Princess Marina

Still in search of an extracurricular activities that are a good fit, last week Derek and I got connected with a shadowing opportunity at Princess Marina Hospital (PMH). The process was refreshingly efficient. We met with an administrator in the Medical Education department on campus, she made one call to PMH and had a meeting arranged for us later that day. At the meeting, the coordinator of clinical exposure for the hospital asked what our interests were and outlined a shadowing program that would fulfill our needs.

That same day we met with a specialist in the medical ward and she gave us a brief tour and introduction to the work she does. She told us to come back at 7:30 the next morning for the daily meeting and after that we could join teams for rounds. We obliged.

Despite the early morning wake-up, the meeting was fascinating. It opened with nurses reporting admittances and mortalities from the night before and we got to hear all of the different cases the hospital faces. The words I heard over and over were anemia, meningitis, pneumonia, TB, and the most common, unfortunately, was HIV.

More than half of all patients admitted to PMH are HIV+. Botswana is at the point in the epidemic, however, where patients are no longer coming in because they have HIV (they have already been diagnosed and are receiving treatment) but rather because of a secondary or concurrent condition caused by HIV.

Meningitis incidence is fairly low around the world, but due to its co-infectious nature with HIV, it is the number one diagnosis made upon admission at PMH. The same is true for pneumonia and TB, cases of which seemed to be everywhere I turned as I moved through the hospital.

Even if a person avoids co-infection, the antiretroviral (ARV) drugs that patients take have serious side-effects. One patient we saw had Stephen-Johnson syndrome, which is a disease of the epidermis that can be life-threatening. Rashes and painful lesions appear near mucus membranes all over the body, most notably in the mouth and eyes. Official websites list the syndrome as extremely rare, but the dermatologist at PMH said she sees it all the time here because it is a common repercussion of ARVs. Of course, the immunodepressant aspect of HIV makes the side-effects from drugs that much more serious. Also, Steven-Johnson syndrome is easily treatable by taking the patient off of the drugs that cause it, but with HIV, stopping a drug course risks the development of drug-resistant strains of the virus. It's like being stuck between a rock and a hard place and another rock.

After admittances, the nurses reported mortalities and the response from the room was not what I expected. When the first name was read, the doctor who had been responsible for that patient said, “I never saw it coming” and the whole room laughed. Apparently that’s what they say every time one of their patients die, and it's become an inside joke. Another name was read off and another joke was cracked. I was sitting there becoming quieter and more introspective, but I suppose I should have been developing my own coping mechanism; you certainly couldn’t sit through those lists day after day if you lamented the injustice of every passing.

Next, one of the doctors made a presentation about an interesting case he had the week before. It was an interactive talk, as the doctor would discuss the symptoms and ask the room what they would have done. It was such a good mechanism for professional development and keeping people on their toes. If I had understood more of the medicine I would have learned a ton.

The meeting broke after the presentation, and Derek and I were assigned to two different teams who were going on rounds for the morning. The first case my team saw was an elderly man who was recovering from a second round of TB. We looked at his chest X-ray and the doctors explained how his right lung was decreased and pointed out signs of chronic lung disease on the left side. I got to listen to his breathing through a stethoscope and experience what the breathing of a two-time TB sufferer with lung disease patient sounded like. Raspy, to say the least.

We moved on and tended to patients throughout the ward. Some were anemic, others just had dizziness. One patient had such bad fluid build-up around her brain that she was delirious. She needed daily lumbar punctures to relieve the pressure and relieve her neighbors of her nonsensical screams.

One man, who was a 62-year-old named Rocket, had originally been admitted with a mysterious illness that left him bed ridden and speechless. Over the past week, however, he had made a recovery and was walking around, talking to whomever he could. My first encounter with him occurred as he was trying to fill up his water glass. He went to sink and turned the faucet on full blast. He stared, fascinated, at the stream of water. Once in a while he stuck his cup under the water and it was running so hard that it splashed everywhere. He would pull his arm back, but eventually test it again, like a curious child. The nurses courteously shut the water off as the basin began to overflow and I asked the doctor what the fascination was all about. She responded that Rocket perhaps had never seen running water before being admitted to hospital. It reminded me of the inequalities that are prevalent in Botswana – not only between rich and poor but between urban and rural as well.

In talking to Derek afterwards, he had been in the surgical ward for part of the day, and while his team was tending to a patient, the neighboring patient started to crash. The head doctor tried defibrillation, but it didn’t work, and none of the local staff could find a ventilator, and the patient died. It highlights the lack of resources the hospital has. Some of the doctors on my team were from America, and they were constantly saying things like “well in America we would do this, but Botswana doesn’t have the supplies, so we do this instead.”

One American doctor said the supplies aren’t even the real issue. She thinks the hospital desperately needs a workplace engineer to come and solve the issue of miscommunication between nurses and doctors and between various departments. It certainly reinforces my drive to go into public health and do what I can for places like these, where they run out of tape to keep IVs in place and have nurses lose track of patients' files. The list of things we take for granted in the states was building by the minute.

The hospital was enlightening in many ways. Going on rounds is not something I could do everyday in the states, and I tried to make the most of it.

If anyone has spare medical ventilators, maybe donate them to Bots…

Chicken quesadillas (Derek’s idea) with homemade guacamole for dinner…