclusion... People are just very chill, and excited to make new friends. Maybe its because of the vast diversity of cultural backgrounds and geographic upbringings. The braai was at a backpackers hostel, where Donnovan is friends with many of the staff. We cooked up some porterhouse steaks and boerrivores (this awesome spicy sausage thing). So much meat in this country!! And lots of beetroot (same things as beets), which is amazing cause I love beets.
Around the fire, a local was telling me about the continued issues of violence in this country. She told me that “life is cheap here.” People die from HIV, violence, accidents… most never make the news… This is not immediately obvious if you just came to visit as a tourist, but is apparent from working in the hospital. Despite the flaws of the country, she told me she wouldn’t want to live anywhere else. People here firmly believe in the potential of South Africa.
Over the weekend I also visited a food market in Woodstock. Luckily we had a car attendant help us park… just kidding. Not sure if this is an Africa thing or just South Africa, but whenever you park on the street there are people who help you park and will watch over your car. I mean everywhere. “I watch your car boss.” Even at like grocery stores. Most are unofficial. The going rate is like 1-2 rand, which is like 15-20 cents. At the market, a couple funny things happened. Silvan was offering me and Jonas (another swiss student) a piece of gum, and this random guy said “oh sure, I’ll have one.” Whaa… Why not? Then I was talking to Jonas about the music playing and how I thought it was swiss folk music, and someone behind me said “actually I think its German.” Whaa… People just interact a lot here. I love it. In the states I often do similar things, but am given looks that say “mind your own business.” We met lots of people, a student from California, someone from the republic of congo, Zambia… what a mix! Silvan and I ended up doing some polka dancing… why not, no one cares what you do here. My kinda place.
While I’m on a roll of random thoughts. So Miller beer is popular here! Haha. My cousin offered me one and I was quick to inform him that the Miller brewery is in Milwaulkee, WI. They have a brewery here in South Africa… random. Their local beer is Castle. At a bar its about 12 rand (which is 1.50 USD) a bottle.
Last weekend I went into Cape Town again to stay with relatives. No night casualty shifts for now due to my health. My friend Silvan, the swiss medical student, moved to Tygerberg hospital for the month. That is the tertiary care center where we transfer our complicated patients. He is staying at an international dorm, which has medical students from Germany, Netherlands, Switzerland, US (Illinois) and others. It is so much fun to meet other students in the same field but from such different places.
Last night I went for a Sunday evening Braai (aka BBQ), a local end of the week festivity. I actually went with a local colored guy named Donnovan (this is a politically correct adjuctive in SA) who I met on a taxi ride home. After just meeting him he invited me to come… why not? This seems to be another common theme here. One of inclusion... People are just very chill, and excited to make new friends. Maybe its because of the vast diversity of cultural backgrounds and geographic upbringings. The braai was at a backpackers hostel, where Donnovan is friends with many of the staff. We cooked up some porterhouse steaks and boerrivores (this awesome spicy sausage thing). So much meat in this country!! And lots of beetroot (same things as beets), which is amazing cause I love beets.
Around the fire, a local was telling me about the continued issues of violence in this country. She told me that “life is cheap here.” People die from HIV, violence, accidents… most never make the news… This is not immediately obvious if you just came to visit as a tourist, but is apparent from working in the hospital. Despite the flaws of the country, she told me she wouldn’t want to live anywhere else. People here firmly believe in the potential of South Africa.
Over the weekend I also visited a food market in Woodstock. Luckily we had a car attendant help us park… just kidding. Not sure if this is an Africa thing or just South Africa, but whenever you park on the street there are people who help you park and will watch over your car. I mean everywhere. “I watch your car boss.” Even at like grocery stores. Most are unofficial. The going rate is like 1-2 rand, which is like 15-20 cents. At the market, a couple funny things happened. Silvan was offering me and Jonas (another swiss student) a piece of gum, and this random guy said “oh sure, I’ll have one.” Whaa… Why not? Then I was talking to Jonas about the music playing and how I thought it was swiss folk music, and someone behind me said “actually I think its German.” Whaa… People just interact a lot here. I love it. In the states I often do similar things, but am given looks that say “mind your own business.” We met lots of people, a student from California, someone from the republic of congo, Zambia… what a mix! Silvan and I ended up doing some polka dancing… why not, no one cares what you do here. My kinda place.
While I’m on a roll of random thoughts. So Miller beer is popular here! Haha. My cousin offered me one and I was quick to inform him that the Miller brewery is in Milwaulkee, WI. They have a brewery here in South Africa… random. Their local beer is Castle. At a bar its about 12 rand (which is 1.50 USD) a bottle.
