We're home!

Just wanted everyone to know that we made it back to Danville safe and sound. Thanks for all of your prayers and well wishes while we were in Africa. It was an amazing trip, much of it very hard to put into words. Thanks for reading our blog.

And that's a wrap!

Today was our last day at the hospital. The interns brought in cake for morning report. I asked for a group picture and they begrudgingly obliged (the guys wanted to keep eating cake.) Here is the group.

Its so hard to believe that we have been here for a month. Part of me feels like its been years, but another part feels like we just got off the plane. Its been an amazing month and I'm so glad that we got to come down. I am still saddened by the many devistating cases we saw. I know that will stick with us for a lifetime.

We are all packed and ready to fly home tomorrow. Our plane leaves Namibia at 410pm and arrives at JFK at 740am Sunday. Oh, just in case you were wondering, all of those kids DID turn our to have measels. So, you might want to steer clear of Stacey and I if we develop cough, coryza or conjunctivitis (and NO, you aren't allowed to check me for Koplik spots.)

See you all soon!

Coming to an End

Anna and I can't believe that we only have one more day left in the hospital. Our month has gone by so quickly! It seem like only yesterday that we stepped off the plane in Namibia. It is difficult to put into words the impact this trip has had on us. I can definitely say that our experiences have changed who we are as people as well as pediatricians. I will go back to the United States with a much greater appreciation for the resources that we have available not only in medicine but also in every day life.
This month has significantly enhanced our training in pediatrics. Here, we have to rely more on clincial skills and not simply lab values or imaging studies as these are not available when the diagnosis and treatment plan is formulated. We have been able to see diseases here such as TB, HIV/AIDS and even measles which are illnesses that we do not see often in the United States.
As we have described in this blog, we have experienced firsthand the devastation of HIV/AIDS. It has been very difficult to see the suffering of these children who are simply innocent victims. This has had one of the greatest impacts on me personally. I could not get used to the idea of so many innocent children dying from this disease.
As I reflect on this month, I believe that the memories that we made here will be ones that will last a lifetime and have a lasting impact on our practice as pediatricians.

Complacency

It doesn't matter how long I am in Africa, I just can't get used to the blase attitude toward death. Last week, we had a 9 year old girl admitted with epistaxis. She was found to have pancytopenia. No blasts were seen on the peripheral smear and she had a normal LDH. She was put on high dose steroids, but her counts never improved. I kept pressing for a bone marrow. I thought the girl either had ALL or aplastic anemia (the latter being more likely due to the normal LDH.) The last time I saw her, she looked sick but wasn't acutely ill. This morning, I asked Gigi (one of the interns) if they ever got a bone marrow on the girl. She said "Oh, she died." She said it with absolutly no emotion. I tried to ask questions about the death, but she kept saying "She just died." I could tell she was getting frustrated with my questioning, so I stopped. Later I found out that they think she died from sepsis. She was put on some big gun antibiotics (pip-tazo and amikacin) but it was too late. I found this whole thing frustrating. Had this girl been in the US, she would have had a bone marrow within 24 hours of admission followed by prompt treatment of the underlying cause of the pancytopenia. Plus she would have been covered with antibiotics from the beginning. But, she wasn't born in Pennsylvania with all of our state-of-the-art medical care. She was born and died in Africa.

Say what?

Several different languages are spoken in Namibia. English is the official language, but most people are at least trilingual. Africaans, German, and at least 10 tribal languages (some with clicks!) are spoken here. However, Stacey and I have learned that sometimes English is the most difficult to understand or at least to get used to. Here are some examples:

"Pleasure" means "you're welcome"
"Coke light" is diet coke (but it tastes more like Tab, which they have here too.)
"Braai" (Br with a long i) means barbeque. It is a noun and a verb.
"Is it?" means "really?"
Most Cs are pronounced as Ks. So hydrocephalus is pronounced "hydrokefalus"
"Sorry" means "excuse me" or "pardon"
"backi" is a pickup truck
Instead of CBC with diff, they order a "FBC."
Instead of a BMP, its a "UNE."
Panado or paracetamol is Tylenol.
Parents don't know what poop or stool means. They say "Kaka"
"Running stomach" means diarrhea.
"Now" means sometime in the next day or so. "Just now" means sometime soon. "Now now" means immediately.
"Tomato sauce" is ketchup.

On a sad note...

