Failure and Success

Failure:

 

JC is the third or fourth patient I see in clinic today. He sits down, shows me his ultrasounds report, asks me his CD4 count, wants to know what is the next step. I'm caught off guard, because I don't even know what step we're on. And I'm pleasantly surprised. I find his direct questioning a deviation from the usual patient encounters. It shows he is concerned about his health. I glance over his details, I realize his birthday is a year and a day after mine. I can't explain why, but I know I'm going to like him.

 

He's new to our clinic. Yet he has been on antiretroviral treatment for 6 months, which was started at an outside clinic. This is pretty unusual for persons who have been initiated at a clinic to be referred to us; mainly they end up here if they move closer to our clinic, or if there is a problem. And JC is here because there is a problem. Though, I think "problem" is a bit of an understatement.

 

I needed a minute to digest the note from his visit 2 weeks ago. He was seen by one of the attendings/consultants, and there is a detailed note. Something really isn't right. JC was started on treatment with a viral load of 60,000, and a CD4 count of 20. After the usual 8 weeks, his viral load plummeted, but his CD4 never picked up, and in fact, testing 2 weeks ago shows that his viral load is suppressed (less than 25), and his CD4 count is 24. He seems to have immunological failure (his CD4 count hasn't risen), but has a good virological response (his viral load is undetectable).

 

But there is more. Way more. He's lost a significant amount of weight. Actually, he's lost a shit load of weight in the past 6 months. He's gone from 63 Kg (138 lbs) to 49 Kg (108 lbs) in the past 6 months. He has lost 14 kg (or 30 lbs). No cough, no fevers, no sweats. TB would be the main culprit causing the weight loss in him. But his work up for pulmonary TB was negative.

 

When our doc saw him last week, she noted his complaints of stomach pains for the past 6 months, as well as back pains. These have been treated with pain medicines and anti-ulcer treatments, and they haven't gotten better-at all. And then she examined him.

 

I flipped back through his notes from the other clinic. Nobody has listened to this man. For months he has been saying he isn't well, and nobody has listened. For 6 months they watched his weight plummet. For 6 months they gave him antacids. For 6 months they continued to note that his CD4 wasn't picking up like it should.

 

And for 6 months, they didn't notice the mass in his abdomen. Which he has known about. Back in March, it was mobile. But for the past 3 months it has been fixed-- unable to be moved about. The doc last week noticed it. Unfortunately, the abdominal ultrasound shows lots of abnormalities, but didn't mention this mass.

 

I sympathize with this man. Sitting with him, I had flashback to where I was 5 years ago. In the GP office in Ireland, explaining how all of a sudden I couldn't run, how I was winded just trying to go up stairs, and how miserable I felt with a persistent cough. I told him there was something wrong. I was given a script for allupent (which is basically a placebo medicine-technically an expectorant), and sent out the door. It's the exact treatment that JC has been getting. A dose of failing to really care about the patient, and pacification with placebo medicines.  There are so many red flags in his story, that I don't even know where to start explaining things to him, partly because I know the outcome isn't looking too good.

 

We talk, I tell him my frustration that he has been literally wasting away for 6 months and nothing has been done, and that I think it's best that I admit him to the hospital so that he can get a CT scan, a endoscopy, and more work up. I tell him that based on the ultrasound results, it looks like he may well have TB in the abdomen, but that the biggest concern is that he also has a lymphoma or other cancer in the abdomen as well. We negotiate. He'll spend the weekend with his wife and 2 year old child, and then will be admitted on Monday. I give him my mobile number so that he can call if anything changes. Initially I balked at handing out my number in clinic, but I'm realizing that negotiating/manipulating the system here is beyond the capability of many people (as it is in the US as well), and that most will likely be too embarrassed to actually call, but at least they will have the option.

 

 

Success:

 

It's mid-afternoon, and I scan the people sitting in the waiting room for VM. She has been sick since she came to the clinic three weeks ago. I'm relieved she made her appointment today. I call out her name, and watch as she walks toward me, and she smiles. She looks completely different. For a minute, I wonder if it was her I really saw at that initial visit.

 

It was late in the afternoon three weeks ago. She had decided to not start HIV treatment back in November, and then had changed her mind and came to the clinic. And she was ill. Chronic diarrhea. Losing weight. And she was coughing, with sweats. She had horrible thrush, and wasn't able to drink enough to make up for the lost fluid of the diarrhea. She really needed to be admitted. But she declined. (I almost said refused, but that's medico-legal speak, which means if something bad were to happen because she didn't go into the hospital, then it's her own fault, and the clinic/hospital/doctor aren't responsible). But she couldn't go into the hospital. If she did, and were away from her home at night, it would be likely that her home (shack) would be broken into and her stuff stolen. She needed to be home. It was too late in the day to do labs, or get medicines, or get xrays, so she would have to take 3 mini-bus taxis home, and return the next day to do the stuff, and then return the following week for results.

 

When I saw her 2 weeks ago, she looked even worse. And I feared that she wasn't going to make it. Her chest xray confirmed likely pulmonary TB, which would mean she would need to be on TB treatment for 2 weeks before starting her HIV treatment. And so that's what we did. Gave her the pills for TB, and said we'd see her again in 2 weeks to start her HIV treatment.

 

And today, after 2 weeks of TB treatment (as well as treatment for diarrhea) she finally feels a bit better. It was a huge relief to see how well she was feeling. Again, I found myself thinking back 5 years, and retrospectively realizing how lousy I felt when I had TB. Once the TB treatment kicked in, and breathing became less laborious, and I had energy, it was easy to smile. You literally feel like you get your livelihood back. And I completely understood why she was smiling. 

 

Three weeks ago I wondered if she would really have the strength to take the 3 mini-bus taxis back to Bara. Or would she simply resign herself to what she saw as her fate, stay in bed as the TB continued to consume her, as the diarrhea wreaked havoc on her electrolytes, and at some point die at home. She's going to make it. And having the privilege of helping somebody like VM get healthy is the most rewarding aspect of this job.

 

-

Keeping Silent

I sat at the computer this morning to review labs. And I don't know why, but the moment I saw that RD had a blood culture that was growing a gram negative organism, I knew he was dead. I can't explain why or how I knew. I just knew that the minute I saw his culture results. I knew I need not even bother walking to the ward. His bed would be empty.

 

I'm quite pissed about the whole event. And you can bet I am censoring my post. I know where I place the blame. I know to whom I would point my finger. And I know where in the system I point the blame. All I can say is that if you watch the Al Jazeera documentary, you'll get an insight into what goes on when a medical system cannot cope.

 

But of course, I needed to know for sure. So I walked to ward 16, praying that the antibiotics that we desperately recommended yesterday would have been started in time to give him a fighting chance to fight the sepsis that had started DAYS earlier. And as I was about to enter the ward, I met the person I would point a finger at, who informed me that he had died late in the evening. It sucks to be right sometimes.

 

I'm seeing big disparities between medicine and pediatrics. I'm glad we're in clinic for the next 3 days.

 

 

PS: if you're a fan of Abraham Verghese, he has a new book coming out and a book tour as well. Not that I've heard him speak, but I bet it would be an inspiring event.

http://www.abrahamverghese.com/

 

Keeping Silent...

 

 

 

 

 

Real Live Bara

A documentary series has been made about Bara. It has started showing. The old episodes can be found on YouTube.

 

Check out:

 

http://www.lefthandfilms.co.za/soweto/synopsis/

http://english.aljazeera.net/programmes/general/2009/01/200919143440701450.html

 

Also, the series is called "Saving Soweto" and if you google that you'll come up with some other articles.

Will I?

 

         Will I?

 

Will I lose my dignity?

Will someone care?

Will I wake tomorrow from this nightmare?
   -RENT 1996

 

I'm at the gym, and listening to RENT. Which isn't ideal gym music, but I was lacking inspiration as I walked into the gym. I've listened to RENT countless times, I know the lyrics, and yet often when listening to it, what ever message I need to hear at that moment seems to ring louder during that time when I listen. It is a profound musical. And when "Will I?" started, I had to stop doing chest presses, and listen.

