Early End of the Week

We have had Internet access issues and have had to put the blog on hold. The week was eventful and stimulating. The best thing that happened was that Emily was hired by Thomas College in Waterville as their new political science professor!
Life went on here in Botswana, however. I was asked to consult on a patient with a huge pericardial effusion that prompted an echo-guided pericardiocentsis and resulted in >2L drainage. The next day, I encountered a man with a hemodynamically significant effusion (early tamponade) that also required an echo-guided tap and resulted in >200 ml drainage that relieved the tamponade symptoms and signs. Other findings this week were an ascending aortic aneurysm (nearly 6 cm) with AR, acute AR in a poor woman with underlying hypertensive heart disease, cryptococcal meningitis, AIDs, and TB (I think she had acute infective endocarditis), Ebstein’s anomaly of the tricuspid valve in a patient with severe ischemic cardiomyopathy, and a secundum ASD with RV enlargement and pulmonary htn.
Barbara’s birthday was today. She did some therapeutic shopping at the Botswana Cultural Center (a wall hanging for Duncan and an African story book for him also). We went out for dinner at the Gaborone Sun hotel, and had a very enjoyable meal, served in relaxed Botswana style.
We have been struggling with the Internet, and have had to delay contribution to the blog. Our Email access has been limited. Hopefully I’ll be able to convince the folks at the BUP office that fixing our internet access and ability to print are priorities.
Friday morning Barbara and I are traveling to Chobe, a game reserve in the northeast part of Botswana, where we'll be for 3 nights. We'll spend an additional night at Victoria Falls in Zimbabwe. This should be a great trip and both of us are ready for a break!

What did you do today?

Both of us were busy.Barbara prepared a talk to the Gaborone city clinics about TB law.She had been asked to speak by the medical director of the clinic based on problems with non-compliant TB patients and TB control laws in Gabarone. She found a rather blank group until she decided to switch to more practical information: she discussed a similar legal case in Maine with a non-compliant TB patient and the many problems with the adequacy of the laws this case uncovered. This account resonated with the group and created an interchange that kept the group engaged.
I was kept fully occupied at the hospital. I did an echo on a 14 year-old girl with a congenital heart disease who I recommended to undergo ASD repair. I tried to explain to the parents that a hospital that is experienced and that has high volumes of this type of surgery would be the best choice for closure. I encouraged them to go to Johannesburg despite the potential costs.
I also encountered a woman in her mid-fifties who had a 5.9 cm ascending aortic aneurysm with aortic regurgitation-- a perfect case for aortic repair and aortic valve resuspension. I hope the doctors here refer her to Johannesburg for surgery. I also found a patient with severe heart failure, likely due to hypertensive cardiomyopathy. The unique finding was that he also had sever tricuspid regurgitation likely related to a congenital problem, Ebstein's anomaly.
We are planning trips for the remainder of our stay. This week we are off for Chobe and Victoria Falls in Zimbabwe. We are also planning trips to the Okovanga Delta and Kalahari desert. At Easter, we'll do Cape Town and the wine district. Barbara told me there's golf at Victoria Falls, so be prepared for more details in this vital subject!

Not an exciting Monday

Morning report had exactly one cardiac patient, and the consult was quick and echo revealing. He had an ischemic cardiomyopathy with an apical mural thrombus and needed a cardiologist from US to recognize the problem and initiate appropriate therapy. I have a Penn med student with me for the next 2 days, and spent the off-time delivering extemporaneous lectures on heart failure and arrhythmias to him. I gave the 4pm Residents' lecture on heart-failure stages, pathophysiology,and guidelines for diagnosis and therapy, This subject was in part stimulated by the "grand rounds" delivered by a local cardiologist of questionable reputation who basically blew smoke and gave a polished, if somewhat inaccurate, review of drug therapy last week.
Barbara has been working on a review of TB statutes in the US to review with concerned persons at the Gaborone TB Clinic tomorrow. Her talk appears to be well prepared, but she needs to find out where exactly to deliver it!

