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

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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.