Yesterday started with a typical morning of rounding in an under-served hospital with really sick HIV/AIDS patients.  The middle consisted of a shock back into the reality of modern medicine with a teleconference with Columbia presenting cases from South Africa.  The day ended with the slaughtering of 30 chickens, on a hill, at midnight...Let me explain.

Since the new interns have started, the chief of medicine has given small introductory lectures each morning.  This morning he discussed how the hospital came to be such a challenging environment to work in.  Its mission was always to the under-served, and in a place like South Africa, that seems equivalent to under-funded.  However when the AIDS/HIV pandemic hit South Africa in the late 1990s, the hospital was in the thick of the action, the patient presentations were novel, they were sick, the hospital was unprepared and not well funded and many died.  It became such a challenging, hard place to work that many doctors and nurses left thus depleting the hospital even more.  In fact, in the room with us, there was only one internal medicine physician that was present during the start of this pandemic that is still working at Edendale today.   Never-the-less outside funding finally came in, new staff were hired and it seems that most of the energy was directed towards the most dire needs, HIV/TB and complications from these diseases and not so much to systems improvement and expansion in the hospital.  Hearing the chief of medicine speaking about the timing of HIV, I finally came to understand how new this disease truly is.  

Rounds started and we were post call.  As we walked to the admitting area to see our patients it was a mess.  200+ people were in the waiting area (I had to put my N95 mask on early) and it was impossible to tell who were the patients, the family and the friends.    Yet somehow there was some order to the madness and thanks to the help of some well placed nurses we found our patients.  They were on cots, by the wall, waiting to be told they had a bed so their family member could transport them upstairs.  The first patient we came upon was the sickest.  She had defaulted on her ARVs, had the most profound cyanosis I had ever seen and likely had PCP pneumonia.  She had decompensated quickly since her initial evaluation and by the time we saw her in the AM, we all knew her prognosis was poor.  While the team moved on (they had to secondary to the sheer number of patients) I volunteered to get IV access, ensure her meds were given and watch her status.  It became clear by midmorning she either needed to be intubated or made comfort care.  Unfortunately an ICU consult was less than helpful.  They have only 6 vent beds for the entire 900+ bed hospital.  She was not a candidate for ICU.  She was too far gone and deemed not fixable. She passed by noon that day.   

In the early afternoon after rounds had finished it was my responsibility to present cases from Edendale hospital in a teleconference with the medicine residents at CUMC along was an ID MD and a pulmonologist.  As I presented numerous chest x-rays, cases on cryptococcal meningitis, TB and aspergillus I was asked about bronch capabilities (none, they are transferred out), pleural biopsy (yep…but booked for several months away and I doubt with VATS) and culture data (sparse, there is no official micro lab with microbiologists).  Hearing these questions, it again dawned on me how much the medical house staff and consultants are asked to do on a daily basis without the benefit of ever present specialists, diagnostic tests and rapid lab turnaround time.  How under-served and resource limited the hospital is and much they are asked to do, with less.

After conference it was time to go to Krista’s (the head of ITEACH and the person who helps set up my time in Edendale) for dinner.  On arrival I was greeted by her and the chief of medicine at Edendale and was asked a simple question.  Would I like to go with them at night to the middle of a township on top of a large hill to watch 15 traditional Zulu healers perform a traditional ceremony?  Ummm yes.  The two questions I had were:  1, is it safe?  Yes absolutely, no one in the township would dream of ever harming anybody associated with traditional Zulu healers.  And 2, what does this entail?  These traditional Zulu healers had been working with Krista and ITEACH on the acceptance of ARVS into the community.  These Zulu healers were branching out on their own to start a new ARV integration program where they would promote amongst other things these ARVS and to help with their acceptance.  They were performing a ceremony to ask their ancestors for help and good luck in this endeavor.  Krista (and by proxy us) had been invited because of her previous relationship with many of the healers.  Oh, and by the way, 30 chickens were to be sacrificed (2 per person). But don’t worry, we weren’t expected to bring our own chickens.  I proceeded to ask if anybody had ever seen Major League the movie where a practicing voodoo baseball player on the Cleveland Indians demands he sacrifice a live chicken before a high stakes game?  Instead he is brought a fried chicken from KFC.  There are crickets in the room, no one thinks it is funny and I can only imagine the look my wife would be giving me right now.

After dinner we leave for the township.  It is dark, misty and visibility is only 10 feet in either direction.  As we pile into Krista’s old, beat up range rover and drive into the township I start to question this whole safety thing.   