Party Animals

We started today off with a long walk in our neighborhood, which includes many embassies and gated large homes of dignitaries, both foreign and domestic. It was a beautiful morning: sunny, warm, and summer-like. Later in the day we attended the jazz concert at the golf club. Today was special, as the Botswana motorcycle club was invited to attend. They arrived about 1/2 hour into the concert, spewing smoke with engines roaring. Here, as in our country, Harley is king. The typical burly bearded bare-armed denim vested look also is apparently required. The concert was fun and my colleague, Matt Dasco, a UPenn attending (from Houston) played tenor sax eloquently.
About 5pm we walked about 6 blocks to the home of Branco and Gordana Cavric (she is chief of medicine at PMH, unfortunately visiting family in Belgrade this week, and he is a UB professor of urban planning) for a Wildebeest and Oryx roast. Their friend from Serbia, staying with them, had hunted the animals in the Kalahari, and brought them back for stewing (along with ox-tail, pork, and goat). The stews were served with rice, peppers, and pop (maise prepared like dry cream-of-wheat), and actually were delicious. They had been stewing for 6 hours over a wood fire while the Yugoslavs (9 at my table alone) exercised their hepatic function with beer, wine, and other alcoholic consumables. We spent the evening re-fighting the Serbian war of the '90s, as we seem to do every time we sit down with a crowd of former Yugoslavs.
We also heard lots of stories about wild animals of the Kalahari and the Okovango Delta, which was fun and good preparation for our upcoming trips in late February and March.
I sat next to the Anglican Bishop of Botswana, who was asked to give the blessing before we ate. I was relieved they didn't ask me...the motsie might not have been well understood by the Yugoslavs. Barbara was at a table with all women, except an interracial couple, married in Moscow 40 years ago, who have found acceptance here in Botswana, where they have lived now for a long time.
Full of Wildebeest, we came back to our flat to prepare ourselves for the coming week.

Public Health Law Botswana Style

For those of you looking for something a little different in your BB diet, this one's for you. I have been spending time with a variety of players in the public health world here in Gabarone. Like all countries, how health policy and law is developed is a byzantine and mysterious process (especially if you are coming at it from the outside). This is a highly centralized system in which the Ministry of Health does a fair amount of micromanagement of the public hospitals for example (Princess Marina being the largest of this group). So many decisions that would in the US be made by some hospital VP or even some mid management person are kicked up and up the ladder to some Ministry of Health person. Last week I met with a senior management officer at the Ministry of Health who is in charge of "outsourcing", basically negotiating the contracts with many of the country's partners to build and service many of its health needs. Botswana is relatively affluent but has not yet had the opportunity to develop its human professional resources, so it needs to import much professional talent. On the other hand, there is a strong desire to put Motswana (Botswana natives) in all available positions. I understand from my contact that new public health acts are under development to modernize their system and look forward to seeing them when they become available.
In another venue I have been meeting with folks from an organization called BONELA (Botswana Network for Ethics Law and Advocacy). They advocate for the rights of HIV/AIDs patients in employment, access to health care, and housing, etc. They are a small NGO and I have agreed to help them with a position paper on a matter of great concern here. Botswana provides universal access to ARV (antiretroviral therapy) for HIV for all "citizens" of Botswana. So the many refugees to the country (many of whom are from Zimbabwe) and also prisoners who are non-Botswana have no access to these drugs. We are trying to come up with some good legal and policy arguments to persuade lawmakers to expand access to non-citizens.
I have also been meetingwith a UB law professor who teaches human rights law and is very interested in the development of research ethics guidelines and regulations - an important concern in countries in which a lot of foreign clinical HIV/AIDs research has streamed in.
Last night we had dinner with a new friend, a Fulbright fellow at UB from
California (USC). She teaches Alternative Dispute Resolution here - we discovered we had frieinds in common ( a frequent occurence in Gabs- crossroads of all nations!). At dinner we also met an American who works for a Belgian political consulting company charged with advising the Office of the President. Many interesting stories of this and former jobs, consulting during the troubles in Rwanda and Georgia.