 

Will I lose my dignity.

Will someone care.

Will I wake tomorrow from this nightmare.

 

Written in 1996, reflecting the emotions of a group of people who were embattled in the fight against HIV/AIDS, poverty, and social ills, it is about the lives of  Bohemians in New York city. 1996. Now 13 years ago. I remember I went through a phase where I read a lot of AIDS literature. And what was striking about the stories then-was the stigma, and the lack of compassion, and the lack dignity during the decline to death. The decline to death.

 

I'm walking down the back corridor of the waiting room today, and I see a familiar face. I see EM. I am slightly confused as to why she is back in the clinic. I saw her yesterday. In fact, I saw her in the evening. She was the last patient of the day, and came into my room at 5:30 pm. To start antiretroviral treatment. When I grabbed her chart, I had a slight sinking feeling. It was late. I was tired. It had been a hectic day, the now usual story of seeing lots of patients, some well, some sick. But to start somebody on treatment that late in the day was slightly irksome. So I called them from the waiting room, and this smallish woman was pushed in a wheelchair by another woman and we headed to the end of the hallway to my exam room. I glance through her notes, she was diagnosed a few months when she was found to have TB in her lungs. Typically, she has something like 60 CD4 cells probably working overtime to try and keep her from succumbing to pathetic opportunistic infections. We talk about the treatment, and I go into my now familiar spiel about how she'll need to, in all likelihood, be on these medications for the rest of her life. It's a way to help me see if a person understands how important it will be to take these medications.

 

"I just want to live."

 

I don't suspect she's at death's door, she may not even be on the right block, but she has this determination in her that strikes me. Did I mention she is 62. Short. And spry. And she just wants to live. She is 62, but looks years past that. She's passed the first hurdle of this visit, which is to indicate that she understands the importance of the medications, and will be ready to start taking the pills. I flip through her past labs on the computer. There is some mild anemia, which is so mild I barely consider it anemia for this population. Everything else looks good. She tells me she is feeling well, except that she has noticed she gets full really easily when eating. If she were a routine clinic patient, I'd likely do the bare minimum examination-look in her mouth for thrush, listen to her lungs if she had a cough, check for sign of anemia. But since she's about to start treatment, I have a sense of responsibility to at least do a bit more on a baseline examination. I help her get onto the examination table, and when she lies flat, I notice her protuberant abdomen-which was masked as she sat in the wheelchair (which she got at the entrance to the hospital because she was too tired to walk the block to clinic). When I get to examining her abdomen, it's rather distended, is full of fluid, and has some dilated veins. Her legs are also swollen. There's a problem. She almost looks like she should have cirrhosis, but nothing to suggest it by her history, and what labs I do have. Does she have TB hiding in her abdomen? Could it be ovarian cancer? 

 

EM is in clinic with her sister. It's approaching 6pm. Nothing will get done at that hour. No labs. No pharmacy. No xray. Nothing. They have taken a mini-bus taxi to get here, and now I'll have to send them home, only to return tomorrow to get new blood tests done, go to the pharmacy, as well as book an abdominal ultrasound, which won't be done for two, or three, possibly even four weeks. They have been waiting since the morning to be seen. They will have to slowly make their way out of the Bara complex, over the bridge to the mini-bus taxi rank, take a taxi home, and return tomorrow to complete these tasks. Don't forget the costs of the taxis.

 

So I see her in the waiting room today.

"EM-are you ok?" I'm worried that somehow she feels worse today.

"Oh doctor, I am good."

"Why are you in the clinic?"

"I just wanted to see if there was anything else I needed to do."

 

I ask about the labs, pharmacy, and ultrasound. Check, check, check. Done.

"Nope, you've done all the things you needed to do."

 

I review, again, how she'll start her medications tomorrow. I remind her to start taking her bactrim prophylaxis today-almost out of anxiety on my part hoping that ward off any infection before her immune system recovers.

 

And she reminds me, "I just want to live."

 

I see a very pleasant 30 year old woman today who has been on treatment for 215 weeks. A long time. She is on the starting regimen. There are only 2 regimens. I glance briefly at her last few notes. They have been uncomplicated visits. She is a pro. She does well with her treatment. It'll be a routine visit. I go through the standard questions. I ask how she is feeling, if there are any new problems. I consider not even asking if she has missed any pills, I mean, she's been taking these pills for longer than I have been a doctor, and her CD4 and viral load are where they should be. But I ask.

 

"Doctor, I don't always take my efavirenz at night."

 

And admittedly, this catches me a bit off guard. People who have compliance/adherence issues, or who have defaulted treatment in the past carries these labels with them on their charts, and I glance again at her last note to review compliance. This woman is bright, and articulate, and has volunteered this openly and honestly. It turns out, this isn't new, and in fact she has been skipping efavirenz doses at night for more than a year now. I wonder why it is, that this is the moment she has chosen to disclose, not that I ask, because I want to encourage her to feel she can disclose these things in the clinic. It turns out she can no longer tolerate the nightmares she has from taking the efavirenz. This is a known side effect of the medication. She has reached a point where she knows that not taking it regularly is going to have consequences for developing resistance. I ask a little to clarify, if these are dreams, or nightmares. It's purely out of my own curiosity. Some antimalarials give dreams, as I experienced in Zimbabwe, and I loved the 6 months of vivid, colorful dreams I had when I was on treatment for TB. But had they been nightmares, I likely wouldn't have been as keen to keep taking the pills for 6 months. And she's been taking them for years. Perhaps she has been worried about how we, the clinic, would react to this disclosure, and that is why she has kept this to herself. Her options are tough... But we come up with possible plans to deal with this issue, and she'll come back to us with her choice...

 

Clinic finishes at a decent time today-and I have 3 consults to do, and I also want to check up on the other patients I'm seeing on the wards. I decided to pop in and see the guy with infective endocarditis, who is doing great and should be heading out of the hospital soon. As I walk down the ward, I look at the patients lying in bed. I look at the faces. Confused men, lying naked in bed. A man trying to get a cup to his lips, struggling, and spilling water over him. I head to see my patient. After 3 plus weeks, he's bored, we chat for a bit. I write a brief note in his chart. When I look up, I recognize the guy in the bed next to him. It's the guy I admitted this morning.

 

"Doctor" is the patient's first name. Not an all too uncommon name. He showed up at 8am this morning, I handed him his admission papers, and sent him to get an xray and then head over to the admission ward. I checked a few hours later to see if there were any labs on the computer, as a surrogate measure of if he had maybe been seen yet. No results. I hoped that he wouldn't sit for hours waiting to bed admitted. And here he was. He smiled, and we talked a bit. I looked over the admissions orders that the registrar had written. Doctor had a biopsy of an abdominal mass weeks ago, was told he had non-Hodgkin's lymphoma, and needed to follow up with the hematologists. When I saw him yesterday, I wasn't even sure if he knew he had cancer. I imagined the conversation when he got his results went something like this.

 

"Well, your biopsy results show you have non-Hodgkin's lymphoma, we'll send you to the hematologists good luck and take care."

 

Yesterday, after weeks, he hadn't been to the hematologists, and the work up that should have been started wasn't anywhere close to being done, or even started. Doctor is about my age. But looks at least 10 years older, though I have more grey hair. The striking thing is how wasted his face is. You can literally imagine what his skull bones look like, because he basically has a thin shell of skin covering them. He was in the office yesterday, with his girlfriend, and their infant (maybe 6 or 7 months old). You can see the fear in this guy's eyes. He has no immune system. He has cancer. He knows this. Yet, like EM, you can see he desperately wants to live.

 

Will I lose my dignity?

Will someone care?

Will I wake tomorrow from this nightmare?

