As a disclaimer - Eric didn't proof read this!

I rounded today with the chief of medicine and learned the history of the hospital.  Edendale Hospital was designed as a 900 bed public hospital built in the 1950s before Apartheid.  When the laws came into existence it turned into a public black hospital.  Funds were not allocated for support nor resource development and it essentially remained untouched until the late 1990s/early 2000s when at the end of Apartheid a CT scanner and new electronic core/pathology lab was added.   A very small ED has since been established with a main entrance still undergoing renovation and current planned renovations include a new psych department and a renovated area for medical evaluations prior to admission.   At least in medicine, computers exist only on doctor's smart phones which they use to connect to the core lab to see results. 

Zebras

Entering the wards feels like entering the 1950s.   The medicine wards on the 5^th floor are separated by sex and essentially look identical.  There are approximately 6 sections separated by chest high brick walls and each section has 8 beds.   There are no curtains, private restrooms, tvs, phones or privacy.  As a patient, you get your bed, hospital gowns, food, a small night table and of course medical treatment.   Rounding with the chief of medicine was a very pleasant experience where we discussed the differences in test ordering and time to completion.   For example, a CT and MRI can take a maximum of one day at CUMC (which we still find difficult to tolerate) whereas in SA it can take weeks.  Because of this, endocarditis is ruled out by stethoscope, not echo.  Bilateral crackles and no fever is pulmonary edema and does not require a CXR.  While I cannot comment on exam skill level, I can say there is a much higher level of comfort using exam skills to rule in or out disease.   

The prevalence and incidence of disease also plays a huge role in diagnosis.  Given the high HIV burden, LPs are done like blood draws and a brisk flowing CSF is assumed to be crypto meningitis until proven otherwise.  A CXR with multifocal pneumonia is miliary TB because of possible small nodular opacities.  On rounds, I also noticed the high burden of ETOH abuse and THC but very few patients because of cost use heroin or cocaine.  The THC is grown by farmers in the surrounding area but in Lesotho the farmers alternate a row of corn with a row of THC to prevent police airplanes from seeing the crop. 

No procedures today L.  I was going to do a blood draw but then realized….That is the one thing I don’t need practice on

 

This weekend (copying Dave and Christine’s itinerary to the point) Eric and I travelled to Kestell to the Drakensberg Mountains and for a hike up to the Amphitheatre to see the start of Thukela Falls.   We stayed at a very homey backpackers where a jolly, slightly obese elderly South African women hosted guests and provided unlimited supplies of homemade jams, coffee, tea and hiking route advice.

The hike the next day was 6 hours round trip and included a 2km hike up to a set of chain linked ladders leading to a large flat plain which extended 1km to the start of Thukela Falls. Despite the threat of rain including thunder, the weather cooperated and Eric and I made the 6 hour round trip hike in 5 hours.

See pictures below:

 

Posing on the way up!

 

 

The water fall

 

 

Eric, Myself and our German hiking friends

 

In order to make the South African elective more generalizable to our CUMC IM program, the department has asked the residents going abroad to revive a blog that was started several years ago (but no longer updated) about the resident experience in South Africa.  

Arriving in South Africa after a long, 33 hour flight including a 10 hour Munich Layover, I was met by Sipho the ITeach driver who gave me a warm hug, guided me to the rental car agency and led me to a grocery store which much like in the U.S., was packed with throngs of people on X-Mass eve.  Driving on the wrong, aka left side, of the road is not a new experience to me but disorienting nonetheless.  Everything has to be flipped in your brain and one constantly thinks of the reverse.  While I am now an excellent left sided driver, on day 1 (see below) I unfortunately failed.

Day 1 started on x-mass day with me misjudging the entrance gate.  Upon driving up the poorly paved back road to the hospital my car was stopped, searched, and subsequently allowed through a set of gate doors.  Unfortunately, the guard refused to open up the second gate and I ended up denting and scrapping the front part of my bumper;  South Africa 1, Mike 0…  After parking, wandering around for an hour or so, I was met by a very kind, soft spoken chief of medicine who came in specifically to orient me to the hospital.       

The Hospital gets the majority of its patients as referrals from local clinics.  These patients are sent to a waiting room and triaged by a registrar/medical officer (medicine resident).  Should the patient need admission they are sent to another back room where two interns (doctors who are doing two years of work prior to deciding on any specialty;  surgery, medicine, optho etc…) perform all of the necessary paper work, blood draws, IVs – scut work.  If the patient is too sick to stay in the waiting area until a bed opens up on the wards, they are sent to the medicine emergency department to be further triaged to the ICU, wards or referred out to a subspecialty service at another tertiary hospital which only takes referrals called Greys Hospital.   

After seeing the hospital, learning the above, and meeting some extremely nice registrars who were dumb-founded that I came in on x-mass day despite my explaining I did not celebrate, it was suggested that I not come in on Thursday and present Friday for a resumption of the regular schedule.

 

A view from the Lodge where I am staying!

Friday, day 3 was my first real day which started with morning report going over cases from the day before.  Eric (my pod mate) had flown in to join me for several days and we were assigned to the post call team to round which consisted of a consultant, a variety of registrars/interns and the consultant’s younger brother who had come to observe.  Rounds started in the ED where two patients had been assigned and admitted by a team, but no beds were available and where thus being co-managed by the ED consultant (Attending) and medicine team (This all sounded too familiar!!!).  Patient 1 had intentionally overdosed on combined organophosphate/synthetic warfarin pills and had improved somewhat on an atropine drip but now had a heat rate in the 150s (more on this later).  Patient 2 had AIDS and had been admitted and treated recently for cryptococcal meningitis.  While it is unclear how she re-presented, on morning rounds in the ED she had an SBP in the 60s, febrile, altered, and anuric AKI with a k that eventually came back at 6.  Her LP was normal and her lungs clear.  The consultant saw this data and stated the patient needed antibiotics, a renal consult for peritoneal dialysis, no fluids as the patient was anuric and she didn’t want to volume overload her and then requested that an inotrope, dobutamine be started.  She debated about Lasix to induce urine but the hypotension prevented this.    Eric and I stood there, still unsure what our role/responsibility was in all of this.

Rounds eventually went to the 5^th floor where an intern asked us to come over and help manage a patient in cardiogenic shock 2/2 to afib with RVR with an SBP in the 70s, altered mental status and a HR in the 190s.  This required multiple shocks and while sedation was given the patient was in an incredible amount of pain.  The consultant’s younger brother then asked if we couldn’t “hit him over the head to knock him out.”  I just stared…

Rounds ended and Eric and I circled down to the ED to check on the overdose and septic shock patients.  On our way down we tried to remember back to 2^nd year of medical school, the cholinergic effects of organophosphates and why this patient was tachycardic and not bradycardic.  The ED consultant stated “in Edendale Fashion” the atropine drip had been ordered off 24 hours ago but was turned off only minutes ago, thus he was now suffering from atropine overdose.   He was also altered and the patient could not go to the medicine wards until a head CT was done to r/o bleed given the warfarin OD and coags that were still pending .   As for the septic shock patient, renal had recommending a non invasive CVP which was 0, the ED consultant gave 1L NS and switched to epinephrine and the ICU had declined the patient 2/2 to no beds.   In addition to a failed LP on a patient which the intern then got in 1 stick, it was a fairly eventful Friday.

More later with pictures on our trips around SA, the hospital itself and our lodge.