On his way

Jeremy is about to take off from Atlanta on the marathon 18 hours of being on the same plane. I am so excited to see him tomorrow night! Just a half day at Bara tomorrow, then it's time for traveling!

Here's our basic itinerary:

Feb 27-28: Hanging out at a B&B and around Jo'burg
March 1-3: Kruger Park doing a safari
March 4-9: Cape Town
March 10: Get home!

Hope everyone is wonderful!

Cheers.

Finishing up

As I only have 1.5 more days at Bara, I am starting to reflect a bit on what I have seen. It is so hard to express into words the experiences that I have had here. I have been trying to tell enough without telling too much to invade patient privacy and not gross you all out. Bara is a place with many things that need improvement. Today we were discussing the differences between private hospitals and public hospitals here in South Africa. Although I have not been to a private hospital here, it sounds and looks (from the outside) that they are much like the hospitals we have in the US. They have many of the ammenities that are available to us, unlike those which are not available at Bara. The divide between the private and public sector is astronamical. The more you can pay, the nicer facilities that you get to stay in when you are at the hospital, the less time you have to wait, and the more staff attend you.

I am sure that I will have much to write once I get home and think on these experiences some more. Hope you all are well!

Cheers.

Shock value

As I am finishing up my time at Chris Hani Baragawanth Hospital, I am realizing how used to the conditions that I have become.

Someone will go down the street with 2 different crutches, mothers will carry their infants tied to their backs (I have yet to see a stroller), and a patient who can barely walk will climb the stairs since the elevator is broken. The hospital runs out of prednisone for weeks, we search high and low for IV starting equipment, and patients wait for hours for a clinic appointment. Patients carry around their x-rays and their medical records so they won't get lost, patients go to the ward to check themselves into the hospital, and patients stay in the hospital for weeks, if not months.

I have only been around for 3.5 weeks, yet I am already getting used to the things that shocked me in the beginning. Doctors struggle everyday to fight the system, our consultant calls in favors frequently, and the registrars do as much as possible on their own in order to provide their patients with the best care possible. It is so encouraging that they care so much, but to not become burned out in a system like this would be so difficult.

Another general medicine ward rounds tomorrow, so should see many new things!

Cheers.

Names

All of the patients in the hospital have 2 first names. One is a name that they were given by their parents when they were born, the other is the name that was given to them when they entered school by the officials, who said that their African names were to difficult to speak.

Example:
Nelson Mandela was born Rolihlahla, but was given the name Nelson by his teacher when he started school.

Pilanesburg Game Reserve

After having a great day on Saturday, including eating at Moyo and going out with some registrars from the hospital, we went on a game reserve drive today.

We saw:
Zebras, elephants, giraffes, monkeys, hippos, tons of birds, impalas, wildebeasts, warthogs, and so much more!

It was a great weekend! Now I'm just excited that Jeremy is coming on Friday!

Community

Unlike most hospitals in the US, our haematology patients are often stuck in the hospital (with an occasional weekend pass) for as much as a month or two. This is due to many reasons, but especially because many of the patients are from too far away to come back and forth so regulary to receive their chemotherapy. They also need blood tests several times a week. At home, there are many outpatient centers that allow you to receive your chemotherapy as outpatient as long as it is not too strong.

These patients stay in rooms of 1 or 2 people (unlike the rest of the hospital, which is more like a giant room of 70 people) next to each other. Because they are in the hospital so long, as well as not having as much privacy as we are used to in the US, the patients all get to know each other. They move from room to room, keeping each other company and watching tv together (because the only rooms with tv are the ones where the patient brought their own).

The women in the upstairs unit watch their soap opera, "Sunset Beach," everyday when we come in the room to see how they are doing and take the bloods. The men were at lunch together at the cafeteria together when we tried to go by and round on them today. They all know about the other's conditions, therapies, and complaints. Often we will go into one patient's room and they will talk about how another patient is not feeling well.

Yes, they have much less privacy here than they do at home, but they also have support of people who have often been stuck in the hospital as much as themselves and who are suffering similar illnesses. They provide amazing support for each other, which many times they could not get at home because no one else understands as well as those who are going through it.

Cheers.

This weekend agenda: awesome, fancy African restaurant, the mall (seems to be a main weekend thing around here), and Palanesburg Game Reserve. Should be fun!