 

As I'm lost in a moment of vanity at the gym, I hear these lyrics, and these are the faces and stories that immediately came to mind. Dignity. Care. Nightmare (both literal and figurative). How is it that lyrics written about this damn disease 13 years ago in America still perfectly capture what is going on today in other parts of the world.

 

-

Inauguration and ID

I went to an inauguration party last night. Must have been close to 75 people there. A mini UN of people. And it was wonderful. You could feel the excitement that the world shares in this change of leadership of the country. Seeing non-Americans get sentimental at the swearing of President Obama was very moving.

 

As for ID-

Whoa. Man these Wednesday clinic are killer. Non-stop from 8am to 6:30pm. I'm quite frankly exhausted. There are things I want to say, but honestly it's so late that I think about all I can do is pop into the gym, have dinner, read up on one topic briefly, and then crash.  I've never seen people so ill. Today I could have admitted 3 patients, but instead will admit one tomorrow (so he could take his wife and infant home, get his HIV medications from home, and will return tomorrow to be admitted for the rest of his lymphoma work up), and am going to try and work up the other as outpatients. What I do kind of enjoy, is that I'm also working up pretty significant hypertension in a young woman, as well as abdominal swellings in 53 year old woman whom I started on HIV treatment today. I also tried to convince a 66 year old man with schizophrenia (well controlled on meds, you'd never know he had schizophrenia if you met him on the street) to start treatment, especially since his CD4 count is hovering at 41. He's thinking about it for a week or so.

 

I find myself telling people to hang in there, that they are going to get stronger and feel better. And every time I say this, I have flashback to KR (the child who died after telling his family he would get better), I scold myself to not say these things again. And because, quite frankly, I don't know if they will get stronger or feel better. That's what I certainly hope will happen, but those who are already emaciated, have no immune system, and barely have faith themselves, are already behind the 8-ball...

 

That's it. For now.

 

 

Parallels

I walk into the clinic at 7:45 this morning. The waiting room is full. It is already warm in the room as well. And muggy. I know that within a few hours it will be hot in this room, yet the people will continue waiting until they are seen. I left at 6pm Wednesday night. There were 250 patients registered to be seen. There were 5 of us working all day, with one or two others popping in when they could, to help out. When I left yesterday, I went home, walked down the street to have a beer and dinner, and had to just sit and watch the sunset to let my mind unwind.

 

But it is a new day, and I'm ready. I've set a goal to be more efficient today. I call the first patient to be seen. Mr. AN.

 

A man stands up. He looks no different than many in the room. Aged. He looks fifty plus, but looking at his date of birth, I see he is actually 40. We walk to the end of the corridor, and enter my exam room. I glance over his details.

 

Week # 48 of ARV (anti-retrovirals, aka HIV treatment). Doing well. His viral load was not detected 3 months ago, and his CD4 count is around 300. No other real medical issues that will have to be dealt with. I look over his clinic note from 3 months ago, and he's compliant with meds (as expected given his undetectable viral load, and decent CD4 count). I breathe a mini sigh of relief, first patient of the day will be out of my office in 5 minutes. I go through the standard questions. Have you been hospitalized? Have you been started on TB treatment? Have you missed any of your medicines? No, No, No. Is anything wrong? No. Perfect.

 

I look at his vital signs. No Problem.

I look at his weight. Problem.

 

We're using a simple bathroom scale, the kind that you may buy at Target, or any store. It's not all that accurate. But AN's weight is down 5 Kgs since his last visit. About 11 pounds. Where is the problem??

 

I worry about hyperlactateaemia. A complication of HIV treatment. Asymptomatic elevation of blood lactate levels. The only sign may be weight loss. Possibly some abdominal pain as well. He is feeling fine though. I can only really rule this out by doing a blood lactate level. I tick the box on the lab form.

 

I worry about TB. He doesn't have a cough, or fever, or night sweats. He had TB in the past, but that was years ago, and he's far out of the risk of IRIS. And he has a decent CD4. He shouldn't have TB. A chest xray would likely be pointless (but I'll get one anyway), and no chance of getting sputum because he isn't coughing.

 

I worry that maybe he's too embarrassed to admit to having chronic diarrhea. So I reword my questioning, but he's consistent. "Doctor, the caca is fine."

 

I worry that his liver has taken a hit from the HIV medications. But he tells me he has a good appetite. He's already denied abdominal pain. He hasn't been jaundiced.

 

I wonder if he has hyperthyroidism. But his heart rate is normal, and no other real stigmata of thyroid disease.

 

There is a problem. He has lost a significant amount of weight, and I can't forgo finding out why. I'll throw out some target screening labs, in addition to the lactate, I'll check his thyroid, his liver, his blood count as well as his renal function. Maybe he needs an ultrasound of his abdomen too?

 

We talk about these possibilities. I write up his note, and his lab forms, and his xray form.

 

"Doctor, I take my pills on an empty stomach."

"Well, that's fine," I say, "but luckily the pills you are taking can be taken on an empty stomach, or with food."

 

I go back to writing. As I'm writing, he grabs some papers out of his bag, and I recognize the familiar disability grant paperwork. And the light bulb goes off. I've made such a gross assumption, that I'm quite embarrassed

 

"Is there a reason you take your pills on an empty stomach?"

"Doctor, I'm not working, I don't have food."

 

Is it possible that the reason he's lost weight is because he doesn't have food. Is the simplest explanation the most likely?

 

I take the disability paperwork. All of a sudden I have a flashback to the resident clinic back home, and the sinking feeling of getting those fat envelopes in the mailbox when somebody wants disability, when in fact, there is no disability, but rather poverty and poor social circumstances. Today, I filled out 5 disability forms. For 5 people who all are unemployed, some supporting 3 kids, but none of them qualifying for disability. I didn't know what to do in these circumstances, so I filled out the forms, and told the patients that they wouldn't qualify. Perhaps I (grudgingly) filled out the forms to make me feel better, but knowing that they were only going to waste time and effort for these patients, as well as "the system."

 

After clinic, talked to the clinic attending, Dr K, and asked about what to do in these situations, when somebody wants disability, but won't quality... We talked about the breakdown in "the system" and what to do...

 

I see AN in 2 weeks.

 

Cholera (aka: The world is f*cked up)

We had our grand round today-both the infectious disease team and the microbiology staff. We went to see a patient, who may well be the first cholera case at Bara, related to the outbreak in Zimbabwe. There have been plenty of cases up in the northern region of South Africa-the Limpopo area which borders Zimbabwe. And there have been a smattering of cases at Jo'burg hospitals (JHB General and HJH), but none at Bara. Which seems a bit unusual... But the cases at the Gen and HJH have been patients who were seen in the MSF (Doctors w/o Borders) clinic in the heart of Jo'burg, and they refer patients to the Gen.

 

So, it was a great bedside (well, not at the bedside, since the voluminous diarrhea makes it somewhat distracting to talk at the bedside) tutorial on Cholera. In addition to all the stuff that would bore most people (pathogenesis, treatments etc) we also looked at the Zim statistics.

 

Consider this:

-only 10% of people with Cholera are symptomatic. There are a reported 30,000 cases of cholera. Which means that that the actual number of cases, based on the reported 30,000 is therefore 300,000 cases. Take into consideration that Zim is falling apart, that there is poor disease reporting, and that people are likely not accessing health care, and the figure of 30,000 reported cases is likely a GROSS under-reporting.

-that the expected death rate of cholera is 1%. It doesn't take any special, drastic measures to treat. Simply rehydration alone, and antibiotics for those severely ill. But, the overall death rate in Zim right now is 5%. BUT the death rate in the community (i.e., those not in treatment centers) is estimated to be 55%, of those who have been diagnosed.

 

I say that this is "aka the world is f*cked up," because there is plenty of bad news in the media these days. (Though I have to admit that I spend less time on my favorite news sources-the BBC and NY Times, and simply look at major headlines to see what new f*cked up problems there are). The Economy. That guy who stole all the money. Gaza. Iraq. Pakistan. Iran. The US. Unemployment. Somali Pirates. Jacob Zuma. The Denver Broncos.

