During one of my last conversations with the chief of medicine, he has been working desperately to improve the quality of nursing care at the hospital.  While interns are responsible for all IVs and blood draws, the chief has been attempting to at least have successful daily vitals and ordered daily medications actually given.  In one example, I spent some time in area R (where patients go for medical care by the interns after triage before getting a bed on the ward) and had participated in a patients care.  The pt came in screaming with severe abd pain, no bowel movements in a week, tachycardic and possibly febrile but no temperature had been done.  A floating consultant walks in, sees the patient, and immediately asks the nurse for a temperature and help with management.  He gets a long blank stare with no movement from the nurse and 30 seconds later is told the patient will be wheeled back out down the hall to the thermometer in a little bit.  The consultant then walks off and 20 minutes later comes back with the thermometer, the temp is 38.  This consultant seems different than the others.  Instead of accepting the status quo he took action.  I ask the intern who he is, and the intern says this consultant mostly works for the CDC and “is a little scary at times.”  I try to offer other, non-intrusive ways to help such as suggesting fluids, antibiotics and a pregnancy test.  The pregnancy test is still pending…

I have other examples, but they probably are not appropriate for online posting.

 The clinical case presentations in the hospital are usually quite dramatic.  Most patients are pancytopenic, many have crypto meningitis and the default diagnosis for a headache, neck pain and a negative bacterial and crypto LP is TB meningitis.  Frequently, if the patient does not fit into an HIV, TB or pneumonia mold, they become a mystery and a work up is pursued only if it is worth keeping the patient in the hospital.   It seems that answers can take weeks to happen, as CT scans, biopsy results and esoteric labs can take weeks to come back.

Today on rounds, I was with a very thoughtful consultant and two British registrars who had trained in the UK and came to South Africa as they enjoyed overseas work.  We discussed how I still can’t get over the way sepsis is treated.  At least three times now, sepsis was managed with no fluids, either dobutamine or epinephrine, very little re-rounding and the same antibiotic – ceftriaxone.   As it turns out, they are actively studying the problem and agree it is not a resource problem but systems problem.  They are planning to report on their results soon and the chief of medicine is apparently very open to improvement and change but we all have a feeling the hospital mortality rate will be high.

I went on an amazing game drive at the lodge I am staying at.  See pictures below!