Autonomy

The other day we attended an ethics lecture (by a lawyer, so a lot was really a law lecture), which made me realize how many laws/ethics are exactly the same as they are at home. By law, doctors have to receive informed consent before doing a procedure or else it can be considered an assault. Doctors have to do what any other "reasonable" physician would do in their situation. We talked about the basics of ethics: autonomy, beneficence, non-maleficence, and justice. Same as at home. No real differences. Except this is theory, and in practice they tend to not emphasize autonomy in the same way as we do in the US.

Patients are scolded, literally, whenever they do something that is not in the best interest of their health. The doctors here tell them that they need to lose weight, that they need to know their medications, that they never should skip an appointment, and so much more. They are all very caring, but often do not sugar coat things in order to make it more palatable. The doctors just tell it how it is. No worrying about being sued or hurting the patient's feelings. Just telling them what is in the best interest of their help. Never cruelly or offensively, but matter of fact.

At home we seem to tip toe around tough issues, worrying that we may somehow offend them. Who is really doing what is in the best interest of the patient?

Essentials

One of the essential supplies that all of the doctors have in their coats at Bara are staplers. Yes, to staple papers together. The charting system is very unlike our 1/2 paper and 1/2 computer charting at home. Whenever more medication sheets, progress notes, and other forms need to be added to the chart, they are just stapled to the notes that are already present. The inpatient charts often end up looking like a wad of crumpled up paper, which has been separated and restapled many times because parts of the chart are sent to different places like the pharmacy. Due to all of this stapling and restapling, parts of the chart often go missing, and sometimes we do not even know if the patient has received all of the medication that they need.

Although their charting may still be mostly paper, at least they don't use pagers. Unlike at home, doctors carry cell phones, where they receive texts and calls. This would be so much easier than the 3-4 pagers the resident on call has to carry.

Nemesis: HIV

The amount of human tragedy here in Jo'burg secondary to HIV is astronomical. I cannot even describe the devastation that this disease causes in this country. On the bus today, we (Ashley, Tina, and I -- all American students) were discussing how it is like our heart failure, diabetes, cardiovascular disease, and COPD all rolled into one, except instead of having the average age in 60-70s, these people are usually in their 30s.

HIV (or RVD--retroviral disease) status is treated like a vital sign. During a presentation of a patient's illness, it must be stated whether someone is HIV+, whether they are on ARVs (antiretrovirals), how long they have been diagnosed, and what their CD4 count is (a marker for their level of immunosuppression). My attending told us today that unlike the justice system where you are innocent until proven guilty, in South Africa "you are positive until you can prove that you are negative" in the hospital.

Today, Ashley and I went on general medicine intake rounds (which covers all of the patients who were admitted to the hospital overnight). The intern that we were working with told us that 1 of every 11 people in South Africa has HIV/AIDS (I have personally read numbers as high has 2/10), and that about 90% of the medicine admissions are HIV+. HIV is part of the basic testing that is done whenever a patient enters the hospital.

Although people seem educated regarding the prevalence of HIV, as well as the need to get tested, many people have not been tested, lie about their testing, or are not taking ARVs although they know they are positive. A patient we talked to today who is 4 months pregnant kept stating that she had never been positive, but after some more interrogation by our consultant, we discovered that she had tested positive 1 time, but never returned to have a confirmatory test. My perspective of the reason why people refuse to get tested, to not believe their test results, and why they do not take ARVs may not be completely true, but I have given it much thought:

People do not want to have HIV (obvious, sorry), so they deny it in every method possible. They do not want to acknowledge the fact that they may have hurt their loved one(s). They do not want to accept that they may become very ill themselves. They do not want to be looked down upon by those who surround them. By not taking meds and not getting tested, people are able to deny the fact that they have HIV/AIDS, so they do not have to take responsibility for their condition.

Today, I saw at least 10 patients with HIV. I saw tuberculosis, Non-Hodgkin's Lymphoma, cryptococcal meningitis, a lung abscess, aspiration pneumonia, aplastic anemia, polyarthralgia, and pure red cell aplasia all compounded with HIV. These diseases are so difficult to treat without the added burden of an immune system that is entirely depressed by HIV.

So therefore, I call HIV a frightful nemesis.