Friday, November 6, 2009
Medcine rounds, plaster of paris, and TB-o-rama
Only doing a single entry this week. I have somehow gotten a nasty sore throat, lots of posterior lymph nodes, and not sleeping well. Not been easy to focus when I leave the hospital.
This week I was assigned to the medicine team, but still attended community and orthopaedic clinics. Medicine team is constantly slammed with a number of very sick HIV+ patients, with various TB related issues. In order to receive anti-retroviral treatment at the ARV clinic, patients with TB need to be on atleast 2 weeks TB treatment. If you start ARVs right away then can get IRIS, an immune reconstitution syndrome where your white cells gain strength at HIV is suppressed and then vigorously attacks the TB. I only knew about IRIS with regard to chemotherapy and transplant patients. Only issue is figuring out who has TB… They do an X-ray, sputum looking for TB, and then a screening ultra sound. The u/s was surprising to me, but I guess they frequently can see lesions in the spleen and liver. Many patients are just treated for TB with enough supportive sx (night sweat, spiking fevers, cough) and family members with TB.
Some of you may be thinking, so what precautions are taken for these patients to prevent hospital workers from getting TB. Well… there is an open window policy, and some patients are made to wear masks, So basically minimal. No negative ventilation rooms, or fancy hepa masks. I still cringe a bit when someone is coughing and sputtering… Just kinda the way it is here.
There are serious limitations on the hospital financially. Deep venous thrombosis prophylaxis has been an issue, since they do not have pneumo boots or even TED socks. I guess those simple socks are not cheap in south Africa. So they rely on heparin. LMWH is too expensive.
Resources to address psychiatric and psychologic needs are very limited in the region. They have issues getting of those positions filled in the public sector. Social workers take on a lot of that responsibility. There is no psych ward or anything like that at the hospital, again managed to the best of their ability by the family med docs.
On Thursday I went to ortho clinic again. It is so much fun to play with the younger patients. There is not very much play or fun with patients. I think that is a by-product of the high patient load, and possibly the more old school doctoring. I am slowly introducing them to my clown nose…
In ortho we had a really crazy case. A 40 year old wheel chair bound guy came to clinic cause he thought his elbow was infected. The notes were very skeletal, so all we knew is that he had two recent open reduction internal fixations of his distal arm. Presumably from trauma. His x-ray was so abnormal, severe osteomyelitis, just eating away at his bones. We took off his bandage and plasma like fluid just gushes out… What a mess. Not sure what led to the breakdown of his care, but he bought himself a ticket to tygerberg to sort out a repair.
Rest of the clinic was looking at some dramatic spiral and oblique fractures from various traumas. I find it strange that none of the kids draw on their casts! When I broke my thumb in elementary school I got this awesome glow in the dark fiberglass cast and had friends draw on it. I’m encouraging the kids to do it, next week I’m gonna bring markers and stickers.
What else. Oh, so I have seen a common trend with patients in which they are referred to the hospital by their private general practitioner. My understanding was that the private system was only for people with ample money, but it seems many will pay some money to be seen urgently at a clinic. Still the private hospitals are reserved for those who can pay upfront or who have insurance plans with them.
It is so refreshing to work in a place that has no money exchange between patients and providers. No talk about insurance or hospital representatives coming into your room to make patients sign their payment responsibility forms.
That’s all for now. I was in casualty until late last night, so am struggling a bit energy wise. This weekend I will be in Sea Point staying with family.
This week I was assigned to the medicine team, but still attended community and orthopaedic clinics. Medicine team is constantly slammed with a number of very sick HIV+ patients, with various TB related issues. In order to receive anti-retroviral treatment at the ARV clinic, patients with TB need to be on atleast 2 weeks TB treatment. If you start ARVs right away then can get IRIS, an immune reconstitution syndrome where your white cells gain strength at HIV is suppressed and then vigorously attacks the TB. I only knew about IRIS with regard to chemotherapy and transplant patients. Only issue is figuring out who has TB… They do an X-ray, sputum looking for TB, and then a screening ultra sound. The u/s was surprising to me, but I guess they frequently can see lesions in the spleen and liver. Many patients are just treated for TB with enough supportive sx (night sweat, spiking fevers, cough) and family members with TB.
Some of you may be thinking, so what precautions are taken for these patients to prevent hospital workers from getting TB. Well… there is an open window policy, and some patients are made to wear masks, So basically minimal. No negative ventilation rooms, or fancy hepa masks. I still cringe a bit when someone is coughing and sputtering… Just kinda the way it is here.