When people think of Africa, they often associate it with HIV/AIDS. Throughout our trip, we have seen the devastating effects of this illness on the children in Namibia. Today, I was able to see the effects right before my eyes. We had started rounding on patients in the high care unit on 8B when one of the nurses called the team over to the isolation unit. The intern was the first to arrive and I was following her. When I arrived to the room of this young infant who was HIV + and was admitted for respiratory distress, the intern was giving chest compressions. We were told that the baby had stopped breathing. The bag mask was not in the room so the nurse went to get it. When the bag-mask arrived, the intern tried to give breaths however we noticed that the baby had vomited and likely aspirated. More vomit came out of the mouth during the attempted positive pressure ventaliation. I informed the medical officer of the situation who advised that we were not going to proceed with any resusciation as this baby has HIV with a poor prognosis. At that point, it was unlikely that anything we could have done would have saved him. The medical officer examined him and pronounced him dead. In this hospital, if a patient has HIV they are not intubated. Although this death was not surprising as I have seen this baby over the last couple of days and watched him in such distress, it is still very different how death is approached here compared to in the United States. At Geisinger, we would have called a code immediately and a flurry of people would have arrived to start the code process. This approach is very different from what I am used to and somewhat difficult to understand due to the way we practice medicine in the US. As Anna and I have stated in previous blogs, death is something that occurs frequently here therefore people become almost indifferent to it; however, the bond between a mother and a child can be seen in any culture as I watched the mother crying and grieving over the death of her young son.

This is Africa

Ever since we stepped off the plane, and everytime something seems different or out of sorts, Dr. Brown says "TIA, this is Africa!" In clinic today, I had my very own TIA moment. A woman brought a baby in, sat down at my desk, and handed me the baby's medical passport. I looked at the birth date (July 09) and said "So, she is 2 months old." The woman replied "No, she is 4 months old." I must have looked confused because she pointed to the birth date and said "that's the day she was found in the river." I was quite surprised and I'm sure it showed on my face. The woman went on to explain that she worked at an orphanage and the baby was brought there by social services after someone found her in the river. (It is currently the dry season in Namibia, so she really meant the river bed. The rivers haven't run since March.) Baby dumping is a big problem in Africa. Women can't support their babies, so they just drop them off anywhere. Many babies are found in the bush. This little one was lucky people found her before the animals did. What really shocked me about this situation was the nonchalance when the woman told me about the baby. She said "She was found in the river" with about as much expression as I would say "We ate peanut butter sandwiches for lunch." It just goes to show that baby dumping is so common down here that its just accepted as the norm. TIA. This is Africa.

Measles Monday!!

We came into the hospital today and found that the gastro ward was turned into the measles quarantine area. A while ago, there were a few confirmed measles cases up north, near the Angola border. This made the news, so now any patient with a cough and a rash gets admitted with "probable measles." None of our cases our confirmed yet, and I don't think any of them will be. We haven't seen any koplick spots or any impressive conjunctivitis. And none of them are from the north; all of the "measles" patients live in Windhoek, most in the slums of Katutura. I am pretty sure all of our patients just have colds with viral exanthums. We have sent out measles IgM on all of the suspected cases, but they take a long time to come back. For the sake of everyone's sanity, the IgMs better come back soon. We are going to run out of beds for the actually sick patients! Both Stacey and I know that people with measles don't need to be admitted unless they have complications, but its hard to get that through to all of the interns and the outside docs. And yes, Mom, we are washing our hands frequently and wearing masks on rounds (even though we should be immune.)

TGIF!!

Stacey and I had quite the clinic afternoon. In under 3 hours, we saw a total of 14 patients (just between the two of us) admitted 3, and sent one patient's blood for measels!! It was exhausting! We have had a long week and are too tired too type much now. I am posting a chest xray of one of the patients I admitted. I'll let you figure out the diagnosis. With that said, both of us are turning our brains off for the weekend and going to the mall.