Far from home

Things I miss (a lot):
Jeremy
Family
Friends
Mexican food -- including chips and salsa
Having a car -- not waiting for a bus
My own shower
Fitted sheets
A refridgerator
Not being able to go out after dark

Things I will miss when I leave:
Bara
Amazing fruit juices
Awesome weather
Cheap restaurant prices
Napping on the bus
Learning about a new culture

So the facilities aren't the greatest

So today, I was sitting with my registrar talking to a patient that has been quite confused for a few days now. I'm sure that it doesn't help that he is in a large room with approximately 70 patients lined up in beds, but he also has multiple myeloma, so his calcium is so high that it often makes him confused. Anyway, back to the story. My registrar was asking him how he was feeling, and he began to talk about a mouse. She looked at me and said, "oh no, now he is hallucinating." Then, we looked in the direction that he was looking and saw a mouse walking around under a bed across the aisle from him looking very comfortable and unafraid. Yes, mice live in the heating vents in the ward. Not that it would help to kill them because the doors to the wards are always open. Hmm . . . our patient was quite fixated on the mouse for the rest of the conversation, but can you imagine if you saw a mouse in a hospital in the US? I think there would be a lawsuit.

Also, my other registrar, Cathy, went to the bathroom later in the day, shut the door, and the door handle fell off. She had to get the doorknob back together before getting out of the bathroom. she almost had to call one of us to rescue her from the bathroom.

And again, we were walking by the dining hall today and saw a sign for a "waffle sale" (yes, not a bake sale) to help one of the departments in the hospital. After getting a waffle on a napkin that we ate with our hands, I asked Lindy why a department in the hospital would need to have a bake sale. She informed me that they usually like to buy paint and new furniture for their offices because the government doesn't like to pay for those kind of things.

And finally, I sat in an air conditioned room for the first time this week for a lecture and completely froze.

Needless to say, though the people are wonderful, the facilities need a little help.

Cheers.

Education

South Africa's medical education is much different than at home. Most of you all know that we go to college for 4 years, then spend 4 years in medical school, and then do a residency, and some continue to do a fellowship, in our chosen specialty, which can last anywhere from 3-infinity years. Due to tmany reasons, the students go to medical school directly from high school for 6 years, then do 2 years of internship (which encompasses all areas), then have to do 1 year of community service in a high need area, and then go on to be a registrar if they would like to specialize. In order to practice in South Africa, you must do at least 1 year of community service. Some physicians stop after that and can practice as general practitioners. Needless to say our registrars have seen a ton! One of them was telling me stories today of when one of her c-sections went wrong, not fault of hers, and she just happened to be lucky enough to get ahold of someone who could come in to help her complete a hysterectomy. Due to the shortage of physicians in the "bush," these community service doctors are the most qualified available for many miles. It makes the Kansas system of helping to pay off family practioners debts when they practice in the town for several years sound luxurious.

Thursdays are education days in haematology, which are fantastic! We meet with radiologists to discuss our patient's films, as well as with pathologists to discuss their slides. It is amazing to have performed a bone marrow, then be able to actually have someone explain to you what they are looking for on it. I am actually learning incredible amounts just about haem, as well as cultural differences!

Cheers.

Saving Soweto

We are not allowed to take pictures at the hospital, but I have taken a few from http://www.lefthandfilms.co.za/gallery/P16/, which are exactly where I walk around every day at the hospital. I thought you all might like to see what it is like. I only included pictures of places I see daily:

Pitching = showing up

Everyday we arrive at the hospital whenever our bus decides to drop us off. We get to the bus stop at approximately 6:50 am and hope for the best. Sometimes it gets there and leaves before 7:00 am rolls around, others we wait until about 7:20 am. We have officially discovered Africa time, which according to our registrars is very common. The bus could leave early or late, we just have to pitch to the hospital whenever we can. Our "bosses" are so worried about us making the bus in the afternoons, we actually leave about 20 minutes before its scheduled departure to wait for it. Needless to say, we do a lot of waiting every day.

Yesterday I officially saw my first patient on my own. Needless to say it was a little difficult. Not only was she the first person that I have met here that did not speak a word of English, but we could not find a room in the clinic for me to talk with her. After conquering these obstacles, I came to find out that she has had a deep cavitating lesion on her right thigh, which has been getting worse for the past 7 MONTHS! She had just been told to dress it, and eventually someone took a biopsy, which demonstrated lymphoma. She was unconcerned about it due to the fact that it was not painful for quite some time.