There are serious limitations on the hospital financially. Deep venous thrombosis prophylaxis has been an issue, since they do not have pneumo boots or even TED socks. I guess those simple socks are not cheap in south Africa. So they rely on heparin. LMWH is too expensive.
Resources to address psychiatric and psychologic needs are very limited in the region. They have issues getting of those positions filled in the public sector. Social workers take on a lot of that responsibility. There is no psych ward or anything like that at the hospital, again managed to the best of their ability by the family med docs.
On Thursday I went to ortho clinic again. It is so much fun to play with the younger patients. There is not very much play or fun with patients. I think that is a by-product of the high patient load, and possibly the more old school doctoring. I am slowly introducing them to my clown nose…
In ortho we had a really crazy case. A 40 year old wheel chair bound guy came to clinic cause he thought his elbow was infected. The notes were very skeletal, so all we knew is that he had two recent open reduction internal fixations of his distal arm. Presumably from trauma. His x-ray was so abnormal, severe osteomyelitis, just eating away at his bones. We took off his bandage and plasma like fluid just gushes out… What a mess. Not sure what led to the breakdown of his care, but he bought himself a ticket to tygerberg to sort out a repair.
Rest of the clinic was looking at some dramatic spiral and oblique fractures from various traumas. I find it strange that none of the kids draw on their casts! When I broke my thumb in elementary school I got this awesome glow in the dark fiberglass cast and had friends draw on it. I’m encouraging the kids to do it, next week I’m gonna bring markers and stickers.
What else. Oh, so I have seen a common trend with patients in which they are referred to the hospital by their private general practitioner. My understanding was that the private system was only for people with ample money, but it seems many will pay some money to be seen urgently at a clinic. Still the private hospitals are reserved for those who can pay upfront or who have insurance plans with them.
It is so refreshing to work in a place that has no money exchange between patients and providers. No talk about insurance or hospital representatives coming into your room to make patients sign their payment responsibility forms.
That’s all for now. I was in casualty until late last night, so am struggling a bit energy wise. This weekend I will be in Sea Point staying with family.
Saturday, October 31, 2009
Casualty department
Geez, the week has gone quickly. Fridays are slower at the hospital, until things get crazy in casualties in the evening.
Today I spent my day with an 83 yo doctor who has been practicing for like 59 years! He is also retired, and just does weekly clinic. We had grand rounds in the morning, topic was on the new forms for psychiatric patient holds and their legal rights. The doctors were not very pleased with all the changes and hurdles.
The older doc mostly does dermatology stuff. When in doubt, freeze it off, seems to be the common denominator… Saw molluskum contageousum for the first time. Also learned that having those lesions gets you an automatic HIV test because of the higher prevalence in HIV positive patients. Nail removals, candida, dermatitis.
I went home in the early afternoon, and relaxed until my late night shift. This weekend is pay day, which means lots of ETOH with a side of violence. I arrived around 9:30pm, already the ambulances were busy dropping of patients.
In the resuscitation room were two young boys, maybe 5 years old, whom had drank their parents amitryptilline. One boy required intubation, both got activated charcoal. X-ray is not immediately available, but they have a portable wheeling one that came later. The hospital is a small community site, so they transfer him to Tygerberg academic hospital.
Next patient, 16 year old guy, out drinking with family and somehow things escalated and his nephew stabbed his neck with a broken beer bottle. You can see the picture above. Right over his posterior triangle and barely missing his carotid. The hole was huge when we reflected his skin. He consented to me taking his picture. When I showed him the pic, he said “holy shit, f*** f***.” I don’t think he had any idea how severe the injury was. The pic sobered him up for a short time. The attending sewed him back up, good as new. He was transferred to tygerberg for an angiogram of his neck
Another younger guy was stabbed in his chest. Exposing the wound, you could see the bubbles of air coming out. X-ray would take a while. Given the skin crepitus from air, and hyperessonant left chest to percussion, he bought himself a chest tube. Its really neat how much they use physical exam, and do it well. Chest tube placement was just like the states.
Casualty is a pretty crazy place. From the back area with Whitney Houston playing from the stereo, to the ample blood soaked bandages from stab victims, to the flickering light in the stab room. The interns and staff are great teachers, and just really fun people. I’ll be doing more late night casualty shifts in the future.
Broken bottle neck stab
All better
stab/resuscitation room
Pic of Silvan and the views from our student flat.
