A couple pics to tide over my mother. Happy weekend!!!!

Kevin looks awfully serious. I think this one is bee-ooo-tiful. I ordered myself a herd boy with herd, dog, and green mountain backdrop. I'll pick it up in a few weeks.
Ethel got a great rug.
This boy was biking up and down the walkway when we got back from the weaving cooperative. He was pretty psyched to have his picture taken.

The process

Wow, I love Charlie Haden and Pat Methany’s Beyond the Missouri Sky album so much. I also love peppermint tea with a dash of 2% milk. This might be a short entry. Sorry, mom, but I am staying daily so you can hardly complain.

Seven momentous days in a row is a lot to handle. Today my first patient died. When Mdate (“mister”) L. came into the hospital on Tuesday he seemed like the healthy guy on the ward. He was having some difficulty breathing but could speak in full sentences of broken English, helped by his lovely sister, could walk to the bathroom without oxygen on and, with a brave smile, told me to pull the tourniquet tighter to expose his prominent veins to draw his blood. Like nearly every inpatient, he was HIV+, but had the relatively high CD4 (immune cells preferentially decimated by HIV) count of 138 a couple months ago. A count under 200 designates AIDS and puts people at risk for serious opportunistic infections that I’ve never seen in the States, like PCP (Pneumocystis Carinii/Jiroveci Pneumonia), Toxoplasmosis, and Cryptococcus, but CD4 counts in Lesotho tend to be ridiculously low, so he seemed in relatively good shape. He was a smiley and tender 32yo man who had worked as a driver until September, when he had started wrestling with bouts of fatigue that precluded work. He also had some bilateral nontender facial swelling, broken blood vessels on his tongue, an enlarged heart, and some very recent blurring of distance vision. His difficulty breathing was his most serious problem so, using our limited formulary, we gave him antibiotics and steroids to cover possible PCP, antibiotics for community-acquired pneumonia and a possible oral infection (which might explain his salivary gland swelling), collected sputum samples which did not reveal tuberculosis buggies, and he seemed to be getting better.

This morning Phil picked us up at the convent house (he lives in a neighboring houselet) and we swung by the Leribe Hotel to get a visiting family medicine doctor from Blomfontein, South Africa, who is a specialist in tuberculosis, and drove to the Maluti hospital. I was seriously bushed and read Don’t Let’s Go to the Dogs when I couldn’t muster conversation in the truck. She gave a helpful lecture to several residents, doctors, and us visiting medical students on pediatric TB and, after a short tour of the Maluti facilities we picked up a hitchhiking nurse and headed back to Motebang.

I thought my female patients were pretty stable, so I went to the Male Medical Ward to round on Mdate L. The nurse, whom Ethel had warned me was potentially senile and certainly unhelpful, was leaning into the window onto the patient room as if she were watching a Little League game. I introduced myself to her before I followed her gaze. She then said, “One of the patients is ill.” I saw that the brother of a very, very sick patient was standing at the head of Mdate L.’s bed wiping his mouth. His head was slumped onto his chest and the kind brother was wiping trickling saliva from his lips. As soon as I saw his irregular gasps I knew he had turned a really bad corner. (Jeez, I just wrote “coroner” by accident; thanks, Sigmund). I listened to his lungs which were junky and infrequently used, listened to his heart which was strong but somewhat irregular and 40 beats per minute slower than it had been the evening before, and was unable to feel a radial (wrist) pulse, a clue that his blood pressure was likely lower than maybe 90 systolic. I sat him up, put oxygen on him, and went for a bag to help him breathe and IV supplies while Ethel went to get Phil. The supplies are terribly hard to find, since they’re in short supply and erratically placed around the ward. I managed to find IV supplies but no bag-valve mask.