Thursday

Today, we had an acedmic conference to discuss how to evaluate a blind patient. On 8A, we have a 12 year old girl who has experienced progressive bilateral blindness for one year. She had a previous diagnosis of optic neuritis and was treated with steroids. She is now totally blind bilaterally although she has no other neurologic symptoms. She came to Katutura Hospital for further evaluation. A CT scan of the head suprisingly revealed hydrocephalus and a tumor in the cerebellum. Due to the hydrocephalus and the location of the tumor, the presumed diagnosis of tuberculosis meningitis was made and she was started on treatment. She is now awaiting evaluation by the neurosurgeon for placement of a VP shunt. TB meningitis continues to be one of the most common diagnoses that we see here, one that is very uncommon in the US.
We also experienced another afternoon in the POPD (outpatient clinic). Anna had two interesting patients. A 3 month old male with macrocephaly and signs of increased intracranial pressure who was admitted for evaluation for VP shunt placement by neurosurgery. It is amazing the number of cases of hydrocephalus that we have seen here. Often, the cause is due to TB meningitis. She also saw a 7 month old patient who had been treated repeatedly for chronic constipation. On further examination today, it was felt that she may have an abdominal mass so she was admitted for further work-up. It seems that every afternoon, we see patients with interesting diagnoses. Today, I felt like I was back a Knapper seeing patients with diarrhea, atopic dermatitis and URIs. It is sometimes nice to see that African children can have many of the same illnesses that American children have.
We are looking forward to the radiology conference tomorrow morning where we can view and discuss all of the images of the patients from the week on the wards with the radiologist.

Our patients: the good, the bad, and the adorable!

Tuesday

Today, we continued our daily routine of rounds in our respective wards in the morning and seeing patients in the clinic in the afternoon. On 8B which is the ward for patients older than two years of age, there are a lot of interesting cases that continue to be a work in progress. As we have commented before, many of the patients are waiting for imaging or for a subspeciality service to evaluate them which can sometimes take a long time. There is 2 year old boy who was admitted for evaluation of potential malignancy. He has had an extensive work-up including a lymph node biopsy and an abdominal/chest CT scan. We are still awaiting the biopsy results. His potential diagnosis is Histocytosis X based on the differential given by the radiologist who read the CT scan. He was supposed to have a bone marrow aspiration today however the correct supplies were not available at Katutura (the bone marrows are usually performed at Central Hospital) so the procedure was postponed until tomorrow. We also had a 3 year old female who was admitted with bilateral lower extremity weakness. All of the work-up including the LP was unremarkable therefore the potential diagnosis of Guillan-Barre Syndrome was made. The management here is simply supportive care. The weakness does seem to be improving and she will be discharged home soon.
Outpatient clinic continues to be an exciting place where we are getting to see a variety of illnesses that are not as common in the United States. Anna and I are getting the opportunity to see patients on our own and formulate a management plan. Each day, it gets a little easier trying to navigate through the medical passport that contains each child's medical information. I was very lucky today the the majority of my patients mothers spoke English which makes communication so much easier. Today, we saw a one year old female with varicella who was otherwise healthy. We also saw a patient with newly diagnosed Hepatitis B. We continue to see our share of many of the same diagnoses we see in the US including eczema, diarrhea and otitis media. The challenge here is trying to determine what medications are on the formulary and available to prescribe for treatment. Each day continues to be a tremendous learning experience.

Happy Labor Day!

It may be a nice day off today in the states, but here in Africa, it was just a typical Monday. We rounded on our respective wards again and went to clinic in the afternoon. One of the things that keeps striking us is timing. At Geisinger, we can order lab tests, xrays, even MRIs and they will be done pretty quickly. We can even view the imaging studies minutes after they are completed. This is not the case here in Namibia. Lab tests are ordered on rounds, then the intern draws the blood after rounds and it is sent to the lab. The lab (or Namibian Institute of Pathology) completes the labs within 1-2 days. Usually, we have to call the lab to get them to hurry tests along. Imaging studies take even longer. All of the larger machines (MRI, CT scan, echo, ultrasound) are located at Central Hospital. It is a few miles from Katatura State Hospital. So, anyone who needs any of these tests has to wait until the days that the techs are at Central to do the tests. We have several kids waiting for echocardiograms that will not get them until October. Stacey has a 13 year old patient who came in because she couldn't see. It took over a week to get the CT done and even longer to read it (actually it isn't even officially read yet.) The CT showed a large ring enhancing lesion. So now they are waiting for neurosurgery to come see her and decide what to do next (the neurosurgeon is on vacation.)

All of this waiting can be very frustrating. It is making us rely more on our clinical judgement. We only order tests that are absolutly necessary. In clinic today, we saw a 6 day old infant who was jaundiced. If we had been at Knapper, we would have ordered a stat bilirubin, waited an hour for the results and then either admited her or sent her home on a wallaby. This baby was a preterm infant and she was jaundiced down to her toes, so we knew that she would need phototherapy (and they don't have wallabys here.) Rather than waste 3+ hours waiting for her bilirubin level, we decided to admit her and start the phototherapy right away.