Today I spent my day with an 83 yo doctor who has been practicing for like 59 years! He is also retired, and just does weekly clinic. We had grand rounds in the morning, topic was on the new forms for psychiatric patient holds and their legal rights. The doctors were not very pleased with all the changes and hurdles.
The older doc mostly does dermatology stuff. When in doubt, freeze it off, seems to be the common denominator… Saw molluskum contageousum for the first time. Also learned that having those lesions gets you an automatic HIV test because of the higher prevalence in HIV positive patients. Nail removals, candida, dermatitis.
I went home in the early afternoon, and relaxed until my late night shift. This weekend is pay day, which means lots of ETOH with a side of violence. I arrived around 9:30pm, already the ambulances were busy dropping of patients.
In the resuscitation room were two young boys, maybe 5 years old, whom had drank their parents amitryptilline. One boy required intubation, both got activated charcoal. X-ray is not immediately available, but they have a portable wheeling one that came later. The hospital is a small community site, so they transfer him to Tygerberg academic hospital.
Next patient, 16 year old guy, out drinking with family and somehow things escalated and his nephew stabbed his neck with a broken beer bottle. You can see the picture above. Right over his posterior triangle and barely missing his carotid. The hole was huge when we reflected his skin. He consented to me taking his picture. When I showed him the pic, he said “holy shit, f*** f***.” I don’t think he had any idea how severe the injury was. The pic sobered him up for a short time. The attending sewed him back up, good as new. He was transferred to tygerberg for an angiogram of his neck
Another younger guy was stabbed in his chest. Exposing the wound, you could see the bubbles of air coming out. X-ray would take a while. Given the skin crepitus from air, and hyperessonant left chest to percussion, he bought himself a chest tube. Its really neat how much they use physical exam, and do it well. Chest tube placement was just like the states.
Casualty is a pretty crazy place. From the back area with Whitney Houston playing from the stereo, to the ample blood soaked bandages from stab victims, to the flickering light in the stab room. The interns and staff are great teachers, and just really fun people. I’ll be doing more late night casualty shifts in the future.
Broken bottle neck stab
All better
stab/resuscitation room
Pic of Silvan and the views from our student flat.
Day 3 and 4
Yesterday I went on medicine ward rounds with the internal medicine team. As expected, the common denominator was TB and HIV. My intern recommended to answer any question asked by an attending with “it is likely caused by TB.”
I kept hearing the team refer to RVD, and RVD treatment. Given the strong stigma associated with the term HIV, they just refer to it as Retroviral disease… Not sure if I agree with this technique. With so many south Africans having the disease, I don’t know if using a code word around patients really makes sense.
Our hospital has a laboratory on site for basic labs, and sends out to the regional lab for more sophisticated tests. No electronic charts, which is refreshing. People write very succinct, but effective notes. If you want an IV, you place it. If you need blood, you draw it. Supporting staff and services are limited, but it still works surprisingly well. X-ray is widely used, as well as ultra sound. Physical exam skill are emphasized and very important in the assessment and plan.
What I find so interesting is how many similarities there are to medicine in the states. It is kind of neat that there is this thing we call allopathic medicine, which is conserved across nations. Similar presentations of patients, transudate vs. exudates, liver disease, BMPs… Just a shift in the diseases… They have a major issue of immigrants to south Africa from other African nations who go and visit their home and return with malaria. People assume they are immune but are not.
Today I attended orthopaedic clinic. This is run by a retired doctor who just comes in a few days a week to help out. He practiced 23 years in a very remote south African village as the family doctor. This clinic is mainly for assessing fracture healing, casting and cast removal. Same routine, grab a chart and just go for it…
Cutting off casts is a ton of fun. We had the vibration saw and scissors. My first patient must not have known the saw will not cut skin because he just about hit the ceiling when I bumped his skin… He had an open fracture, and when we removed the cast we found a few skin staples and a partially extruded bone fragment. Hmm, that must not have helped the wound heal… Came right out and he was on his way.
The common denominator at this clinic was “xxyo post MVA” or “PVA (pedestrian versus auto).” One of my patients was hit by a township taxi, which are these crazy taxis that drive by their own rules, stop anywhere, honk a ton. Casting is good old plaster. It gets the job done, patients seem very happy, especially when we remove the casts. Many fragrant smells to save the least. Many patients had been prescribed a drug called Panado… I’m like, what the heck is this panado. It is Tylenol. Why so many names!
It is very interesting to me the patient population. There are many xhosa speaking patients, and Afrikaans. But there are a number of older white Afrikaans speaking people who grew up in Strand and Somerset west. They speak excellent English and tell me they are very pleased with the governmental care they have received. They actually remind me of rural Minnesotans, haha. What a unique mix of patients here.