The Week Draws to a Close

A young woman was referred by the private cardiologist in town with a large cardiac silhouette on chest Xray and an echocardiogram in his office revealing a pericardial effusion. He had considered that her problem might be due to TB pericarditis. I repeated the study on our own machine my eyes widened. She indeed had an effusion, but also had rather impressive hypertrophic cardiomyopathy. I examined her with one of the Penn students who was spending a few days with me, and the findings were classical! I hope to establish a series of TB pericarditis considering the numbers of patients with this problem I'm seeing. I tapped her pericardial effusion yesterday. The procedure was challenging, not because the access was difficult (I used the tried and true Mayo technique using echo guidance) but because all the lights in the room had burnt out, including the Xray viewbox. As a result, most of the procedure was done in relative darkness. I obtained my own minor tray from Central Supply. The lead technician there told me, "usually the nurses obtain sterile supplies from us, not the doctors." I told her that if I had to wait for the nurses, I couldn't count on when the procedure would happen. But the clincher was when I said, "if the nurses obtain the sterile equipment from you, you will need to depend on them to return it. If I obtain it, you know I will make sure it gets back to you promptly and in good condition!" She couldn't wait to get the tray into my hands.
The procedure went well, and we obtained plenty of fluid to smear and culture, and perform cytologic and biochemical testing on. The microbiology laboratory at Princess Marina Hospital is in a remote corner of the grounds, no signs for guidance, in a temporary building with the smallest of signs to identify the lab. Susan Lipsett, the med student who worked with me on this patient, poses in front of the lab "building" in the picture above.
The patient will be treated for her infection (likely TB). However, the fact that she also has hypertrophic cardiomyopathy will be an important factor in her future management and a survival issue.
Today, I didn't make it to morning report because of a critically ill 17 year-old primipara in pulmonary edema, who turned out to have chronic mitral regurgitation and required intubation and mechanical ventillation. She is in her 32nd week, and I think we can control her cardiac function without resorting to preemptive early delivery. Thereafter Grand Rounds was given by the same private cardiologist on "heart failure" that was quite a show. The talk appeared to be a protracted drug commercial. There was little emphasis on pathophysiology, the critical piece required by the housestaff to understand the basis of management and treatment.
A popular feature of the preceptorships I held at MMC over the years has been to take the residents to The Woodlands to play golf on my 1/2 day off. I have continued this tradition here. Matt Devers and I played at Gaborone GC (with caddies, no less) and had a beautiful afternoon. Our rental clubs were such that we had to share a driver, a "Big Brother" (Callaway knock off from China) that, despite all I have done to improve my swing, unrelentingly brought out my fade.
Tonight we had Shabbat dinner with the Ludmir family (Jack is doing a 2 week OB-GYN teaching position, while his son Jonah is a pediatric resident working at PMH). Jonah's wife Yael is an attorney volunteering at Bonella, a non-profit organization looking out for the downtrodden here in Botswana. Barbara will also be volunteering time with the organization.

Rain and Shine

The rainy season can produce prodigious thunderstorms and high-volume downpours. Yesterday evening, we went out for dinner at the local Chinese restaurant, "China Restaurant" at a nearby mini-mall. The restaurant had one other table of diners (a couple eating "Hot Pot" that began before our arrival and was still going strong when we left). There was a large group of maurauding 5 year-old children who treated the nearly empty dining room as their gym. Two secluded rooms on the side were set for dinner and when we left, we saw the large assembled Chinese family of the owners enjoying their meal.
The rain was pouring and the thunder and lightning powerful when we exited the restaurant. The parking lot was flooded with what appeared to be ankle-deep water. We swallowed hard and took steps into the deep puddle toward the car. Suddenly, Barbara was into water thigh-deep! She had inadvertantly stepped into either a giant pothole or a drain-pipe. Fortunately, the damage appeared to be limited to a mild foot-sprain, but the surprise, the mess, the wet, and the concern about worse injury made the entire event frightening. A warm bath, ibuprofen, neomycin ointment, icing, and sleep helped diffuse the potential injury a great deal, and Barbara is back to normal 24 hours later. We were glad we updated our tetanus vaccinations!
Today at the hospital was another productive experience. Among the cases I was asked to see was a 26 yr-old woman referred by a local "cardiologist" for a pericardial effusion, found on his echo exam. She indeed had a 4 cm effusion, likely due to TB, which I will tap tomorrow. However, he totally missed the fact that she had an enormous intraventricular septum with evidence of dynamic LV outflow obstruction, a condition called Hypertrophic Obstructive Cardiomyopathy. This is a major finding and will significantly affect our management strategies for her. Other studies ruled out myocardial scarring in a 60 year-old diabetic woman with an abnormal ECG, and helped forstall aortic valve replacement in South Africa in a 63 year-old man who had only moderate AS/AR and LV systolic dysfunction, who really needed appropriate medical care to reduce his symptoms. Yesterday I echoed the Foreign Minister, who will be happy to extend my greetings to Mrs. Clinton when he next sees her.
This evening, I had the pleasure of meeting Dr. Howard Moffat, the former medical director of Princess Marina Hospital, who shared tea and wanted to know my opinion about how to raise the level of subspecialty care in the country. We had a great discussion, but I suspect that the problems here are complex and have no simple answer.