I had tied a glove around his biceps (for lack of a tourniquet) and was about to start the IV when Phil arrived and, when he said, “I don’t think that will help” I immediately knew he was right. Mdate L. seemed remarkably comfortable despite his brainstem-driven agonal breaths so we held his hands, kept his oxygen mask on, and listened to his heart and lungs every few minutes. I stepped away to speak with his sister, who was looking on wide-eyed from behind the male nurse who had gathered potentially helpful supplies. (The female nurse stood by silent and remarkably inactive for fifteen minutes before retiring to her desk; what?!) Kevin and Ethel had told me about the ways that the Basotho people seemed most comfortable (not) talking about death, so I put my hands on the arms of Meh L. and said, “I’m so sorry, Meh, but your brother is critical. He is close to the end and there is nothing we can do for him.” She scrunched up her face and said, “Is he gone?” I said, “Not yet, but soon I think he will be.” She sank towards me a little, turning her face towards the outside window and cried a very little. I told her she could stay or leave, whatever she wanted and, making sure she was steady on her feet, let her walk into the hallway with the other sick man’s brother at her side. For the next half an hour Phil and Kevin and Matheko and I stood holding the man’s head and hands and just being with him as his breaths and heart beats got farther and farther apart. A couple minutes before his last heart beat he pulled his left arm towards his body, protruded his tongue a little, then relaxed one final time. It was good to be there with him.

After we had removed the oxygen, closed his eyelids, and pulled his blanket up to his chin Matheko helped me talk to his sister and her husband. I squatted down at his sister’s feet and, trying to feel out what she wanted to know, explained a little that his lung disease had gotten so bad that trying to help his heart would have been a futile effort. Looking calm and resolute she said, “Thank you, doctor. I am satisfied.” I walked with her to give her one last look at her brother then wrote the final paperwork, including the traditional “R.I.P.” at the end of my last note. I found out later today that the family had told Matheko they had lost a sister just last week. What an overwhelming disease this is for this little country.

The rest of the clinical day was long and inefficient but allowed me to feel useful and even to feel nice connections with patients and nurses. And what a comfort it is to take care of patients with friends. A girl who was stung by bees developed hives and low blood pressure but responded well to medication and never had airway problems. Fadya left me with her to track down medications, keep her IV open (despite the crap-ass cheap plastic tubing which kinks if you look at it funny), and decide when it was safe to leave her for the night. It was nice to be trusted. Kevin and I took turns trying to place an IV in an older woman with terrible veins. Something was therapeutic about the focused task and I felt a disproportionate rush of satisfaction when he finally found a good vein and the saline we attached flowed easily up her arm. Small victories. The mother of the young woman who had vomited on her nasal cannula and been moved to the isolation room to die overnight grabbed me in the hallway and beckoned me into the small converted storeroom. The girl was sitting up and smiling at me with a light in her eyes I certainly hadn’t seen when I stole her oxygen for the seizing mother yesterday. I got tingles down my spine and the mother clutched my shoulder and said, “You doctors work so hard”. I had a hard time finding my voice to say, “I am so happy to see your daughter looking so strong”. Just then an old woman lost control of seven chickens in the hallway and somehow wrestled them into two cardboard boxes now empty of IV fluids. The heaved the boxes onto a nurse’s cart and rolled the cart outside while the nurse yelled, “She’s stealing our cart!” and we busted our guts laughing. I gave out only one more sticker, a shiny dragonfly perched on a daisy, to a 5yo girl with a secret shy smile who then tried to place the sticker on the face of her infant brother papoosed in a blanket on the back of their amused mother.

The visiting doctor gave us another lecture, this time on neonatal care, and I had to change position in the warm room every ten seconds to keep my eyes open. All of us-- students, residents, and attendings-- seemed to be fighting the sleepies despite the quality of the talk. We all seem wiped out. This is hard work, even for those used to it. After a little evening email session a couple public health interns dropped us at the Pelican where we picked up the same old chicken and rice take-away meal and strolled, sipping our beers, back to the convent to eat dinner and play Bananagrams to the soothing voice of Johnny Cash. Ethel and Kevin finalized details for their upcoming tour of Southern Africa while I knitted for Miss Cletus the Fetus and reached my goal of transferring to my second skein of yarn before Coach Ethel’s departure. In a strange way, all is right with the world (except that Kevin’s Smartwool socks are missing from the laundry line, a problem which is comforting in its pettiness). Tomorrow I’m hoping to start two patients on TB medications, get another tested for HIV before she transfers to a smaller hospital closer to home, and send bee sting girl back to school in her uniform, hopefully in time for us to get a ride to the women’s weaving cooperative before it closes. And this weekend I will sleep. Good night, Liz

A birthday, Versace, Walmart, and Seizures of Pregnancy

First off, HAPPY BIRTHDAY, SCHUYLER!