In the afternoon we did group neurology clinic with a visiting neurologist from the major tertiary tygerberg hospital. It was interesting because I was part of a group of doctors and interns (about 10), and we were sitting facing the neurologist and patient. Surprisingly the patients didn’t seem to mind the crowd.
Our first patient only spoke xhosa, somehow we found a person to translate. He had been having “spells” for the past year. He has them 2/week, and says his vision and brain go black. All of a sudden he turns his head to the right and stopped responding to our questions. He stand up, pulls his phone out of his pocket, and begins to lick it, walks outside and urinates, then comes back and sits down in a very tired state. All the us observers look at each other trying to figure out what was going on. Our patient conveniently showed us his complex partial seizure. Crazy timing. We just increased his phenytoin dosage, hopefully it helps.
Another patient is a white woman in her 50s with multiple sclerosis. Unlike in MN, MS is very rare so many general practitioners do not have much experience in management. She was dx in 2001, and since then has been taking cortisone. I mean, high dose, she said 8-10 pills per day (not sure of dosage). She came in on a wheelchair, very frail, big red cheeks with moon facies, muscle atrophy, tremor, skin brusing and lesion from thinning, stasis ulcers on back and ankles. The neurologist said it was the most extreme case of chronic cortisone overuse. They are going to very slowly reduce her prednisone.
Well those are some more of my experiences. I will be heading back to Cape Town for the weekend, but might spend Friday night in casualty. They get a lot of stabbing trauma on the weekends, and tons of opportunities to suture and place chest tubes.
I kept hearing the team refer to RVD, and RVD treatment. Given the strong stigma associated with the term HIV, they just refer to it as Retroviral disease… Not sure if I agree with this technique. With so many south Africans having the disease, I don’t know if using a code word around patients really makes sense.
Our hospital has a laboratory on site for basic labs, and sends out to the regional lab for more sophisticated tests. No electronic charts, which is refreshing. People write very succinct, but effective notes. If you want an IV, you place it. If you need blood, you draw it. Supporting staff and services are limited, but it still works surprisingly well. X-ray is widely used, as well as ultra sound. Physical exam skill are emphasized and very important in the assessment and plan.
What I find so interesting is how many similarities there are to medicine in the states. It is kind of neat that there is this thing we call allopathic medicine, which is conserved across nations. Similar presentations of patients, transudate vs. exudates, liver disease, BMPs… Just a shift in the diseases… They have a major issue of immigrants to south Africa from other African nations who go and visit their home and return with malaria. People assume they are immune but are not.
Today I attended orthopaedic clinic. This is run by a retired doctor who just comes in a few days a week to help out. He practiced 23 years in a very remote south African village as the family doctor. This clinic is mainly for assessing fracture healing, casting and cast removal. Same routine, grab a chart and just go for it…
Cutting off casts is a ton of fun. We had the vibration saw and scissors. My first patient must not have known the saw will not cut skin because he just about hit the ceiling when I bumped his skin… He had an open fracture, and when we removed the cast we found a few skin staples and a partially extruded bone fragment. Hmm, that must not have helped the wound heal… Came right out and he was on his way.
The common denominator at this clinic was “xxyo post MVA” or “PVA (pedestrian versus auto).” One of my patients was hit by a township taxi, which are these crazy taxis that drive by their own rules, stop anywhere, honk a ton. Casting is good old plaster. It gets the job done, patients seem very happy, especially when we remove the casts. Many fragrant smells to save the least. Many patients had been prescribed a drug called Panado… I’m like, what the heck is this panado. It is Tylenol. Why so many names!
It is very interesting to me the patient population. There are many xhosa speaking patients, and Afrikaans. But there are a number of older white Afrikaans speaking people who grew up in Strand and Somerset west. They speak excellent English and tell me they are very pleased with the governmental care they have received. They actually remind me of rural Minnesotans, haha. What a unique mix of patients here.
In the afternoon we did group neurology clinic with a visiting neurologist from the major tertiary tygerberg hospital. It was interesting because I was part of a group of doctors and interns (about 10), and we were sitting facing the neurologist and patient. Surprisingly the patients didn’t seem to mind the crowd.
Our first patient only spoke xhosa, somehow we found a person to translate. He had been having “spells” for the past year. He has them 2/week, and says his vision and brain go black. All of a sudden he turns his head to the right and stopped responding to our questions. He stand up, pulls his phone out of his pocket, and begins to lick it, walks outside and urinates, then comes back and sits down in a very tired state. All the us observers look at each other trying to figure out what was going on. Our patient conveniently showed us his complex partial seizure. Crazy timing. We just increased his phenytoin dosage, hopefully it helps.