 We end up picking up two of Krista’s associates; fortunately one is a spiritual healer in training and has been “chosen.” He is able to direct us.  We head up a long, steep, rocky hill with drop offs on either side and mist in all directions.  The pitch on the range rover is intense and at times I think we are going to tip over.  Finally we can’t go any further and we head out.  There are drums playing in the distance and on our approach we spot several fires surrounded by 15 people and 30 live clucking chickens.  They were waiting for us and we are greeted warmly, all of us like friends with huge hugs and warm smiles.  It doesn’t matter that we don’t speak Zulu and very few speak English. 

The ceremony begins with dancing, singing and drums blaring, the ritual sacrifice of 30 chickens commences and it appears much like a koshering.  While chants are sung the throats are slit, the blood drained out, the chickens plucked and tossed into a pin and salted.  The gallbladders however, are removed.  The Zulu healers believe that the souls of their ancestors reside in the gallbladders and these are to be saved. 

 Finally around midnight, after enough dancing, singing and drum playing Krista, myself and the chief of medicine at Edendale have to leave.  It is late and while the healers will be there all night, we have work the next day.

As we head down the hill getting intermittently lost in the township and dealing with the same rocks and pitch I start reflecting on what I had just witnessed.  This was a very spiritual and old ceremony revolving around something extremely modern and contemporary, ARV compliance.  I think about many of the patients in Edendale and those who do or don’t take their meds.  How much work has actually happened in Kwazulu-Natal and that the mortality curves for HIV and TB are finally flattening.  Krista had explained that the first modern ARV attempts in South Africa weren’t until the very late 1990s into the year 2000.  That she was there for major role out in 2004.  It has finally occurred to me that this disease is still so new and when it hits resource poor, underdeveloped nations like South Africa, perhaps what is happening here could be much worse.  People are actually getting there medications, mass treatments with standardized approaches to medication availability, acceptance and adherence are happening and people are getting better.  And I think the take home of working at Edendale hospital is that while it is happening at the population level there is still a lot of work to be done for it to happen at the individual level.

The best quote I have heard so far while here:  “Just another day in Africa”

January 7^th, the official start of the new year and the hospital is back in full swing.  The previous one minute it took to get through the security gate now takes 20 as cars line up to be searched prior to a wave through.  The wards, previously devoid of techs and nurses are now swarming with never before seen ancillary staff.  And finally, new interns, new medical registrars, and new medical officers have arrived which has coincided with the post holiday patient rush as those who had attempted to minimize illnesses over the holidays have now been admitted over the weekend.  The hospital is chaotic.  But surprisingly it is a controlled chaos and could have been a lot worse with all of the new interns.

The Iteach office is now open as well and I have been introduced to the entire staff who are all extremely friendly and helping me plan my cultural and community outreach trips.

ITeach Office:

Today seemed to be an acute hepatitis day.  At least 4 patients had LFTs into the 1000s.  One patient we were able to make the diagnosis of acute Hep B (something I have not yet seen in the states).  Others unfortunately did not have hep labs drawn so they will be discharged with follow up of labs on d/c.  The new consultant I am with also seems to have a better grasp on antibiotics than the previous ones and feels comfortable stopping unnecessary meds.  Patients on a seemingly common combination Augmentin/Flagyl for CAP are finally having the flagyl dc’d.  Bactrim has been dc’d on at least 5 patients with CD4 count s that have been > 200 for months.  We also had one patient who was in status right in front of our eyes and the consultant was able to counsel the new intern/medical officer team on how to get an expedited head CT that day (in a sense what we do at CUMC, don’t take no for an answer).  Finally he discussed appropriate fluid usage and transfusion goals with the new intern and medical officer.  The take away from this, even in resource poor situations, without readily accessible internet, without the appropriate speed for diagnostic tests, it is possible to practice reasonably evidence based medicine if it comes down to the basics such as appropriate antibiotic usage, appropriate fluid content and correct transfusion goals.

Edendale Hospital:

 

 

 

For Eric's last weekend, we went to St. Lucia (again copying Dave and Christine J) and stayed at a very nice beach getaway called Lidiko Lodge.  St. Lucia seems like a major resort town although I think because the holidays just ended it was a little quieter than usual.  It kind of reminded us of the Caribbean but with signs all over the place saying "beware of the Hippos".  We had some great food, and went on a game drive.  Not nearly as good as Rob’s, but we did see some elephants, plus we had a killer lunch of steaks and South African sausage. 

No Hippos :(, it was too hot.  Eric and I have both decided that the South African diet is very meat heavy.  During our drive home we stopped in a cheese shop.  When parking, my car got stuck in a ditch and I had to get it towed out… South Africa 2, Mike 0.   I think I'm at my limit for uploading pictures, see FB for the car getting towed out.  Luckily the cheese shop was also a farm which had a trailer hitch!

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!

 

 

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.