 

But this is f*cked up:

"healthcare" in Zimbabwe-as per BBC

Cholera: 2,204 died since August

Anthrax: Eight deaths since November

HIV/Aids: Estimated 400 deaths a day

TB: Brain-drain has practically closed the national testing laboratory which now has only one staff member

Maternal mortality: Risen from 168 per 100,000 in 1990 to 1,100 in 2005

 

(Please read the full article at http://news.bbc.co.uk/2/hi/africa/7826304.stm and also check out http://physiciansforhumanrights.org ).

 

So, our one patient with probable cholera will have an uneventful course at Bara. He'll get his hydration, and antibiotics, and he'll head home in a few days. But had he been in Zimbabwe, there's a good chance he could have been #2,205...

Ward 15, Bed 14

I got to work an hour early today. I knew it would take me some extra time to get use to the system, the system of actually finding patients. I'm not too sure how many medical wards there really are, but there are quite a few, and they are scattered about.

 

I think there are about 10 general medicine wards, each holding 65 patients. As best as I understand it, each general medicine team has 2 wards, a male and a female ward. Teams are on call every 5 days, and take all the admissions for 24 hours. The day of call, some patients from that team will be sent to wards with free beds to make space for the admissions. And then when the new admits have filled all the beds on the ward, the overflow admissions will go to other wards.

 

The average number of admissions seems to be well above 100 -ONE-HUNDRED, and probably closer to 130+

 

So, I admitted 3 patients last week. One on Thursday, and two on Friday. And it was my goal to locate them all by 8:30 am, and to have hopefully rounded on at least one, or two of them before meeting the consultant at 8:30. I started with what I thought would be the easy way of finding the patients. I looked in the lab results of the computer, hoping that they had labs done over the weekend, and that the lab results would say which doctor (in which ward) had ordered the recent labs. And, so I randomly picked a medical ward to go use the computer. (I had to fight the urge to go back to the pedi admission ward, or even ward 18 to use the computer). As luck would have it, I ran into a resident there who I knew from my time in pediatrics. (She doing her mandatory community service at Bara). And she was kind enough to inform me that the computer in her ward didn't work. So I did the next logical thing, or so I thought, I headed to the next ward, and searched for the computer. Same story, not working. But, while I was there, I skimmed the book to see if the patient was on the ward.

 

The bloody books. The manual record of who is on the ward, or who has been transferred to another ward. The is no computer system to indicate where patients move, but rather one relies on multiple log books of patients. And no success in that ward. So I moved on to a third ward, as I looked at my watch and realized that it would be less likely to see 2 patients before 8:30. Strike 3.

 

Somewhat getting desperate, I decided I would head to pedi land and use the computer there. And as I was walking to pedi, I passed the same resident from earlier, who told me to pop into the medical admission ward and use the computers there. Which I did.

 

Patient #1- no labs since admission. Not helpful.

Patient #2 and #3-no ward indicated on the lab computer.

 

Shit. Now I don't know where they are. But at least I have some lab results.

 

I run into the resident again, and try to figure out how to find these patients. And it's simple. Knowing what day they were admitted, means they were allocated to either the male or the female ward of that team that was on call that day, and then all I need to do is head down there and look in the books to see where they are. And here I've spent the better part of half an hour to learn this.

 

I head to the male ward (16), to see Patient #3. I saw him in the clinic on Wednesday. Nice guy, 52 y/o male. On HIV treatment for 3 months now, and on TB treatment for 2 months. But he's lost 7Kgs (about 15 pounds) in a month, has a horrible cough, and just has that unwell appearance which made me think that something bad is going on, or something is being missed. So, since I saw him late on Wednesday, and they were done drawing bloods in the clinic, I send him out with a lab form and instructions to come find me in the clinic the following day to review his results. To make a long story short, his results were all out of whack, new kidney failure, worsening liver function tests, and he didn't come find me on Thursday. So I called him back and saw him on Friday and admitted him to the hospital. Since his admission, there really hadn't been much progress in his work-up. I find him in the ward, don't really have time to write a note on him, since I haven't even found the other 2 patients yet, but we chat briefly, and I glance through his notes. It'll be nice to come back and see him later and leave better instructions about which tests I'd like done. He likely has either MAC, or MDR-TB, or Non-Hodgkin's Lymphoma, plus his renal and liver issues.

 

Patient #2 was admitted the same day as patient #3-so she must be in the female ward (15) of the team that was on call on Friday.

 

So, on Friday, as I was writing the admission letter for #3, there is a knock at the door, and the sister opens the door.

 

"Doctor, the next patient is sick, can you see her?"

Of course I think "no" let her see a consultant. But I'm here to learn... "Sure, let her stand outside the door while I finish writing this note."

 

I send off patient #3, and then patient #2 is wheeled into the room by her aunt and uncle. And she looks like crap. She will have to be admitted. Turns out she's 26, was seen in the HIV clinic back in October, but then never came back for any visits. And today is brought it to our clinic by her aunt and uncle who are worried about her, rightfully so. Her CD4 count is 60. She has a weeks worth of a horrible headache, as well as she can't swallow anymore because of the pain. She also has Kaposi lesions all over the face and her arms. She's unwell. She's going to need a lumbar puncture (spinal tap), lots of labs, and empiric treatment for a bunch of stuff. I check her vitals (I know-it's a universal... I don't even ask ancillary staff anymore to check vitals.. I just do them myself). Heart rate of 160, BP of 82/54, RR of at least 30. (Ok I didn't formally count the RR, it was at least 30, and I didn't want to know if it was 40, or 50). So I ask the consultant to see her when I'm done with my note, and he agrees, book her for admission.

 

I'm walking into the ward, and I look over her results. Her lumbar puncture is actually bland. Will have to see what grows out on the cultures. I hope they've started her on antibiotics. Her other labs show bad acidosis on admission, which improved a bit as of yesterday. There are blood and urine cultures pending. I'm thinking what my plan will be for her. She's unwell, and needs to get on HIV treatment, fast. But she may need TB treatment for 2 weeks first...

 

I look in the book, and she's in bed 14. So I walk down the ward. Curtains are closed at pts are getting bathed. And I peek behind curtain 14, and the sheet is pulled up over her head. For a minute I wonder if she's been having chills with fever, but then I realize that it's also tucked in around her body, and she's not really moving.

 

She's dead. Too little. Too late.

 

 

home

I am home.

 

Yesterday when I woke up at S&S's place, I was longing for home. Don't get me wrong, it was a great week staying with them, I just longed for home. I was, albeit, slightly confused about where home was. I was certainly eager to get back into my own space, in the Mondeor house, but also had a bit of longing for home. But which home?

 

My definition of home is changing. When I was travelling last month, and people asked where I was from, or where home was, I went into the lengthy explanation. I had to make it clear that I grew up in Colorado (which arguable is the best place in the world to grow up), but that I currently live in Johannesburg, and that I'd be returning to Massachusetts in July. And often times somehow it would come up that I'd lived in Dublin as well.

 

For a while, I defined Home as where my dog lives. Not that she's really "my" dog anymore. After 9 neglectful years of not paying alimony for her care, I'm pretty sure I've lost the right to call her my dog. (I am a deadbeat dad). And then I had this complicated definition of where home was. I'd thought that Colorado was really Home. But Dublin had been a home, just like Massachusetts had been a home. But Colorado remained Home, with the big "H."

 

But waking up yesterday, and longing for home, I wasn't sure where that was. Or rather, felt an equal pull to Colorado, Massachusetts, and even a pull to Dublin. I wasn't able to exactly figure out what I was missing. With the ability to access internet anywhere in the world, I've been able to keep in touch with people easily via email (and facebook); and skype has made it possible to have regular phone conversations with people-a true luxury. I found myself longing for random things yesterday. Seeing the Rocky Mountains. Seeing how big my nieces and nephews and godchildren are getting. Going out to dinner with the work crowd after a busy week in the hospital. Sitting with J&A having way too much coffee, having breakfast, and letting their daughter entertain us. Having a study afternoon with GK at Barnes and Noble. Meeting up randomly at Metro Café, or a drink at The Front Lounge. Ironically, I'm sure that 12 months from now I'll be able to add waking up at S&S's house after a night out having a late dinner (and lots of wine) and then heading out to breakfast at Espresso and watching the crowd.