Another patient is a white woman in her 50s with multiple sclerosis. Unlike in MN, MS is very rare so many general practitioners do not have much experience in management. She was dx in 2001, and since then has been taking cortisone. I mean, high dose, she said 8-10 pills per day (not sure of dosage). She came in on a wheelchair, very frail, big red cheeks with moon facies, muscle atrophy, tremor, skin brusing and lesion from thinning, stasis ulcers on back and ankles. The neurologist said it was the most extreme case of chronic cortisone overuse. They are going to very slowly reduce her prednisone.
Well those are some more of my experiences. I will be heading back to Cape Town for the weekend, but might spend Friday night in casualty. They get a lot of stabbing trauma on the weekends, and tons of opportunities to suture and place chest tubes.
Outpatient activities
Last night I went out with my roommate Silvan to the fanciest restaurant in Somerset West. I ordered the Kudu (a huge antelope animal) carpaccio, and for main course had Ostrich fillet, topped with mushrooms and parmesan, on top of sweet potato discs and drizzled with a port wine sauce. Of course we paired it with a local bottle of pinotage red wine. It is incredible! Ostrich is like a beef filet mignon, but little softer. Absolute bliss. The food here is spectacular. All total it cost about 200 rand, with is 7.5 rand to 1 USD, so it is about $26.
The last two nights have brought heavy storms, winds up to 150km and pelting rain. It really destroyed a bunch of vegetation, and woke me up like very hour.
Today at the hospital I went with Dr. V, Silvan, and two local University of Stellenbosch medical students to a clinic in Gordon’s Bay. We arrived at a single level white building, full of people waiting for us. From children, to elderly, white, black, colored, and everything in between.
The head nurse, also known as the head sister, brought over a huge stack of patient files. The building had a large waiting area, plus a pharmacy, and then our medical care open space with beds against the wall. Dr. V said, “ok, grab a bed and a chart...” We proceeded to just see patients one after another. No time to for being shy or hesitatnt. 10 minutes per patient was the challenge to us.
Every patient has their blood pressure, heart rate, weight checked. Diabetes patients get a HGT, which is a blood glucose, but it is in mmol, so normal is like 4-6. Some also get urine dips.
I saw all sorts of people. Many patients with chronic diseases come every 6 mo, since they need to get their governmental prescriptions renewed.
Some patients I saw:
- 55yo male with dermatitis, and concerns about weight loss… turns out he was observing Ramadan, problem solved.
- 19 yo guy, who looks about 14. Very charming smile, his mom tell me he has Prader Willie syndrome. Turns out he has had issues with hygiene and repeated episodes of dysuria. Plan, referral to the hospital for a circumcision. The other issue is his out of control diabetes, with glucose levels at 19, which is like 3 times normal; and spilling glucose into his urine.
- 84 yo female with hx of CVA, angina, hypertension… She is very frail, but well dressed, and has a nice little zippered flower purse. She had a number of symptoms she was concerned about. Listening to her heart, she has a loud systolic murmer, and has an irregular rhythm with dropped beats. She had just been seen recently at another clinic for angina, but never had any cardiac work-up… Referral to the hospital for a ECG and possible echo. Not sure how long it will take, we checked the box for urgent. --- It is so wild to be given almost full responsibility with patients. If I had not listened to her heart diligently, I might have missed her heart block. I wonder how long she has had it, since she is symptomatic from it…
- Then I had a patient that was dealing with concerns for her safety and domestic violence issues. Privacy is pretty much non-existent… Yet I pulled the curtain around. She became tearful. I learned there aren’t many services for women in abusive relationships.
That is just a snapshot of my first away clinic day. I can’t believe its only been two days, I’ve done and seen so much already. Dr. V pulled me aside and asked me to reflect about my experience yesterday. He is a true family doctor at heart, very interested in how we process experience, and our psychological welfare.
In a follow up to the mom from yesterday who was breech. I also told Dr. V about some articles I had read about using Chinese medicine for breech presentation. A few recent reviews have shown greater success by using moxibustion compared to control, which is burning a Chinese herb, and placing the warm end on the lateral fifth toe. Sounds crazy right… Well its cheap, no side effects or risk (that’s been studied too), and could potentially reduce their c-section rate. He laughed, but said, well get this moxi, and lets give it a try with our breech pregnant moms.
