As the week closes...

I was a bit rueful, despite the inevitability, of the local distributors removing the Philips HD 11 echo machine. I have learned to operate the device pretty well, adjusting to many different body types, chest wall thicknesses, lung interference, and levels of illness in echo subjects. In addition to creating the images, doing an echo is a bit like telling a story...the operator catches glimpses of pathology, and finds a way to expose and illustrate the abnormalities with off-angle shots, images taken from many different perspectives, use of a variety of techniques such as color and spectral Doppler, tissue Doppler, zoom, freeze, colorize, gain, compression, and many other tricks to optimize the information to take from the study. My hat's off to the many talented and accomplished echo technicians at MMC and CCM who spent hours coaching me so that I could perform studies independently to augment clinical assessments heretofore available in Botswana at the bedside only.
The pathology uncovered here is astounding, magnified at times by underlying immuno-incompetence due to retroviral disease, and at other times through inadequate access to competent cardiac care. There were other patients with amazing findings that would be seen (rarely) anywhere. These include: an unfortunate 21 year-old woman 3 years post above-knee amputation for osteosarcoma (a terrible tumor) who now had a left atrium full of obstructive metastatic disease, a patient with right atrial myxoma (an unusual location for this type of tumor), 2 patients with endocarditis that needed urgent open-heart surgery (one with severe mitral incompetence due to valve abscess and perforation, and another with a ruptured sinus of Val Salva aneurysm, localized aortic root dissection, and aortic valve perforation with a large vegetation, all causing a subpulmonic VSD and severe aortic incompetence), and 7 patients with large probably tuberculous pericardial effusions, 6 of whom required drainage (by echo technique). The frequency and severity of pulmonary hypertension and right-heart failure made one jaded about levels of pathology that in Maine would cause us great concern. I found congenital heart disease, rheumatic disease, and severe pathology in patients who had previously undergone open heart surgery in South Africa. What an experience!
The opportunity to teach the Botswana residents was another treat that provided great satisfaction. They are a smart, talented group of men and women, who are skilled in handling HIV/AIDS and its common complications, but lack some basic information and skills that will allow them to grow. The concept of differential diagnosis as a guide to choosing proper testing and treatment strategies is one that needs to continually emphasized. There is small group of dedicated employed physicians, contract physicians, and BUP (Botswana-UPenn Partnership) doctors who have these young people in their hands to mold into mature and competent practitioners. I am proud to have participated in this vital process.