Cardiology Central

Morning report was especially good. The new chief of medicine insisted on cases being listed on the board and to have a special case presentation which would engender didactic interchange and allow the housestaff to hear from the various attendings on the matter of the moment. The
session was less like a Quaker meeting (soto voce) as it had been in the past, and more like an academic exericise.


I saw several cases, as usual pathology in the extreme. A young woman with infective endocarditis and severe mitral regurgitation was especially interesting, with large leaflet vegetations who will certainly need to be sent to South Africa for MV repair or replacement. A man with severe heart failure was existing with insufficient cardiac function to keep his blood from stagnating in the middle of his main pumping chamber, the left ventricle. His ejection fraction was 5%.
I gave the resident lecture at 4pm: my subject was non-ST elevation MI and unstable angina pectoris. I recognize that these conditions are not frequently encountered, but when they occur the housestaff must not be caught flat-footed.
It was wonderful arriving back at the flat and sitting with Barbara and Rob (still here until the weekend) and reviewing the day over Tanqueray on ice (no bourbon here). We checked in with Barbara's mother by Skype and called it a night.

Sunday Church Music

in

After sleeping uncharacteristically late (past 8am!), we walked to the local Catholic church, where the service was in full session. The singing was the main attraction for us. Barbara brought her mp3 player, which recorded the hymns pretty well, but we found we don't have the software to allow us to download the material to our computer, and play it for you. We'll try to obtain what we need and post it later on. The music is very rich and complex. The harmonies have to be at least 6 parts, considering the richness of the sounds, accidentals may end a phrase, giving an African melodic character, and the rhythms mixing triple and 8/4 time with syncopation. Often there is arm waving and Temptations-like dance steps by the choir...great fun for us.
We prepared dinner for 4 guests. Baz Semo, and Ethiopian physician with a Harvard MPh, working for University of Washington, running ITEC, an HIV control activity; Gordana and Branco Cavric (Gordana is chief of medicine at Princess Marina Hospital), and Rob MacGregor, the UPenn ID professor (emeritus, although he doesn't look it) who is staying in the same flat as Barbara and me for 2 weeks. I should say Barbara prepared, and Rob and I cleaned up. We had a great evening, and got to know the local issues as a result of the memories and discussions all our guests had to contribute.
While Rob and I were running around this afternoon looking for a place that was open on Sundays and would sell beer and wine, we saw this sign on a bank that suggests that the HIV message is indeed getting through to the general population!

Saturday Excursion

Today we got up early (not on purpose) and took a walk down to the government center, where parliament sits and many of the foreign embassies are located. After our return we traveled with Rob MacGregor to Thamage ("tmacha"), about 40 km NW of Gabarone, where there is a terrific pottery facility. We contributed mightily to the local economy.
On the way back we stopped at Sanitas, a plant nursery facility that also features a nice restaurant, where we had a great lunch of spicy tomato soup and chicken/bacon caesar salad. We returned to our flat after loading up with the week's groceries and hit the pool (the only rational thing to do in 90+ degree heat). This has been a great day to unwind, given the rather consistent intensity of the medical issues that occupy the work week!

Friday fun

After morning rounds, we repaired to the Gaborone Sun Hotel with former Penn fellow-residents, Jack Schmidt and Rita Watson, physicians in NJ who are parents of one of the medical residents who has been here for the past 6 wks. After lunch, we played 9 holes (it was rather hot...lots of water taken in) and had a very nice time.
As this was the last night in Gaborone for Jack and Rita's children, there was a brai (BBQ) in the back yard. Great time had by all.
We'll stay put this weekend and do more local exploring.

The one that got away!