 

I loaded up the Bakkie with all my worldly possessions in Jo'burg, and drove down to Mondeor. As I pulled down the driveway, I realized I was home. I was excited to be back in this house. I am excited to be back here in Mondeor.

 

As I unpacked yesterday, I realized that I'm fortunate enough to have many places which I could call home, but for the next 5 and a half months, this is Home.

 

200

Wow. Flooded is the proper term. Waiting rooms overflowing, people sitting out on the lawn outside.
 
230 patients in clinic yesterday.
210 patients in clinic today.
 
There are many things I want to jot down, but am a bit short of time right now. And I'm also very sweaty and smelly, and we're going out to dinner soon, so I neet to make myself presentable. I'm sweaty and smelly, by the way, because there is no air conditioning, and when that many people are waiting in a building to be seen, the place gets hot.
 
I'm going to skip patient stories for now, because they are party composed in my brain, and I'd rather save them for later..
 
The clinic, has been incredible. Absolutely incredible. Seeing simple clinic visits which can be done in 10-15 minutes, to seeing sick, sick people. Admitted 1 person with an acute-ish abdomen today, but also saw a sick guy yesterday (who I should have just admitted for his work up) but instead did labs on him, and he failed to show up for results today, and based on his labs alone needs to be admitted to work up his multiple abnormalities.. That's on tomorrow's TO DO list, somehow find the sick guy who didn't show up today and get his *ss in the hospital.
 
I saw my last patient at 5:30 tonight. She arrived at the hospital at about 9 this morning, waited in a queue for a long time to register, and then waited in our clinic for a long time. When it looked like patients weren't going to be seen in time to go get their HIV medicines filled from the HIV pharmacy, they were sent from the clinic with new scripts (and likely waited in line there for well over an hour, maybe 2-3 hours when it was at it's busiest-as there is also pedi HIV clinic so those kids are going for meds today as well) and then back to wait to be seen. But, there were no complaints. Patients were kind and thankful. These docs work incredibly hard, and they just keep picking up charts and seeing patients. It's very rewarding.
 
As for life...
Sadly will be leaving S&S and moving back into my old place on Saturday. Will be nice to be close to work again, but has been great to stay with them.
 
Cheers!

BPB

Back to Adult Land, and more..

It's nice to be back in the land of adult medicine. I feel like part of the team this month. In fact, last friday the clinic director specifically mentioned if I had any ideas on changes that may help their clinic, to please let him know. And then rounding today, when we were at the bedside of the guy with infective endocarditis, (and we were rounding with the microbiologists as well the other ID attendings/consultants) it turns out that just two of them have seen right sided endocarditis from IV drug use before. Now, a couple things to mention. The were still able to quote the current treatment guidelines, discuss the common pathogens, etc etc etc. I point this out because I find it impressive that these guys have seen a case in the past, long ago, but still know current treatment stuff. And secondly, it was odd because I've seen more of this than them. I was slightly jittery when they turned towards me. I had flashbacks to pedi land and was getting ready to brace myself for defending US practices... but rather it was such a pleasant adult conversation about what we do back home in these situations. There were also soooo interested in heroin use, methadone, and these patients back home. They just don't see these patients here. Kind of a cool experience.
 
I like my ID attending. I think we share a similar practical philosophy. Case in point. We were reviewing bacterial meningitis treatment and outcomes in journal club this afternoon. The attending pulled the articles on the use of steroids in treating bacterial meningitis, and outcomes. The mortality rate at Bara is about 55%. I just throw that out as an aside. So we're reviewing all data, which is somewhat mixed, and tough to interpret. You have to factor in HIV/AIDS. Delayed diagnosis and treatment. Etc etc etc. And whereas the literature may be indicating that the use of steroids does not reduce morbidity/mortality (and there are no harmful effects) my attending says:

". . .when you know that more than half the people are going to die it's tough to follow the advice of these articles and hold off on the steroids, I'l still give them. . ."

Ahhhh. Yes. Thank you. If I have bacterial meningitis (heaven forbid) I'll take the steroids too! We're on the same wave-length. He's a practical clinician.
 
And typhoid: There is a 14 y/o boy on the adult ward (which is what happens here), how has ben diagnosed w/ typhoid. Which isn't all that common. Was absolutely superb to be at the bedside and hear the ID and Micro attendings give a lecture, at the bedside, about typhoid. It was just superb teaching. And kind of a lucky event since they don't see that much typhoid..
 
Other stuff of note: One of our attending was the on-call attending yesterday, and did post-call rounds with his ward today. They admitted 135 (ONE HUNDRED AND THIRTY) patients yesterday. Their ward holds 130. It's not worth explaining the logistics. Interns are covering 35 patients.
 
That's it for now. I'm off to read about Typhoid.
Cheers



 

ID Rounds

Keeping this brief (still a bit under the weather-which is perfect for being on the infectious disease rotation)..
 
I roudned w/ another reg today. We say 20ish patients before meeting w/ the consultan, and then re-rounded on the patients.
 
TB.
HIV/AIDS.
MAC.
HIV/AIDS.
TB.
HIV/AIDS.
HIV/AIDS.
Possible cholera.
MAC.
IV herion user with right sided endocarditits.
 
Well of couse all the patients were interesting, but the team was most fascinated with that last one... Here is something they don't see. Infective endocarditits (infection of the valves of the heart) from shooting heroin. In fact, the consultant couldn't really remember the last time he'd seen a case, and the other reg had never seen a case. So it was nice to have a little basis to discuss, and discuss what we did for treatment back in MA.
 
CD4 counts today:
16, 43, 92, 23, 197...
 
More soon.

BPB

Shifting Gears

I asked one silly question today (in the adult ID/HIV clinic), just to prove that I've been in pediatrics for the past 6 months...
 
"Do we give them written appointment cards?"
 
I'm so use to the hand-holding of pediatrics... Do everything to ensure that the parent's fully understand treatment plans, and when the next appointments is, checking if they'll be able to afford to make it to the clinic/hospital etc etc etc.. So the prof looked at me with a small smile.
 
"Nope, their responsibility to keep their appointments."
 
It was a "light" day in clinic today. Jo'burg is still in holiday mode, and the streets are empty of traffic, and most people have been away from work since mid-december, to return sometime between the 5th, and 15th. A light day... we still saw 100 patients today in the clinic. A light day. I didn't ask what a busy day was going to be like.. but I peeked at the patient list from the 30th, and they saw 160 patients that day. Wow, it's going to be busy. And it's going to be a great month..
 
Aside from work, have been fighting off germs that I nicely acquired on my last day in Kathmandu. Am on the mend. Am staying with S&S, and then headed back to my old house a week from tomorrow.
 
Will hopefully have pics up from Nepal over the weekend-need to get somewhere with wifi to upload form my computer. I took about 1140 pics, but have managed to get that number down to 1000. Don't worry,  they are not all going up, but you can rest assured that when I see you next I will make you see all 1000!
 
Hope your 2009 is off to a great start.


BPB

Nepal: Cleaning Up

I have some time to kill until a friend arrives from Pokhara...
 
With the lack of hot water (due to no electricity, mostly), I've become quite comfortable not showering every day. I've tossed aside western standards of cleanliness, and don't mind not showering daily, and when active (trekking or bike trip) if I smell, I smell. And since I'm not working, the dirt under my nails doesn't really bother me either.
 
But for some reason, the unruly hair around the back of my neck was just nagging me. The downfall of having closely shaved hair. [Oh, I shaved my head again in November, which is perfect for traveling]. You can't really shave back there, not without taking a chance and really making a really bad mistake and an erratic mess of a good hair line.
 