Thursday

This morning, we helped Dr. Kaaya put on a very condensed NRP course for the interns. She took the whole course and shortened it to under 2 hours. After that, we had daily rounds and then set off for the OPD again. Stacey and I were allowed to see patients on our own today, but we had to ask Dr. Kaaya for advice several times. We also needed several interpreters. There are at least 11 languages spoken in Namibia, and most people speak at least 2, so we were always able to find somebody who could translate. My first patient ended up being very interesting (and sad) and I had to admit him. I'm not going to tell the story, because I'll probably use him for a morning report.

The most difficult thing about clinic was not the language barriers, but the yellow passports the kids carried with them. Its basically their medical record from birth. They carry them around and doctors write in them anytime they were seen. They were so confusing! I couldn't read most of the handwriting or understand why they were given certain medicines. An 18 month old boy came in with a cough for 2 days and "oh by the way, he was diagnosed with TB in June but never treated and opps, we lost his passport." I was so confused! I think he just had a cold and not TB, but we did a ppd and a cxr anyway. After today, both of us are very thankful for EPIC.

Namibian Knapper

This morning we had rounds like the previous days. The picture is of a cute little guy with congenital heart disease in failure. They don't know what the lesion is because they are still waiting for an echocardiogram. That seems to be a recurring theme. Everytime we walk in the room, he holds his hand out.

After lunch, Stacey and I had our first afternoon at the OPD, basically Knapper Walk-ins Namibian style. In order to figure out how things were done, we hung out with one of the interns while he saw patients. I think we taught him more than we learned. Our first patient was a 2 month old with a cold. We prescribed nasal saline drops. The second patient was a very well hydrated 3 year old with diarrhea and vomiting. We gave him ORS, told his aunt not to feed him too much at a time, and sent him on his way. The third patient was scary. Had we been at the big G, we would have called a "peds 99." The nurse (we call them sisters here) rushed back and said "Doctors, we have a very sick baby you need to see. I already started and IV and drew blood!" It was a 4 month old severely emaciated female in respiratory distress (on the edge of failure.) The sisters told us that she was a "PWA" or person with AIDS. She came from an orphanage and weighed 3kg. It was really awful. She was so sick. All we could do was put oxygen on her, send her for an xray, and tell the caregivers to take her to the peds floor to be admitted. When she left the clinic, her breathing was slowing down and it started to sound agonal. I don't think she will be alive when we round tomorrow.

After we settled from that excitement, we saw a few more patients. One had major nasal congestion and respiratory distress secondary to tonsilar hypertrophy. We sent her to ENT. The last one of the day was a month old female with chief complaint of a cough. 2 days ago, she was put on amoxil for a URI. The coughing got worse. She was coughing so much that she would stop breathing and turn blue. The parents got very worried and her mother gave her a medicine from a friend (it was some kind of bronchodilator.) She still didn't improve, so they bought her to clinic. Stacey and I listened to the story (and to the baby coughing.) The intern turned to us and said "What do you think? An upper respiratory tract infection?" I said that we were more concerned about pertussis. The intern looked at us, slightly bewildered, and said "I think I'll need your assistance on this one!" We advised that he admit her, get an xray (she had crackles on the right), check a blood count, and start azithromycin. I'm not sure if they can check for pertussis here, but I suggested that he do that too.

Then our clinic day was over. I am constantly amazed and horrified at all we are seeing.

Lessons from the second day

Anna and I had our 2nd day at Katutura Hospital today. We rounded on many of the same patients that we had met the day before. We are finding that each and every day, we are learning many lessons about medicine here in Namibia. Anna had an experience in which one of the babies who suffered from severe malnutrition had died yesterday. When she came in today, the nurses said, that baby died and that was the end of the conversation. This is very different than the reactions that we have to death at Geisinger. Death is somewhat of a normal occurance here. Also, we have found that we should be very grateful for the resources that we have at Geisinger. The interns here are responsible for all blood draws as well as IV insertions. Also, we often take for granted the diagnostic tests that we have available to us in the United States. There are many patients on the floor that I am rounding on who are waiting weeks to have a CT scan. Anna had a patient who is waiting for an echo until the end of September. In just the first two days here we have not only seen many illnesses and diseases that we do not see in the United States but we have also realized how very lucky we are to have the resources available to us. We are very excited for our day tomorrow since it will be our first day in the OPD (outpatient clinic). More to come tomorrow!

Stacey and Anna