I’m exhausted. Time for bed.
The last two nights have brought heavy storms, winds up to 150km and pelting rain. It really destroyed a bunch of vegetation, and woke me up like very hour.
Today at the hospital I went with Dr. V, Silvan, and two local University of Stellenbosch medical students to a clinic in Gordon’s Bay. We arrived at a single level white building, full of people waiting for us. From children, to elderly, white, black, colored, and everything in between.
The head nurse, also known as the head sister, brought over a huge stack of patient files. The building had a large waiting area, plus a pharmacy, and then our medical care open space with beds against the wall. Dr. V said, “ok, grab a bed and a chart...” We proceeded to just see patients one after another. No time to for being shy or hesitatnt. 10 minutes per patient was the challenge to us.
Every patient has their blood pressure, heart rate, weight checked. Diabetes patients get a HGT, which is a blood glucose, but it is in mmol, so normal is like 4-6. Some also get urine dips.
I saw all sorts of people. Many patients with chronic diseases come every 6 mo, since they need to get their governmental prescriptions renewed.
Some patients I saw:
- 55yo male with dermatitis, and concerns about weight loss… turns out he was observing Ramadan, problem solved.
- 19 yo guy, who looks about 14. Very charming smile, his mom tell me he has Prader Willie syndrome. Turns out he has had issues with hygiene and repeated episodes of dysuria. Plan, referral to the hospital for a circumcision. The other issue is his out of control diabetes, with glucose levels at 19, which is like 3 times normal; and spilling glucose into his urine.
- 84 yo female with hx of CVA, angina, hypertension… She is very frail, but well dressed, and has a nice little zippered flower purse. She had a number of symptoms she was concerned about. Listening to her heart, she has a loud systolic murmer, and has an irregular rhythm with dropped beats. She had just been seen recently at another clinic for angina, but never had any cardiac work-up… Referral to the hospital for a ECG and possible echo. Not sure how long it will take, we checked the box for urgent. --- It is so wild to be given almost full responsibility with patients. If I had not listened to her heart diligently, I might have missed her heart block. I wonder how long she has had it, since she is symptomatic from it…
- Then I had a patient that was dealing with concerns for her safety and domestic violence issues. Privacy is pretty much non-existent… Yet I pulled the curtain around. She became tearful. I learned there aren’t many services for women in abusive relationships.
That is just a snapshot of my first away clinic day. I can’t believe its only been two days, I’ve done and seen so much already. Dr. V pulled me aside and asked me to reflect about my experience yesterday. He is a true family doctor at heart, very interested in how we process experience, and our psychological welfare.
In a follow up to the mom from yesterday who was breech. I also told Dr. V about some articles I had read about using Chinese medicine for breech presentation. A few recent reviews have shown greater success by using moxibustion compared to control, which is burning a Chinese herb, and placing the warm end on the lateral fifth toe. Sounds crazy right… Well its cheap, no side effects or risk (that’s been studied too), and could potentially reduce their c-section rate. He laughed, but said, well get this moxi, and lets give it a try with our breech pregnant moms.
I’m exhausted. Time for bed.
Hottentot Holland Hospital
Day 1:
Today was my first day at Helderberg Hospital. What is curious is that, a few years ago the name was changed from Hottentot Holland hospital (HHH), yet none of the signs from the road or on the hospital have been updated.
I am living with a Swiss medical student who speaks German and English. His name is Silvan and is doing general surgery and has been at HHH for 3 weeks.
There are like 14 national recognized languages in South Africa, from Afrikaans, to xhosa. Somerset west is in a very africaans area, which is really a crazy mix of dutch german and English. Usually every other sentence is English, so they mix languages together.
Here in South Africa medical school is 6 years right out of high school. Then you do 2 years internship in just general subjects, plus an extra year of community service (at a remote or underserved site). After that you are a general practitioner. Then if you want to specialize you do it after that. That means to do internal medicine and then GI, you would need to do like 3 years IM and then a GI fellowship. That’s a lot of years, but it is great because every south African trained MD will have atleast 2-3 years of just general medicine skills (you name it, they do it).
The doctor who is the student coordinator is Dr. V. He is a very youthful, fun guy, who has been at HHH for 13 years. Originally he wanted to do surgery but fell in love with family and community medicine. He is actually trained in hypnotherapy! Very cool. At the hospital he runs from outpatient high risk OB clinic, to doing C-sections, ectopics, appendectomies, then does medicine rounds. Here family medicine means, you do it all… As he put it, you become a “master of all trades.”