So, after lunch I decided to go get my neck shaved. I figured it would take all of 5 minutes and maybe 100 or 200 rupees... My only hesitation was making sure the blade would be soaking in some cleaning solution... flashbacks to the hepatitis C outbreak among uncleaned razors years ago.
 
So I popped into a HOLE in the WALL place, for a neck shave. Oh, and just to clarify, it is POURING rain outside. And I've been told all month that it never rains in Nepal in December. So if you think it sounds like an assinine waste of vacation time to get a neck shave, there really isn't much else to do beside drink coffee/tea, read, do email, and get a neck shave.
 
With bits of gesturing I think I get the point across that I need my neck shaved. So I sit down, and out come the clippers. And while I wouldn't mind a bit taken off the everywhere, I don't want to hassle with that now, I can do that in a week when I am back home in Jo'burg.
 
So he puts away the clippers, and moistens the hair around my neck and ears. Perfect, I think. I'll back to the coffee shop in 10 minutes, reading, and waiting for Dilip.
 
But I leave an hour and a half later.
 
Wow.
 
So, after a meticulous neck shave (with a new blade on an old style shaver), I got a scalp/head massage. Wow. And I factor in a few more rupees for the bill. And then the power goes out, and a candle is lit. And as the power went out, the rain went from a drizzle to buckets. And I'm dreading heading out in the rain. And I'm really enjoying the scalp massage, and I wonder if I have time to get a real massage (and more rupees flash before my eyes). As I think this, I'm now getting a neck massage, and then find myself leaning over the counter as I get a shoulder and back massage. And the paranoia in me wonders if this guy can read my thoughts (which would be embarrassing, because I'm thinking I wished this massage was coming from somebody younger and cuter). But I digress.
 
Wow. More rupees flash before my eyes.
 
It is still pissing rain. 
 
And now I get a facial-massage. This is a bit different, but I'm seriously taking this all in, and can't believe all I thought I would get in this TINY barber shop is a neck shave. Since the moment I arrived (and we made small talk about my trip to nepal and trek etc) he asks if I want my face shaved. Might as well. Though I am afraid, slightly, that he'll shave off the mole on my face and I'll bleed to death here. And of course I freak out forgetting that this guy can read my mind. I go to my buddhist mantra which I've been using since I learned it a month ago. He can read that all he wants.
 
My face is as smooth as a baby's ass after the shave. I notice he grabs another bottle. And then he paint (literally paints) something on my face, and he shows me and all I recognize is the word sandalwood. I'm cool with that.  But I don't know what it is. And I'm unsure if this is some kind of thick aftershave. But he hasn't undraped me, which I know is a universal sign that the business of salon stuff is over.
 
But now he is cleaning up. And don't forget, there is only a candle lighting the place. So I sit. What the hell, it is STILL raining out.
 
And that's when I realize I am getting a FACIAL. Whoa! [Bonus points for 'the card']. And now I'm really hoping that I get a manicure as well. The face mask dries, which is a bit of a weird feeling as well. I could get use to this, maybe wake up on saturdays, have porridge, apply face mask, read the paper, then shower?
 
The face mask is cleaned off. And I get aftershave on the lower portion of my face, and face cream on the upper portion.
 
And I'm sooo confused. How is it that I have thoroughly enjoyed this long pampering process (and now seem to have radiant skin), but also thoroughly enjoyed being smelly after a day of trekking, or getting to my hotel last night with mud covering various bits after the 40 mile bike ride back to Kathmandu???
 
I suspect, that in a nice salon, that would have been fifty dollars, maybe more...
 
 

Nepal

I find myself:

-kneeling in front of the Tibetan monk, who gives me a blessing "om mani padne hum" (which roughly implies long life and good luck), while he drapes a special cloth around my neck. He adds in a blessing for good health, every day. It's the every day part which I find touching, and secretly hope that it means I'll have healthy knees.. We finish our conversation about life, politics, and then head out. I still have the cloth.

-In the main part of Pokhara, asking my Nepali friend Dilip to please take me away from the tourist trap of Pokhara. We're eating dinner at a local place. I suspect I'm the only westerner that has been here in a long, long time. But am treated with great service, and a great meal. Dilip kindly leads me. We've ordered a variation of Daal Baat (the normal Nepali rice/lentil/curry meal) and are having Dhido, which is a soft polenta-like mash which is dipped in sauces. I know I'm off the tourist path when I don't automatically get offered silverware. So, I eat with my hands. Which is oddly gratifying. And I'm thinking back to the meal LR and I had at a superb Ethiopian restaurant in NY back in the spring, and thinking that silverware is slightly over-rated.

-Having breakfast with Dilip, watching Pokhara wake up. Shop keepers sweeping the stoops of their doorway. It seems odd that more shops aren't opening. We watch a mob trying to attack a taxi driver, as about 20 police officers show up to recue the taxi driver. It will be the last taxi we see that day... We're planning to head a bit out of town to the Tibetan Refugee center, I want to meet these people. We're also planning on seeing a bit more of the real city. But there are no busses. It's oddly quiet. It takes half an hour to figure out what's going on, and as it turns out, there is a one day strike, called by the students, in protest of something??? We spend the day walking up and down, up and down, up and down, the main tourist road. Having tea. Having coffee. Me trying to learn a bit of Nepalese. Learning about growing up here. Difficulties of daily living. We run into 4 or 5 people I met while trekking. We have dinner with a Danish friend I met, and her guide and her guide's wife and child.

-On the bus. Which is typical of what you expect if you think of the stereotype of what you've heard about if you think of buses in India. Except there are no chickens. I could write a whole blog entry alone on the bus. I marveled at the insanity of how the bus was packed with people, mixed with slight waves of anxiety thinking that if the bus crashed, it would be damn near impossible to get out easily. (and buses crash regularly). The bus ride is 17 hours, overnight to Bardia National Park.

-On a stopped bus, at 10pm. On the middle of the major east-west highway. I don't know why we stopped. I kind of don't mind, since it's likely more safe to be stopped at night. A fight breaks out on the bus (while we sit idle) at about 1am. I wonder why we're still stopped. The older women pray. But most people don't seem to care. The police show up. It's dark outside, and I can't see much. It's 8am, we're still not moving. I get out of the bus and se buses lined up and down the road. Seems odd, so finally I enquire. An unannounced strike has been called. the 17 hour bus ride has now been delayed 10 hours. We leave an hour later.

-On a Jungle Safari with Santa. I kid you not. Christmas is the furthest thing from my mind, given that I'm in a hindu/buddhist country, no signs of xmas, and no snow. It could be July for all I know. but meeting my guide, and learning his name is Santa (I asked twice) makes me realize that is is towards the end of December, and xmas is getting close. The Jungle is wet this am from all the dew. I get soaked. It's great fun, just me and Santa, tracking a rhino. I'm informed: If a rhino charges, climb a tree, if an elephant charges, run in a zig-zag. Santa doesn't mention what to do if bengal tiger charges. I'm putting all my faith that Santa will be able to beat the tiger with his walking stick. He has no gun. I think back to having been blessed recently for long life, and good luck. That must count for something. We do end up finding a rhino and an elephant. The tiger remains elusive.

-Riding an elephant through the jungle. Crashing through the underbrush. On the elephant as it pushes over trees in the way. That's impressive.

-On a raft trip. Ok, more like a float trip. But we are on a raft. It's fucking cold. cold cold cold.

-Sitting at dinner, drinking beer with Santa, and the other guides in the lodge. I'm hearing stories of what it was like when the Maoists troubles were going on. Bomb attacks. Constant harassment by the police, the army, the Maoists. Not knowing if the lodge would be bombed. Bad times. I read in the paper that 170 people are still missing from the area, all suspected to be dead, but nobody telling where the bodies are located.

