The multi-drug resistent TB clinic and the Bitterness

Went to the multidrug resistant (mdr) tb clinic today in Greytown, about an hour away. Dr.E drove and when I got in his car he asked if I had my N95 mask (for protection against tb) with me. I said of course (we wear them at all times in clinic and hospital) and he said ok good, by the way do I mind that we need to transport a patient with MDR tb with us to Greytown? 

So we drove to Greytown with a pretty sick looking man in the back who was actively coughing and shivering as we had to drive with all the windows down (to prevent the spread of TB, got to keep things well ventilated). All of us were wearing masks, including the patient and the MDR nurse, but not Dr.E. The pt asked if we could close the windows because he was cold, but we couldn’t.. Dr.E gave him his jacket. He was very short of breath by the time we got there. As soon as we arrived we wheeled him in, the nurse grabbed him a blanket, took vitals, and as DrE wrote admission orders, he was whisked away to the ward.

We saw a few patients in MDR clinic (outpatients), and finished the day sharing some tea and crackers with the head nurse from Greytown hospital and our MDR nurse from COSH. It was really nice, actually.

There was a paper poster in the room where we had tea that I liked. Still having issues uploading photos so here is a verbatim type-out:

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THE BITTERNESS

– the bitterness is the waste energy of yourself

– bitterness is the disease and people with bitterness have for attitudes to everything

-people with bitterness are always negative to everything

-bitterness is self-defense, better hate everynone. Bittnerness is very harmful to you, is destructive disease it affect all people

– bitterness is the killing disease, they don’t take any advise, they always in yhe right side

– they have many visions which they demand everybody to take, if it is good for them

-they have all qualifications they know everything, they belong to all organization, they always lead to everything

-they demand respect to everyone

-people with bitterness they hate themselves they don’t look presentable they don’t qualify to any job

-they always take control to everything, they don’t lead by example

– they always got conflict they enjoy arguing with people above them

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Tomorrow morning Mekham (outgoing J&J peds resident from Texas A&M), Sarah and I are going on a 5am hike with Dr.E. We stopped at a grocery store on the way back and I suspect he picked up a few items for the hike. 

Had an interesting chat with Mekham. He was visiting to shower because their house has been out of water for a week now.  He’s Nigerian and a chief in his town! I asked him what responsibilities that entailed and he said to be sincere, just, and uphold cultural traditions. I could see him being a good chief. There are multiple chiefs and one king. 

It is hard to believe I’ve only been here 6 days. Everyone here has been so welcoming. It’s a built in community with shared challenges. The work here could be unpleasant but the people make it really enjoyable and fun. I think it attracts a certain kind of person who wants to see things better. I’ve also been sheltered these past few days as I get eased into the work and slowly oriented. We’ll see how I feel at the end of my 6 weeks.  🙂

The clinic, the hospital, the LP that never was

I spent most of today on the TB ward with Dr.E. We rounded on a few patients who were in a shared room with 6 beds. Most with HIV/TB coinfections. The first man had lost vision in his left eye from uveitus from TB infection, was being treated with steroid eye drops. The second had Potts disease, or TB infection of the spine. He had made remarkable recovery, from paraplegia to being able to walk on his own. Interestingly, he was HIV negative. The third had TB and HIV coinfection with off the charts viral load, but appeared to be doing relatively well.

Dr.E had clinic afterwards, in a room across the hall from the TB ward. He was seeing follow ups from hospital discharges: Disseminated TB that had an open poorly healing abscess in a woman’s groin, TB/HIV/COPD trifecta that had been complicated with a pneumothorax, pediatric reactivation of chickenpox after starting hiv treatment.. He also saw patients who had special requests, like a woman being treated with peripartum cardiomyopathy who was there with her mother, requesting a temporary discharge to go home and “slaughter a goat”. They wanted to do a ceremony to try to rid her of evil spirits that were causing the disease. Dr.E said no. He was concerned what would happen to her treatments while away, or what alternative treatments she might get. She was upset and left the room, but sitting there upright on the bench, you could see her distended neck veins pulsating. Dr.E seems to know a decent amount of Zulu but had a nurse help translate once in a while. Some of the patients also have a fair use of English, understanding a word or phrase here and there.

Dr.E is an incredible doctor. He seems like one who goes the extra mile for all patients. Much of his time was spent calling doctors directly to make referrals (standard here, but very frustrating when phones don’t work reliably), making appointments, and tracking down missing lab results. All over phone. He is conscientious, holds people accountable and thorough. What’s amazing is that the doctors here are able to do so much – like the others, he will also do c-sections, we took a look at a womans uterus with the ultrasound, and he’s seeing kids as well. 

In the late afternoon I went to the ARV (antiretroviral) clinic and worked with Dr.M. We saw a woman who had LOE, LOA, LOW (loss of energy, loss of appetite, loss of weight). Her BMI was 16 and she had lost over 10 kg over 2 years. He suspected she was no longer responding to her HIV meds but sent her to the hospital for expedited workup to rule out other opportunistic infections including TB, considering how weak and sick she looked. 