Today was a day that could have made public health law history in Botswana. We heard that the doctor in charge of the city clinics was bringing a case regarding a non-compliant TB patient. Although the laws in Botswana, just like the US laws, allow for TB patients who are non compliant to be remanded to a some form of isolation, they are never enforced. This guy, who had MDR TB (multi-drug resistant and very lethal) was out and about and refused treatment. He was also an ex-policeman. A group of us arrived at the local courthouse (sort of like a small district court), along with a bunch of TB doctors and officials. The state's attorney came over and kind of sheepishly told us that the police did not know where the defendant was. Apparently, they served him with a warrant a day or two ago and told him to appear. He had probably slipped out of town. In the past, most of these folks are held in an isolation ward but the drs. suspected that some special treatment was at work here because he was a former cop. We were all prepared - even had our protective masks ready since this guy was highly infectious, the media was ready - reporter and cameraman. The drs. were very disappointed because they hoped to make this case a precedent and send a strong message to the community that TB is a deadly illness, particularly as it routine appears here along with HIV. They hoped to use the occasion to focus attention on how dangerous the situation is. Hopefully, the police will round him up and more likely he will turn up at some hospital soon and then be charged.

So, a no-show, but still kind of interesting to hear about the state of public health law in Botswana and I will certainly follow this case.

Came back home to put the finishing touches on a lengthy report for Muskie that has been keeping me computer bound for a while. Delighted to see that go off in the ethernet. Tomorrow we are playing golf with a visiting couple who are here to visit their Penn resident daughter and son in law. Rita Watson and her husband Jack Schmidt are other old Penn medical colleagues of Peter - amazing how many of these old connections he is finding here! A regular time warp...

Princess Marina Hospital Adventures

The morning began with the usual nurses' songfest around the nurses' station. The place was packed with patients...people on mattresses spread on the floor adjacent to the entrance to each of the 5 "cubicles" of 10 beds. I was asked to do a consult on a 57 year-old diabetic woman with profound heart failure. I went by to see her yesterday afternoon but couldn't intrude on the circle of relatives surrounding her mattress fervently praying for her recovery. She had evidence of a hypertensive and ischemic cardiomyopathy and I encouraged her and the housestaff that she likely would be easily treatable and I would expect her to recover with time.
I did an echo study on an unfortunate 21 year-old man in terminal heart failure 3 years following valve repair in South Africa. His findings on echo were so severe that I forwarded the images to the echo lab at Maine Medical Center for presentation at clinical conference.
This was the 2nd transmission of this sort in 2 days.
Yesterday a 20 year-old girl who had undergone a right above-knee amputation for osteosarcoma in 2007 had evidence of pulmonary congestion and on echo showed a very dramatic probable intracardiac metastasis emerging from the posterior wall of her left atrium.
As I have mentioned before, the dramatic findings I am uncovering here are astounding!
I supervised the residents who performed their first electrical cardioversion, and they were thrilled to be instructed in the synchronized use of the defibrillator for elective procedures.
The steps required to obtain the appropriate IV sedative were frustratingly baroque, and the nurses (see the chain of command chart) are organized in a way that de-emphasizes teamwork and makes obtaining quick and effective assistance difficult. This characteristic is typical of Botswana culture and often leads to buck-passing on even the most elementary decisions.

Barbara speaks -
I am very close to finishing a lengthy Muskie report and am delighted about the prospect of delving into subjects of more local interest. Tomorrow I hope to go to a district court which is hearing the case of a non-compliant TB patient - a perfect public health law case. Our flatmate, Rob McGregor has been involved in TB treatment here in Botswana for the last 8-10 years and is full of lots of great stories. Stay tuned for a new series, Gabs Law!

Hospital Monday

Like everywhere, Mondays are busy days at the hospital. At Princess Marina Hospital, morning report goes on for 1.25 hrs while residents and interns quietly recount the weekend's admissions, occurrences, and deaths. I was asked to do 4 consults and did 3 echoes, finishing in time to give the residents' lecture at 4PM.
Among the patients were a 20 year old primipara (HIV positive) with severe heart failure due to a peripartum cardiomyopathy. Another poor woman, 61 years old, had pulmonary hypertension and also severe heart failure on top of poorly controlled diabetes, hypertension, and kidney failure. She was caring for 2 small children (I presume grandchildren) alone, and was in bad shape. A 75 year-old woman from Lesotho (an island within South Africa) got sick while visiting family here and had advanced heart failure. Her country of origin is relevant in that the government supports the cost of citizens' health care, but not foreigners...they have to pay for everything up front. I'm cheap...no bill for my services or for the echoes I do. The ECG and chest Xray are another matter.
The talk was on Basic Life Support and we did a practical demonstration using the defibrillator. No one got shocked, despite my threats!
I walked home in 90 degree heat, and the Gibson (really, gin on the rocks) tasted great! Barbara, who had worked all day on her Muskie paper (it sounds like a lot of work!) cooked a great dinner and we had a long end-of-day conversation with our new housemate, Dr. Rob Roy MacGregor, from Penn.