-At the "Exact Spot" where Gautama Siddharta Buddha was born. Before he became enlightened and started buddhism. Being the skeptic, I look for signs of this. Maybe some amniotic fluid splash marks? Maybe the placenta? I was annoyed so I didn't pay the dollar equivalent to take photos there, and not it seems stupid to have balked over a dollar. Lumbini is the birthplace of Buddha. And it's not at all inspiring or peaceful. I've already booked to leave the following morning.

-Back in Kathmandu. 3 days earlier than planned. My hotel costs US$ 4 a night. You get what you pay for. :)

-Shocked that the price of a life is 17,000 Nepali Rupees. With is about US$ 250. This is the price a taxi driver has to pay to the family if he kills somebody.

I am booking a bike trip for the next 3 days, so will head out tomorrow on a bike trip for a few days. Then will be back here to finish exploring Kathmandu for a few days before heading back to warm Jo'burg.

From Nepal, I wish you a very happy and healthy holiday season, and a great 2009.


Brian

Nepal: More Random

Ok-maybe I've been a bit harsh.. I know why there are so many westerners camped out here.. It's freaking cheap. My hotel is about US$ 4 a night, and it is entirely possible to eat for as little as US$ 5 a day. And it's beautiful. So the chance to sit, sleep, eat, and read and meditate, do yoga, walk around is pretty alluring. Could you imagine if Aspen, or Vail, or Breck were this cheap.. the same crown would flock there. What I'm not that travel crowd.. I want to be somewhere with authentic culture, not a cheap tourist trap... Thankfully, a Nepali friend is going to take me off the tourist track for this afternoon, and tomorrow. Really interesting guy who grew up in a village 100 miles away but moved away from home and has lived here for many years. We're going to hit up the main part of Pokara, see a Tibetan refugee centre, and some other local stuff not in the Lonely Planet guide...
 
Power Cuts: The power is off from 6-9 am and 6-9 pm. So I'm in an internet cafe this am which is power by generator. I ate dinner last night by a fire, and breakfast this am in the cold. Having gotten up at 6am for the past week +, I woke up at my normal trail time and headed out to watch the city wake up. It's peaceful walking down a street where the shops are open, there are no lights except for the natural light...
 
Supporting the Locals... It is really tempting to BUY BUY BUY. stuff is sooo cheap. The main tourist season is in Oct and Nov, and you can feel the slowness in the shops, and the eagerness of the shopowners to sell. I'm on a bit of a mission today to find a better way to support the local economy than to buy buy buy..
 
 
This was my schedule for 8 days.
6:00 wake up
6:30 get the courage to get out of my warm sleeping bag
7:00 Breakfast/page
8:00 On the trail
2-4 pm: arrive at lodge, shower (ideally), wash clothes
6pm eat
6-9 Chat with other trekkers in the lodge
9pm get into sleeping bag, read or listen to ipod
9:15 asleep.
 
Anyway.. This will be the last blog post for a bit.
 


BPB

Nepal: Trekking

Namaste.
 
I am at a loss for words. If you've been following this blog, you know that often I can summarize. But I can't summarize the past 8 days.
 
How do you summarize:
 
-Spending an hour yesterday, under Tibetan Prayer Flags, looking at the Himalayan Range, completely undisturbed, the only sounds being the occasional hawk flying over head.

-Watching the sunset from Poon Hill yesterday evening, in front of me watching the sunset, behind me the moon rise above Annapurna I (the 10th highest mountain in the world).
 
-Going to bed at 9pm every night because you're beyond exhausted from a days trekking, but also because the only warm place is your sleeping bag.
 
-Hours, literally hours, walking (for me, alone) every day just mesmerized by the scenery, lost in thought, lost in the moment.
 
-Pure physical exhaustion (I made the trek in 8 days, but it's normally a 10-11 day trek) from dropping 1000 meters in a day.
 
-Pure mental exhaustion after a day of second-guessing if I was on the right trail.
 
-Dancing at a wedding celebration (uninvited, but welcomed), drinking the local wine (mulled millet), in the middle of literally, nowhere.
 
Other random things:
 
I've spent a fair amount of time thinking about poverty and life. Contrasting Soweto, Lesotho, Zimbabwe, and Nepal...
 
I did about a dozen medical consults in the 8 days... None of them on locals. I eyeballed the kids as I walked past, looking for the familiar signs of malnutrition (I didn't see any), listening for the chronic coughs (I didn't hear them), searching for those wasting from TB/HIV (I didn't see them).
 

I'm dying to get out of Pokara, Nepal's second largest city. I can't stand the noise. It's way too touristy here. But have decided to hole up here for 2 days of rest, need to give the legs a chance to mend, and also need to replete some glycogen stores, and consume some serious protein. Also, met a cool guy who wants to show me around for a day or so.
 
Headed off the grid again on Tuesday....
 
Cheers,
Brian,

Greetings from Pokara

Namaste (hello greeting)
 
 
Just a quick hello..
 
I started reading Dark Star Safari on the way here (Thanks AB and JS), and the introduction talks about going on this trip for a year and purposely staying away from internet/email, phone, fax, mail etc etc etc.. And that made me wonder how easy it is to stay in touch in this day and age. In fact, as S took me to the airport, we talked about mobile phones, and I had thought about getting a SIM card for my phone so I could have the luxury of sending text messages. Alas, after reading the intro, decided it wasn't necessary.
 
So, with the good graces of the travel gods, I arrived in KTM last night, zipped through immigration, was pleasantly surprised to see my bag, and ended up in a shabby hotel. Walked around, was just in love with the chaos in the streets at 10 pm, the dance that happens in the streets with taxis, motorcycles, pedestrians, cattle, kids. Managed to stock up on some last minute items, and went to bed after a cold shower. With the current power loading, electricity was off this am, so left things out to be easily loaded up this am.
 
Jumped on a plane (small 20 seater) for the flight to Pokara (20 minute flight), and got a magnificent view of the himalayas. Wow.
 
Wandered the town, found a hotel (US $ 7 a night) and then headed off for a small day hike to the World Peace Pogoda in Pokara.
 
It's overcast and a bit cloudy now.
 
Pokara is interesting. Pretty touristy, but have a great vibe to it. I'm slightly envious, I must admit. There is a cadre of folks here who have obviously been her a bit. That transient-wander-around-trustafarians who are all in their 20s, and seem to be totally care-free. Why didn't I do that when I was in my 20s?? But, of course, this sounds absolutely fucking ridiculous now that I have written this down, because I am aware that I'm doing a similar thing this year. And I feel incredibly lucky to have been in Zimbabwe a week ago at this time, and am now in Nepal. The trick will be escaping tourist hang-outs and repeating the feat from last weekend of being the only 2 foreigners in the bar.
 
So, I'm taking off trekking tomorrow... More posts down the road.
 
Oh, some prices..
2L bottle water US$ 0.60
Latte and croissant US$ 2.00 (DOUBLE latte too)
Fake North Face baseball hat US$ 3.00 (and I had to trade in my fake bilabong hat)
 
Cheers,
Brian

 
PS-re: cholera in Zim, it's likely DOUBLE what the UN is reporting, according to the docs in Harare. Don't believe the news...

World AIDS Day (and Zim)

It's World AIDS day.

 

I suspect there are things going on in Jo'burg, but haven't really paid much attention. There are charity events as fund-raisers for orphanages, hospices, clinics. I've seen more red-ribbons today as well.

 

World AIDS day to me, in the past, has been a day to think about the impact, the lives lost, usually spent attending some kind of speech, or service, or candle-light vigil. But here, every day seems to be a World AIDS day. It's a part of life.

 

And I don't feel like partaking today. I don't feel a desire to do anything different today to mark this day (though I am going to dinner with a Hopkins Infectious Disease resident, he husband, and also David-my ID doc friend). I feel like every day since I've been here has had stories of HIV/AIDS, and I feel like I've written about these issues (sometimes passionately) and today I don't see the need to do anything special...