Turns out I am the only the second US medical student to spend time at the hospital. Lots of Germans and other Europeans visit. He is excited that I am interested in seeing everything, because most foreign students come just to do surgery.
The staff is a mix of young interns, young attending, local SA medical students, and international students (a german, sylvan and me).
My first day started dramatically. We are called to the maternity ward for a full term xhosa woman who was transported by ambulance from a surrounding clinic for active labor and cord prolapse. The women was laying on bed, her membrane had ruptured, and was having contractions. Surprisingly, the feeling in the room was very calm, the mother seemed neither excited nor worried. The intern used an older model ultrasound to look for the fetal heart rate, and only found a faint irregular bradycardic rhythm. Using suction, a very pale blue baby boy was delivered. He was not moving, no crying. Cord cut, to the room next door, chest compressions, oxygen, few attempts at IV placement… After a few minutes there was no sign of life. Dr. V and I walked back to the mother, “I am very sorry, but your baby had died.” She relied, “Died?” “no no no…” Shrieking and crying. “oh jesus, why why.” I didn't quite know how to process what I just saw. It was such a beautiful baby boy, and there he was not breathing... If only she had come earlier. Dr. V put his arm around me and said, “Well Justin, welcome to Africa." There are more patients to see.
The rest of my day was spent in the high risk OB clinic. To be high risk you need to have a hx of pre-eclampsia/HTN, previous complicated pregnancy (aka, ectopics)… What is interesting is that have a previous C-section puts you as high risk. How different is that than the US where c-sections seem to be the norm. Here it means something went wrong, so we need to watch out. Patients are called in groups of 4-8 and then seen one by one. HIPPA shmippa. Efficient and effective is the name of the game. Ultrasound is available, there is a skilled tech onsite to do AFI and dating.
Here they expect you to do the full Leopold maneuvers… man oh man, they still do those. Luckily he had time to teach me.. Within no time I did them on all my patients. By the end of the day I felt pretty confident.
39 week gestation, just seen for the first antenatal visit last week at an outside clinic. Now her first time here. She comes with her green card that all pregnant women are given in the governmental system (pregnancy hx, fundal growth, tests). It is my job to do exam and ask the pertinent stuff, checking your work consists of the attending popping their head in for a second. Hmm, can’t feel the head of the baby engaged… Pressing on the vertex… could be a head or just the butt. Ultrasound is busy. Pt was sent for an abdominal x-ray to see where the head is… Wow, didn’t know you could do that. The goes off for a bit and returns with her films. Baby is breech. Very cool to see an x-ray of a gravid female, don’t get to see that every day. Plan totally changes, now a scheduled c-section in a few days. Good thing we picked that up. Thank you Leopold, looks like I underestimated your maneuvers.
Another patient with epilepsy (well atleast thats what we called it), being managed on tegretol… Drug levels? Too expensive said Dr. V, they do the best med management they can without blood levels.
The rest of clinic consisted me calling for patients to a full waiting room with like 50 people, all staring at me. Eeks, how do pronounce ‘Ndw.’ I butchered the name, and I could hear the young docs having a chuckle.
It seems as though the general consensus is to work hard, but have fun. I couldn’t ask for a better match for me.
The day ended with a ruptured ectopic pregnancy… whaa… No general surgeon… Family doc specialist scrubs in. Open her up, clamp, cut, clamp, suction, sew her up… All done. No cautery, no fancy tools, get in and get it done. Wowza.
Well what a crazy, exciting, and full first day.
Friday, October 23, 2009
Howzit! Greetings from sunny Cape Town, South Africa
Hello Everyone. This will be my first time doing a blog to follow along with my travels. I'm excited to document my experiences and share them. I arrived in Cape Town last week, and have just been acclimating. Its been many months since I've just had some time to relax.
So why come to South Africa? Two reasons of many...
1) I was here during undergrad with a group of pre-medical students. We went to Johannesberg, Cape Town, Durban, visiting all sorts of clinics, hospitals. I fell in love with the culture and people, and vowed to return as a medical student to learn more.
2) I have like some 40 relatives that live in Cape Town. My mom's mom, Dorothy Roth (maiden name) Yach grew up in Sea Point, which is a suburb of Cape Town. She met my grandpa, Saul Roth, a member of the US army, during WWII when he was in the Cape Town port. After the war she left South Africa to marry Saul. So thats how I got stuck in the US...
Well I head off to Somerset West this weekend, a small city outside of Cape Town to spend time at their governmental hospital. Its called Helderberg Hospital, or Old Hottentot Holland Hospital. I'll post more once I begin my first elective.
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