Second off, please click the “comments” link at the bottom and leave a little note when you feel like it. It’s nice to feel like I’m writing to people and I’ve loved the comments people have left on prior entries as well as the wonderful emails. I’d also like to know what else people would like to know. Weather? Cultural music (I’ll try to upload an audio file of the women’s support group who sing harmonized spirituals every lunch hour)? Hospital staff? Perspective on HIV? Basotho food options? Attitudes towards healthcare? Currency? LeBoHA program details? Travel options? Amount of sweat produced daily by the average visiting medical student? Flora and fauna of Leribe?

Third off, I gave out my first sticker today and will work hard to give out the 5,999 others that Laurel and Misko gave me. There was a 4yo boy riding the communal Motebang hospital black scoot-along plastic bike and I gave him a “favorite horses” sticker which he stuck on the back of his hand. I’ll take a picture of someone on the bike soon because there’s often someone scooting on it.

Fourth off, fun activity today: some time before I arrived Ethel and Kevin were picked up as hitchhikers by a man from Mauritius who runs the only profitable textiles factory in Lesotho. He employs 2,000 people, 90% female, who produce 1.7 millions pieces of clothing every month for Walmart in the U.S. It’s estimated that over 60% of his employees are HIV positive and, as he was losing 15% of employee time to medical appointments, he decided that he should employ a nurse full time to staff an on-site clinic. He invited them to bring colleagues to come to his factory for a tour. So today, after we finished rounds and urgent patient care duties, Ethel, Kevin, Phil (one of our two attendings, the one from Maine) and I headed off for a late lunch from Shoprite in the truck and took a quick ride to the factory in a neighboring town. The guard let us in the front gate, past the big sign in English and Chinese, and the owner met us at the door in his Versace jeans and led us upstairs past windows onto an impossible number of people in masks at rows of sewing machines to a conference room and offered us Cokes™. He seemed like a really good guy who has partnered with an NGO which looks after textile workers and their health, especially their HIV needs. After talking for a while and finishing our drinks, he took us on a tour of the facilities from the warehouse full of cloth from China, to the fabric mass-cutting area, through the long floor of piece-work sewers, to the ironers, to the spot cleaners (who must drink milk to clear the ethyl benzoate or something and who can only spend a month doing their job before rotating back to the floor), to the incinerator whose heat from burning cloth scraps powers the plant, and finally through the folding and shipping area. I felt like I was on an episode of “How It’s Made”, which was gratifying in its raw-materials-to-packaged-product fullness. We visited with the nurse who hangs out in a little garage across the parking lot, sees a full load of patients each week day, writes prescriptions for antibiotics, works with volunteer HIV staff one day a week (they can start anti-retrovirals and do on-site HIV testing), and has a good shelf full of female and male condoms (though I don’t know how many she ends up giving out). I can’t decide how I feel about this place. It provides 2,000 jobs for Basotho women, the manager credits his success to the “family feel” of the workforce and the company-wide communication, yet factory work sucks and I can’t imagine the employees make a ton of money. We headed back to the hospital with four free moisture-wicking shirts in our hands.