 

But, I have to throw this out there. As I was driving, I heard a broadcast from Zim, where a radio presenter is doing a 24 hour radio-thon to raise awareness of HIV/AIDS in Zim. Which, of course, made me think back to the conversation from this past weekend, as Myr and I tried to get some insight into the HIV/AIDS situation in Zim. Both of us thought the rate if infection was likely on the lower end, not too sure what this is based on.. But I heard on the radio that 1 in 7 are infected, or 15%. Much less than here in South Africa. But there is a set up for disaster. What's going to happen to HIV/AIDS as the medical care system lays in shambles. Is there PMTCT (Prevention of mother to child transmission)? There was mention of HAART (AIDS meds) by a few, but sketchy details on if they were really available anywhere.

 

Last week I met with the Professor of adult Infectious Disease medicine, which is where I'll start in January. Most of their work is taken up by HIV/AIDS/TB, and less by other infections which are seen on the in-patient wards. Clinics are Wed, Thurs, and Fri. They have approximately 6,000 adults on HAART (double what the pedi clinic has), but estimate they need to get 4,000 more on treatment.  There is a backlog of people waiting to get on treatment... The drugs are here.

 

I doubt there are drugs in Zim. And I need to look into this issue further so I don't report inaccurate info, but for now I think it's pretty safe to say that Mugabe is killing Zimbabweans much like Mbeki killed South Africans.

 

Thanks for listening.

More from Nepal

 

 

Luggage-Notes on Zim and Vic Falls

"Where's your luggage?"

 

As it would happen, I arrived back to Johannesburg at the same time S&S were returning from Cape Town, which was fortunate because I couldn't figure out exactly where I had left my car in the airport, so I called them to meet up.

 

Oh, and I didn't have luggage. I was carrying a plastic laundry bag, from the Victoria Falls Hotel, which had my boxers, socks, running jacket, and running shorts. Those were the only possessions I decided to keep. The rest of my clothes, aside from what I was wearing, had been given away to mostly street kids in Zim. And my backpack as a gift to a friend.

 

I couldn't write when I got home from VF yesterday. There was just too much stuff to process. The beauty of the falls, the beauty of the land, the absolute friendliest people I've ever met, the desperate conditions under which people are living, the luxury of being in a grandiose hotel. I'll just present snippets here, in no order.

 

The Falls:

Spectacular, and it's not peak season for the river, which means were were seeing the falls at maybe half capacity. The deafening roar. The first view of the falls was the mist coming about the canopy of trees in the distance. Rainbows everywhere. We arrived on a day in which there were few tourists in the park (and there are way too few tourists period in the area). At times we'd be the only ones having a view to ourselves.

 

Currency:

The Zim currency is basically worthless. As most know, Zim has the highest inflation rate in the world, prices go up constantly. Thus, most things are priced in US dollars, and that's the preferred currency, with the Rand and Euro being used as well. Though, the conversion rate doesn't match exchange rates, so you do lots of negotiating for prices. For example if something is 10 US dollars, and you want to pay in SA Rand, the price should be 100 Rands, but often we found we'd be asked to 120 Rand and we'd have to negotiate back down to as close to the 10 rand as possible. I have included a pic of my 100 BILLION dollar bill. I'm rich.

 

The Banks:

Zimbabweans can only withdraw 500 Zim Dollars a day, a limit set by the government. Bank are closed on Sundays. 500 Zim Dollars will buy a tomato. A single tomato. One must go to the bank daily to get enough money for a loaf of bread. Obviously, people don't keep most their money in the banks. But one of the hotel workers was explaining how his money is directly deposited into the back, which makes it very trough for him and his family to survive. It's not good.

 

Shoes:

"I like your shoes"

Not a compliment. Rather a subtle line to ask if you're willing to part with them. Maybe trade the shoes for some souvenirs? What shoes are for sale (and we couldn't find many, even in the market) are far too expensive for most. On the final day, when Myr and I were walking through town distributing some clothes and food, we easily were met by at least 10 people who for days had been eyeing our shoes.

 

Bike Riding:

Saturday we rented bikes, and headed out into the surrounding areas, went along the Zambezi river, and ended up at this amazing Crocodile farm, which has 40,000 crocs, breed in captivity for food and skins, but also some re-introduced in years past (apparently there are now too many crocs along the Zambezi river). It was great. Got to hold a 2 year old croc. Observe a feeding. Lost a finger. Kidding.. It was great being back on a bike, and made me wonder how it is that I haven't had a bike since leaving Dublin. We were about 3Km from town when her bike chain broke, and it was actually hysterical and we just had to laugh at the situation. We had a HORRIBLE flight to Zim, which included a very tough landing (the pilots didn't come out of the plane) so we just had to assume that this was a continued string of problems with transport. We weren't able to fix the chain, so we rode back with her holding onto a rope tied to the back of my bike.

 

The People:

Fri night we walked into town to seek some dinner. Met a guy along the way who took us to a small house that served some food. We ate Pap (a maize-polenta) served with some chicken. The chicken on my place was a single drumstick, which had barely any meat on it. I suspect that this chicken was rather paltry when it was alive. The food was decent, the price was inflated, but pap is very filling. It's a staple, so not as nutritious as one would like, and given the cost of vegetables and meat, I suspect it's the major diet. Anyway, we ended up having a few beers in a local bar, and that's where we met Jackson. Decent guy. From there we went to a club which wasn't happening and so we went back to the hotel to sleep. The next night, we went back to the club, expecting to hear a band from Harare. We confirmed the time with Jackson and a few others, but of course when we arrived, there was nobody there, yet. We were sitting off in the corner, and were literally about to leave when Kvee (or Vincent) joined us. He's the main DJ of the club. We talked for almost 2 hours about conditions in Zim, and at the end of the 2 hours we had easily met 10 more people. I don't know how it happened, but we ended up leaving the club at after 4am. It was just so enjoyable to meet so many amazing people, dancing, drinking, having mini-discussions about life and politics. What I'm not explaining well is that these people really not only don't have much in the way of basic needs, but can't even get the goods. Kvee and I swapped shirts, check out the pics.

 

Healthcare: Home to Die 

We were trying to figure out what's going on in the area with healthcare. There is a public hospital. But it's basically closed. There may or may not be a doctor there. Which doesn't really matter since there are NO supplies. People don't even think about heading there. There is a local private doctor, but he charges something extraordinary for just a consult fee (something astronomical, maybe US$ 50), and if you get a script for meds, will they aren't available or affordable, so when I asked Ebert people do when they get sick, he said "we go home to die." Pretty bleak. Kvee has to take his 2 year old daughter to a sangoma (traditional healer) which is not what he would prefer to do, but feels compelled to do something when she is sick. Kids are no longer vaccinated.

 

The Grocery Store:

Myr and I went into the local Spar grocery store. Most the shelves were empty. There were some staples like cereal, biscuits, and bottles of water. The meat that was in the freezer looked very old. We were the only 2 people in there. And when we were in town, never really saw people going inside either, as most people were shopping at the market.

 

I have to wrap this up, have a lot to get done before leaving on Wed.. But I'm really bothered by what I saw. In contrast to the people of Soweto, the people in Zim were absolutely delightful, have just as little possessions, without the prospect of really getting more (and we're talking clothing, food stuffs here), but seem to keep struggling on. For comparison, mobile phones are everywhere amongst Sowetans, but I heard 1 mobile phone ring in the entire time we were there..

 

We were fortunate enough to be able to discuss politics with some people, and really most seemed to acknowledge that Mugabe must go.

 

 

How to Help:

We didn't have time to really put together a great plan...

I have a contact in Vic Falls who will distribute goods which are sent to him. The list is endless, but the practical things would be any clothing, (for any ages), shoes, pens (I was able to almost buy things with pens), paper, simple food stuffs, It doesn't have to be a big box, and more ideal would be smaller packages send distributed throughout the year. Luckily, packages are not opened by Zim authorities, and there is no import tax on goods. Please email me (javamania75@hotmail.com) if interested and I will email you the information and instructions.

 

Next post likely from Nepal.

 

 

BPB