Sunday stroll

A beautiful morning--warm, sunny, and very unlike the middle-Atlantic weather happening now. The Super Bowl is tonight, but will happen after we go to bed. It seems pretty remote, and football was always 3rd place after golf (of course) and baseball. We walked 2 blocks to the Botswana National Museum, which had buildings and other structures (including a kgotla, where kgosi, or chiefs, held audiences and trials).
The inside displays showed the geology, anthropology, and zoology of the country, including some nicely done diaramas like the one depicting wild dogs to the right.
After our visit, we passed the corner Catholic church, where gorgeous choral singing with African harmonies and syncopated rhythms were audible from the street. We went to the back of the church, and enjoyed the music for several minutes before returning to our flat.
One of my former HUP attendings, Rob MacGregor, whose interest is in ID, HIV, and TB arrived and will be sharing space with us for the next 2 wks. He had some great ideas about documenting and studying the frequent occurence of TB pericarditis, and this might make an interesting communication at the end of my stay in April.
Tonight, a Penn get-together (an English Roast at the home of Gill Jones, the local program administrator). We had to beg off on the scheduled 3PM jazz gig at the CC, but social obligations call!

Laid-back Saturday

We slept in today...till 6:30 AM. After breakfast, we caught a "combi" (one of a million old Toyota vans that act as minibusses in the Gaborone region) to Phakelane, a community 15k north of here which sports a golf course and surrounding "chalets" and 80 new homes being built. The golf course is a little upscale compared with the Gaborone GC, and a bit more carefully tended. I rented clubs, but the driver was missing. I asked where it was and the attendant described the previous user breaking the shaft after hitting a bad shot. I was able to obtain a replacement. Despite being assured when we made the tee time that there was a woman's set to rent, the clerk could not produce one. Luckly the general manager, a woman, came on the scene, and lent Barbara her own set! The clerk also suggested a caddy (despite our taking a cart) who, she said, would protect us from snakes. We had a nice round and had lunch at the club. There were no snakes, but the caddy at least gave us targets to hit to and general directions from hole to hole.
We returned to Gaborone quickly, and repaired to the pool to get out of the heat.
Botswana steaks for dinner at the Bull and Bush.

Echocardiography contributions to clinical medicine here

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The day started like others here...morning report, with residents and students recounting the presentations of sick patients, mostly with HIV/AIDs and the associated illnesses caused in part by their immuno-incompetance. I was consulted on 2 typical patients. The first was 72 years old, and probably acquired her HIV from caring for an AIDs-infected relative without taking appropriate precautions. She had severe heart-failure symptoms at rest, and had clinical findings consistent with severe pulmonary hypertension. My consult and subsequent echo study provided eloquent illustration of the severity and complexity of her medical situation. Management will be difficult and her outlook is poor.
The second patient was a 30 year-old man who had HIV/AIDs, with sharp mid-precordial chest pain that prevented him from lying down flat. He had a pericardial friction rub on examination, and an ECG that had subtle suggestions of pericarditis. His echo confirmed a normal heart within a sea of pericardial effusion, likely due to TB. The availability of echo to help confirm diagnoses and quantify the issues we deal with has made an enormous contribution. I'm proud to have done this, and hope to stimulate interest among the housestaff to become cardiovascular specialists who can make a similar contribution here.
We're beginning a low-key weekend here in Gaborone. We are having supper with the chief of medicine and her husband (Balkans who fled the Yugoslav wars in the early 90s) tonight, playing golf Saturday morning, and on Sunday attending an English "roast" at the home of Gill Jones, a former nurse who runs the Botswana-UPenn parnership. I tried to explain to our housekeeper Alima what -15 degrees Celsius is like (this is the current temperature in Portland), and she was horrified. Me too.