Another patient that I saw yesterday had 3 masses, which were visible from across the room, under his chin. He stated that he was unconcerned about the masses because, once again, they were not painful. My attending physician told me that this is extremely common here, especially in those who are uneducated and do not know that even and especially non-painful masses are something to go to the physician for.

So Ashley and I pitched (yes, that means showed up) to a "tut" (aka tutorial) today with the other South African medical students. We often feel significantly stupid in these sessions because everyone here seems to know so much more about physical diagnosis than in the US. At home, when we suspect something, we order the tests to discover what is wrong with the patients. Here, they narrow down the diagnosis much quicker and more efficiently just with their physical exam skills. They often discuss signs and symptoms that we have never heard before. It is amazing how much clinical teaching the students and the residents receive here. Several times a week, if not daily, an attending physician (consultant) takes time to teach a case including all of the physical diagnosis signs, which there are a LOT more abnormal findings here than in the US. It has been an amazing learning experience.

Cheers.

Shame (said in 2 syllables: shay-m) = that stinks

One of the most difficult, frustrating things about Bara is the lack of resources. The doctors are every bit at educated and well read as any doctors at home, but they are very short on the number of sisters (nurses), as well as medications and other medical supplies. The doctors are persistant to get the best possible care for their patients.

Example 1:
We went to see an outlier (patient in another ward, whose primary team is general medicine), and discovered that the sisters were giving the morning medication at 1200. Hmm . . . our patient had not had her "bloods" taken for labs yet, she was dehydrated with her IV fluids stopped, and was throwing up. She had received an oral anti-emetic, but had been unable to keep it down. My registrar and I hung the fluids, mixed the Zofran (IV antinausea medicine), and took the bloods while we were there.

Example 2:
For about 4 days now, we have been trying to get an echocardiogram for one of our patients. The registrar has taken the patient to the cardiology department 3 days in a row, but they have not received the echo.

I have come to discover that persistance, as well as a well-respected attending physician can get you much more in Bara than anything else. For the lack of resources here, the difference from the US is that these patients never worry about where the funds are going to come from to pay for their care. When they need chemo, they receive the top of the line regimens that are proven in the literature. Although I have spoken with several who wished they had taken out medical aid (insurance) prior to becoming ill, they do receive the care they need without worrying about how they are going to pay for it if they get well. The also do not worry about it running out, especially since most of our patients are in the hospital for several weeks to a month. They all are also relatively young, so many of them never anticipated becoming ill in the first place. I know so many people like that in the US.

Miss you!

A lesson in South African history

Today we spent the day going back in the history of Jo'berg and South Africa. It started off with the difficult and challenging aspects of the most recent history, and ended with roller coaster rides celebrating the days when Jo'berg was solely a gold mining town.

After finding the best taxi ever, we (Ashley, Ashley and I) piled in with the KU nursing students and headed for the Apartheid museum. The museum did an amazing job of taking us through the history of how the country developed the Apartheid system, as well as how it was successfully overthrown. We started off with a card, which specified our race as either white or non-white, then we had to enter our respective doors and take the tour separately. It was a very powerful representation of what humans can do to one another in search for more power and money. The men and women who fought against Apartheid were incredible. I hope that I would have their courage in the face of such adversity.

From there, we headed to the amusement park next door, which was themed around the gold mining that developed the entire city of Jo'berg. Not quite as powerful, but definately relaxing and fun.

Back to Bara tomorrow.

Cheers.

Taking the bloods

Cheers from Jo'berg,

Today was full of rest and relaxation at a local mall. There is a bus that takes students from campus to a nice mall on the weekends, so we caught that this am and headed up there for some shopping. After a wonderful English breakfast (complete with eggs, ham/bacon, toast, grilled tomato and the all important COFFEE--I have been not getting my usual daily dose), we went to the African marketplace, as well as the very western shopping mall. The weather was perfect today, so it was a wonderful day to spend outside.