Dr.M had been on call the night before and spent the morning with a reporter who interviewed him about XDR TB (which was first described at this hospital; The Church of Scotland Hospital, or “COSH”) and seemed a bit tired but very kindly gave me a tour of the hospital. During the tour he stopped to say hello and chat with a maintenance worker in the hospital, joked with nurses, checked in on a lady he admitted a while ago who was doing well and being discharged. He is the founder of the NGO that shares space with the hospital, and is the South African host of my international elective. He seemed as sharp and compassionate as Dr.E, with a warm heart and soft voice. And laughing eyes! More cliches but all true! He is santa claus!

At the end we ran into one of the British doctors who are here for a year. He is interested in IM/Crit care but also is doing some training in ER. The British and US systems are different but he and I are probably close to equivalent levels in the big course of training, although he seems to have more generalized skills (e.g.general anesthesia). He thinks his system puts more emphasis on clinical work (“service”) rather than education. He was outside trying to figure out where the lumbar puncture results were on a young man who had come in with altered mental status but quickly recovered with antibiotics and was eager to be discharged to write a school exam. If he couldnt track down the LP results, he was considering whether he’d need to repeat one, although it was already after so many doses of antibiotics and could be falsely negative. I offered to do the LP, but he would have to supervise me since I haven’t had much experience with them. Since our intervention radiology departments back home are so great, it often becomes in the patient’s better interest to have the radiologist do it rather than a learning resident. But it does end up costing more and takes away learning opportunities. I’ve only gotten to do them late in the day or in the middle of the night after radiology has gone home. So we don’t get many chances to do them back home, and when we do, they are often really tough to get (larger patients than here). Anyway, it still felt a little evil to put this poor guy through another LP which might not even be helpful, so the British doctor went to the lab to see if we could track down the results. We weren’t hopeful. But with minimal information, they were able to produce the results from the original LP. I was pretty impressed, it had been done days ago and it’s all paper documentation. Lucky patient. For me, I was promised that there would be many more chances to do LPs.

They are doing amazing things here with minimal resources. It doesn’t run smoothly always, but then again, it doesn’t always run smoothly back home either. I can sympathise with the amount of non-medical troubleshooting these doctors (and all other healthcare staff) have to do moment to moment, and how frustrating that can be. Hours on the phone, painfully sifting through books of paper charts… I wonder if they are burnt out or if they feel they are making a difference. To me today, as an outsider looking in, they really are.

P.s. There are some posts from the weekend that I havent published yet because the internet here is struggling to upload the photos. But they will be up eventually, possibly without pictures. We’ll see!

Day 1 recap: arrival

I left Connecticut 8am on Wednesday and after 40 hours of travelling, landed in Durban this morning. The whole trip was pretty smooth, all things considered, even fancy. On the second to last leg, from Munich to Johannesburg, they offered veal, chicken or vegetarian. Chicken ran out and no one wanted to get the veal so they were running out of vegetarian too. Finally they started calling it beef instead. I got the veal because I’m an asshole.

It was foggy and cool in Durban when I landed. Thokozane, the driver from Philanjaro (the ngo running the clinic in Tugela) picked me up, along with his wife. We zipped down windy roads along the edges of valleys with dog just revealing one tree at a time. We were going so fast that I might have been nervous but I was so tired I just slept the whole way. The sun came out and we got groceries and cash in Greytown, the closest town to Tugela. Finally I arrived in Tugela, dropped my bags and left immediately with the residents to backtrack back toward Pietermaritzburg where a music festival is happening this weekend. 

There was a thunderstorm last night but we were cozy sharing red wine and avocado sandwiches in our hotel rooms. We watched South African mastercraft, chased bugs out of the room, and obsessed with our shoddy wifi. It was a good first night.

Arrived

Here’s my view from the hotel this morning outside Pieternaritzburg.

I landed yesterday morning in foggy Durban, had a short stop in Tugela Ferry, my home for next 6 weeks before heading out again to Pietermaritzburg for Pecanfest. More on all this later. I think landing right before the weekend has skewed my view of what these weeks will be like. 🙂

In transit

I turned 31 right before heading off. Surprise gifts, cakes, balloons, brownies and care-packages weren’t a bad way to start the new year.

Yesterday I drove from Connecticut to Toronto with really pretty fall foliage. Helped the 8 hour drive go by. I hear it’s snowing back there already.

My current view. Layover in Munich and I dumped water on my visa supporting documents. Whaddya gonna do. Here they are air-drying in the beautiful German sunshine. Side-note, Lufthansa has pretty tasty food. Good job, Sky Chefs!

What’s happening?

I’m spending 50 days in South Africa and this is my blog about it. I’m an internal medicine resident doing an HIV/TB international health elective based out of Tugela Ferry in KwaZulu-Natal. I’m also a first-timer to South Africa and I’m-so-excited 🎶

I’m actually kind of sleepy and nervous but I think this will be fun!

http://www.africasafari.co.za/info-F&W.htm
How I’m feeling.