Fifth off, nobody I had met died today. That was great but doesn’t mean nothing awful happened. We’re doing a grand reshuffle of patients so that the medical students and our wonderful registrar (resident) Matheko are all carrying an evenish number of patients, all being overseen by Matheko who is building her necessary management skills for her future working in similarly overwhelming environments. So I was getting to know my two patients on the female medical ward when Kevin and I were called in silently and urgently to the maternity ward (though I didn’t yet know this was the maternity ward and thought Kevin was really clever to ask if she was pregnant. That’s not to say he’s not really clever, because he is abnormally clever, but this wasn’t the stroke of genius I thought it was). A 20yo girl who, by fundal (top of the uterus) height, was an estimated 22 weeks pregnant (a finger-breadth above the belly button) was having persistent but physically quiet seizures in her bed. In someone without a seizure disorder, this is mostly caused by eclampsia, characterized by high blood pressure, kidney failure evidenced by protein in the urine, and the potential for nasty hemorrhage in a variety of organs. The two of us and a totally beautiful person of a nurse held her safely, protecting her precious IV line, rolling her on her side so she wouldn’t swallow her secretions or block her airway with her tongue, and gave valium and then, when it was located, magnesium sulfate in her IV and both buttocks. For the non-first-aid crew out there, the ABC’s which dictate the appropriate order of emergency medical management are Airway, Breathing, and then Circulation, meaning you don’t even try to help someone do the mechanical work of breathing until you’re sure she has a clear path to the lungs. To manage an airway you might want a little curved tube that ensures that air gets past the tongue to the back of the throat, an “oropharyngeal airway” (OPA). We don’t have those. If someone is having seizures for half an hour (good lord) you might want to intubate them with a tube that goes all the way down the trachea to where the lungs branch off. We don’t have endotracheal tubes. So we went basic and did the occasional jaw-thrust, pushing her mandible out when she started making tongue-sucking snoring noises. Luckily she never vomited. The valium and magnesium hopefully stop the seizures but also, by dulling the central nervous system, suppress the respiratory drive. Despite some episodes of irregular breathing, she didn’t slow her respiratory rate too severely. The only definitive treatment for eclampsia is to deliver the baby, the unwitting cause of this mother-threatening disease. Fadya, the other great attending (from Rhode Island), grabbed a Doppler machine which amplified an appropriately fast and regular fetal heart rate through the filled maternity room, to see if the fetus, should it prove to be developed enough, would be “viable”. I hate that weird, clinical word, but don’t have a better one. After a vaginal exam, which required serious muscular control of the woman’s flailing legs, revealed a closed cervix not ready to deliver even this tiny fetus vaginally, the only option was to take her for a C-section. Unfortunately the one and only surgeon was already in the operating room (theatre) performing another section. So we had to continue trying to control the seizures, keeping the airway open with our basic first aid methods to receive the oxygen we were giving by facemask (borrowed, by the way, from the face of a young woman with her feet up in the air to return blood to her head while her blood pressure hovered around 70/40 and she vomited onto her pillow – a woman who was moved a couple hours later to an isolated room because her expected overnight death would be upsetting to the other seven women in the room), and continuing to guard the IV line from the erratic and occasionally semi-purposeful movements of the seizing mother. Eventually, after maxing out on our medications in a well-communicated dance of safely-handled needles, Kevin and Fadya and I rolled her on a gurney to the surgical building where she had her hopefully-life-saving C-section. We’ll find out tomorrow how her brain, kidneys, and liver survived the trauma of this weird vascular collapse. The baby was a girl who weighed 800g (1 lb 12oz) and, given the futility of resuscitation efforts, was covered with a towel to slip off with hoped-for peace. The girl had not received any prenatal care during which someone would have noticed that her blood pressure was high and that there was protein in her urine. She was from South Africa and living with her grandmother in Lesotho who found out the girl was pregnant as she was being wheeled to the surgical suite. Oof, oof, oof… the solution is in public health, not bedside medicine.

Sixth off, Kevin made a really nice beans, veggies, sausage, and rice mix for diner which tasted awesome with Milk Stout.

Seventh off, I’m going to sleep. xo, Liz

Day 2 - a little better

My first Basotho thunderstorm is moving out of Leribe and the sounds bring me back to Huron City, my extended family’s Tip O’ Thumb Michigan haven. Oh, sweet, free, easy August!

I wrote in a journal recently, “I am someone whose thoughts are often on the future at some level of consciousness.” That can be a wonderful and balanced state of being but I also find myself fantasizing about being singularly focused in a Paul Farmer, slightly crazy kind of way. Even being a better student with a mind built for memorization and extensive differential diagnoses would be a good start at those wistful times. I give myself a hard time about that with some regularity but always circle back to my love of sanity and breadth; my true wish is to be a happy Renaissance woman.