The western shopping mall stands in stark contrast to the place that I have been for the past week. They are actually broadcasting a special on the English Al-Jazeera about the hospital, I found the website at: http://www.lefthandfilms.co.za/soweto/synopsis/. It is incredible that in less than a 30 minute drive, such wealth can be so close to such poverty. This week, we had a patient die almost everyday. The one yesterday was the most difficult thus far. The toll that HIV/AIDS is taking on this country is inconceivable. We worry about chronic illnesses like chronic heart failure, COPD, hypertension, diabetes, and coronary artery diseases, while their patients are trying to survive HIV, tuberculosis, incredibly high numbers of trauma, and so much more.

The patients at Bara are those who have not been able to afford to take out medical aid (much like our health insurance). My registrar (resident) took me to the pharmacy the other day to pick up some of the patients' chemotherapy (yes, the resident has to do that), and we walked into a room of about 200 people sitting and waiting. She told me that the patients often show up in the wee hours of the morning and wait about 8-10 hours to receive their medications. They sometimes cannot afford to feed themselves, but they can receive their medications if they have the time to wait and hope that the pharmacy is not having a shortage.

As you can tell, there are many shortages at Bara. Platelets, medications, and convenience are hard to come by, but caring and knowledgable physicians take care of all of the patients. On the haematology service, our registrars take the bloods on all of the patients and carry them to the lab themselves. Needless to say, this month is going to be an adventure.

On the lighter side, we enjoyed eating somewhere besides our 2 usual places: the cafeteria and Mike's Kitchen (the only restaurant within walking distance: http://www.mikeskitchen.co.za/). Going to go do a bit of site seeing around the city before returning to the hospital on Monday. One of our residents may take us out the next weekend, so that we can see a game reserve and eat at her favorite restaurant. Should be fun!

Attached are some pics I found on the internet, which are very good depictions of what I am seeing.

Barb wire is everywhere! Every house, church, and building is fenced. Almost all public places have their own private security. This is what it looks like on a typical street:

This is our view as we get close to the hospital in Soweto:

How's it?

Hello from South Africa!

The last 5 days have been exciting, exhausting, and totally overwhelming. Due to our limited access to the computer lab, we haven't been able to get online since we were in the states. The experience so far has been nothing short of unbelievable. I am here with two other medical students (both Ashleys), and two of us are together on a haematology (South African spelling) rotation at Chris Hani Baragwanath, which is the largest hospital in the southern hemisphere. It is unlike anything I have ever seen. There are about 100 one story buildings, which are each wards. Between the wards there are covered walkways (maybe, if not dirt trails), where you walk outside. There are about 50 patients in one large open ward in each building, where there is maybe one bathroom, and definately no air conditioning. I have to say that one of the most unusual things that I have seen is when I looked through an open window and saw someone on a ventilator. The facilities are terrible, but the people that work here are extremely knowledgable (definately more so than the US in terms of physical diagnosis on exam) and I am already learning incredible amounts beyond the culture.

We are living in a dorm on part of the university campus, which is fine since we each have our own bedroom. There isn't any air con (as they call it here), but it really isn't necessary since it only gets to about 80 during the day and in the 60s at night. It rains every afternoon, so we sometimes get a little wet between the wards when we are walking around. We haven't really ventured outside of the hospital and our dorm. We ride about 45 minutes on the facility bus each way to get to Bara hospital. It is down in Soweto, which is short for South Western Townships, which is not the best part of town.

The amount of disease here is unreal. I will try not to bore you, since I know most of you are not interested in it, but our patients are approximately 75% HIV + (or RVD+) here. We see tons of AIDS associated conditions, as well as miliary TB. I also get to do many things that I wouldn't be able to do at home. Today, I actually got to perform a bone marrow biopsy! Super pumped about that. Anyway, enough of the boring medical stuff.

Hopefully, I'll get computer access again soon, so I'll fill you all in on details if you are interested.

Miss you all!

Getting ready to go

On Saturday, I will be leaving for South Africa for 6 weeks. I am doing a hematology (or in South African English: hemaetology) rotation at Chris Hani Baragwanth Hospital in Johannesburg for the first 4 weeks, then travelling with Jeremy for the last 2 weeks.

Right now I'm trying to make sure that I am ready. I've had my shots, have prophylaxis for malaria, and am carrying some cipro for just in case. Kind of funny since I will be working in a hospital, but I am trying to be prepared.

I am going to try to keep this blog up for everyone who is interested in what I'm up to.