Hot Day

The hospital routine was not unusual. A 30 year old woman presented with cardiac enlargement and hypertension. I did a consult, with unusual heart sounds suggesting a continuous murmur only to find on echo that she had a pericardial effusion (and therefore what I heard was a pericardial friction rub), aortic arch enlargement, and mildly impaired cardiac function. She is a bit of a conundrum, and I suggested we look beyond the usual to work up to unusual diseases like SLE. Whether or not this will be possible I have no idea. I appealed to the director of the pharmacy to order a supply of IV metoprolol (common in the US but not a choice here) and IV adenosine, and to the biomedical engineer to provide boards for the male and female medical wards to allow effective CPR. We'll see if my inquiries are given attention.
Barbara and I hit the swimming pool on my return this afternoon, a great relief from the heat of the day!
Barbara's turn
Ok - I am making a little linguistic progress and have moved on to short phrases
Today's first phrase
Ke a huhula - I am sweating - a frequent occurrence here!
and
ke ya gotuma - I am going swimming!

A Typical Day in Gaborone

My days are starting to form some patterns, so wanted to share my musings about Gabarone in general and our little slice of it. We get up early - the sun is bright and Peter is over at the hospital by around 7:30 for morning report. Botswana time is kind of a fluid measure so apparently people straggle in. I start the day with either a walk or run, depending on how energetic I feel. I have not had the nerve to put on running shorts yet - don't want to totally shock the locals. A woman running seems to provoke enough amused surprise. Each day I take a slightly different route and spread out see to see more of our neighborhood. We are surrounded on one side by lots of embassies- the Chinese having the biggest and splashiest that I have seen so far. On the other side is hospital and University of Botswana and then below is the Main Mall and the African Mall - apparently the first shopping area in town.

Men and women are all dressed pretty western. Only older women are in traditional dress with those nifty head wraps. Unlike our experience in Liberia, I have only seen a handful of women balancing enormous loads on their heads. I suspect we will see more traditional dress once we leave Gabarone and set out for villages. Everyone has cell phones and internet cafes are plentiful and cheap ( about7 pula/hr -- around a dollar). I am swapping Setswana lessons for teaching Alima about the computer. She is a quick study so I suspect she will be surfing the net long before I can get through a simple conversation.

Shopping is an adventure. There are some larger stores in outlying malls, full of fancy imports, but our local Spar is more the norm. Lots of big bags of maize and sorghum meal for the porridge that is the basis of a lot of Botswana cooking. Lots of interesting looking spices that I check out but have not purchased yet. Everything fresh is all from South Africa. The fruit is fabulous but nothing local. I asked about what was farmed in Botswana and was told "diamonds."

After the walkabout I come back and do some Muskie work, catch up on the mail, work on my local connections. I met a Peace Corps volunteer yesterday who works with on NGO development. I was kind of surprised to know that PC was in town, but apparently they are involved in all kinds of organization capacity building.

Botswana is ground zero for all kinds of HIV/AIDs research so it is a real magnet for medical and social science researchers and also the govt seems to have invited in a lot of consultants for all kinds of tasks.

Usually have a dip in the pool late afternoon and then on to the evening's entertainment.

Back to Reality

Back to reality! Morning report this AM had 2 cardiology cases. The more memorable was a 65 year old man from about an hour away who presented with at least 1 week of weakness, exertional incapacity, and difficulty breathing. His liver was enlarged and mildly tender, definitely pulsatile. His heart rate was nearly 140 beats/minute. The ECG revealed atrial flutter, and it was plain that electrical cardioversion was indicated. This became a case of Little Red Hen syndrome, where I needed to bring together the resources to do the procedure safely. At home, we'd do a TEE, but that was unrealistic in this setting. I administered low molecular-weight heparin, gave instructions for initiation of beta blockers to begin to slow the heart rate and treat heart failure, and set up the cardioversion. I had brought ECG stickers with me, so we were able to deliver synchronised (monophasic) current. However, I had to obtain electrolyte gel from another part of the hospital to enhance paddle conduction and avoid burns caused by arcing. We also found midazolam in the pharmacy! We were all set and the procedure went smoothly, successful on the first shock, and the patient voiced no discomfort.
The post procedure echo showed him to have serious cardiac dysfunction, which was in part due to the previous days in atrial flutter at a high heart rate. We'll see how he does over the next few days with unloading and other anticongestive treatment.

Barbara and I are having the Penn house officers and students for a chili dinner, and invited the Pilane court maids, too. They are eager to see the Madikwe pictures, so it will be fun to have a little slide show.