November 6, 2005
Dear Friends and Family:
With another week gone, and a little more seasoned, medicine in Botswana is both more familiar and more extraordinary. The average age of my patients is mid-30s, with a few middle aged diabetics and elderly heart patients, and many young people admitted with HIV, meningitis, wasting syndrome, and coughs suspicious for TB, and often all of these. It’s not uncommon that I look at a patient, and only after looking at the chart do I appreciate how disease has aged them 10 or 20 years.
On the one hand, we don’t have all the tests we are used to back home (notably the CT scanner is broken and there are no MRIs; and the young patient we have with a bleed in her brain has to go to South Africa for further investigation since there is no place in the country to get an angiogram). On the other hand, we are finding we don’t need all of these tools for everyday diagnosis and treatment. Blood tests, ultrasounds, and other procedures we might otherwise do at home are passed in favor of empiric treatment for the most likely condition. Some of those tests really are redundant, and others simply confirm a suspicion. Sometimes we use them to decide between a number of different possibilities, but as often we are relatively certain before ordering the test.
One friend, John, before he left said that working here has made him more impressed with the amazing possibilities of trauma surgery, intensive care medicine, and the "good saves" of people with serious injuries and illnesses who we can return to normal lives. John also said his time here has also highlighted the ways that in the U.S. we sometimes lavish painful and expensive treatments on people who are obviously dying, and miss the opportunity to help patients and families come to terms with their deaths. I couldn’t agree more with both of John’s observations.
This practical approach to resource allocation is born of scarcity, but the fact that I can use my time and the hospital’s money doing what is possible instead of chasing rescue fantasies is reassuring. Our new medical student has observed that we don’t call "codes", as we do in the United States. Any patient not on hospice found pulseless in an American hospital will be subjected to a ritual of epinephrine, electric shocks, and chest compressions.
This is rarely helpful. In fact, outside of trauma situations in which a young person is bleeding and cardiac events in which a heart attack leads to a "shockable rhythm", patients who lose their pulse are usually quickly pronounced dead, subjected to another few days to weeks of intensive care only later to succumb, or are maintained in a "persistent vegetative state." This is not to say that we should not "do everything" for people with severe disabilities, but sometimes we prolong suffering without hope of improvement instead of prolonging meaningful life. Unlike at home, those with end-stage diseases are allowed to pass quietly.
There are frustrations: medications that would be useful, or even life-saving, which we are supposed to have, are mysteriously not in stock. Last week the laboratory computer system was down for 2 days, and lab results that take 1-2 hours at home, which can sometimes be had the same day at Marina, were held up in the queue. Supplies appear to back up at every level, with materials available from vendors, but not purchased; materials in the Ministry of Health’s central supplies, but not available at the flagship hospital, and items such as hand soap plentiful in the hospital stores but unavailable on the male medical ward…
On the weekend, we went away as we so often do, this time to the Khama Rhino Sanctuary in the center of the country, where we saw a few of Botswana’s remaining Rhinos (largely hunted to extinction for trophies and Chinese medicines), antelope of various kinds, wildebeests, hartebeests, zebras, and the "wild" painted dogs who are endangered.
Next week on to Victoria Falls and the Chobe Wildlife Reserve, where the largest groups of elephants and hippos in Botswana are to be found.