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.