I guess my favorite kind of sanity and breadth comes with those days or long periods that include feeling singularly focused on several activities I love in succession, like some high school day in 1995 that started with morning lacrosse practice, proceeded through beloved AP English with Mr. Pullman, lunch-time orchestra rehearsal, a double session of mouse dissection, and ended with club soccer practice, a Saxy Four rehearsal, and an overnight of laughing and arguing about the existence of god with my best friends. I think that was the last time I could list six things I did well and fill a day with them. I’ve always thought of sports and music as worlds in which I was forced to be in the present. And I think I need to have several active parts of life to feel like I can give myself fully to any of them. And therein lies Liz’s problem with medical school. Despite fighting hard for sanity and balance by injecting short bursts of athletics or friendship connections, for four years I have not had enough time to do anything else but medicine intensely enough to feel lasting satisfaction. “The rest of life” has been on hold.

This last two months of medical school, which I’m spending in Lesotho, is so damned different from what I’ve immersed myself in for four years that it feels like the beginning of that rest of life. And what on earth could feel more intensely present than learning from a friend how to do a femoral venous blood draw and then a spinal tap on a woman with HIV and suspected meningitis in a room full of sick women and their families in the middle of a small town in Africa where HIV prevalence is 30% and my TB mask strap is slipping slowly up over my head? Thank you, Kevin, for encouraging me through that and for helping keep the calm. There was the orchestral real-time coordination of encouraging the patient to stay in the right position, talking to her through the nurse/interpreter, handing equipment back and forth with Kevin while maintaining a sterile field, and inwardly acknowledging the intensity of the culture in the room which has seen the life expectancy cut from 70 to 40 in the twenty-three years since HIV arrived from the mines of South Africa.

Entering Motebang this morning I had that sophomore feeling of, “Oh this craziness? I know this craziness.” Day two of greeting nurses and families in Sesotho was mostly fun, not an opportunity to screw up. Day two of chickens wandering by the wards was familiarly funny, not distractingly odd. There are those chickens, again. Oh, those goofy old chickens! Building after building of really sick people became the organized surroundings of my particular patients for whom I had plans, not just a mass of awe-inspiring disease. This is not to say anything today was easy because it wasn’t. I still have to think through every tiny little step of my patient care, but at least I can start trying to do it myself, even if I have to track down Ethel or Kevin for every other step. Tomorrow maybe it’ll be every third. And they’ve both reassured me I can ask the same question over and over again until they leave Saturday. And next Monday I’ll start showing Joe, my friend arriving on Saturday, what we need to know.

In any kind of medicine autonomy helps. It’s much harder to take over care for a patient from a colleague than to greet the patient when they first arrive. If you get to take the initial history, ask the questions that make sense to you, establish a relationship with the patient as a primary one instead of being the substitute teacher trying to catch up on the goings-on of the first half of the semester, everybody feels better. Having admitted my first patient to Motebang I feel like I’m going to have a real job here. Even if I’m not ready for that job, I’m starting to have a sense of the goals, the players, and the tools.

Going into medical school I felt I had the paramedic advantage over many of my colleagues of being able to recognize “really sick” from “not so sick” which can be surprisingly difficult. Today, walking home from a skyped conference call to BU Family Medicine grand rounds (a big lecture) on the LeBoHA project, the three of us were talking about who was doing poorly enough that they might not make it through the night. I’m starting to recalibrate my sickness-meter. The question now is not, “who should be transferred to the ICU?” but whose bed may be empty in the morning? They would all be in the ICU at home.

Yesterday we did a transthoracic echocardiogram (an ultrasound picture of the heart through the chest wall) on a 16-year-old tiny, tiny girl with AIDS diagnosed at age 12 and newly suspected TB. Her heart was enlarged on a chest Xray so we took her to the archaic ultrasound machine and did our best, without a cardiologist, to make sense of the pathology of her heart. As her mother was pushing her wheelchair the girl’s head fell back to full extension and the mother had to walk snug up against the chair to prop the cachectic girl’s head up like that of a newborn. On the ultrasound table she lay flaccid and deliriously and repeatedly asked for her father. There is a cardiologist from Canada volunteering in the AIDS clinic on campus and we were hoping to consult with him today but this morning the girl’s bed was empty. I am recalibrating.

Again, I’ve stayed up too late making some sense of the day. There’s a spider in the bathroom and something large and mewing outside. Good night!

And so it begins

(A picture from Ethel's camera from our night out at Mimmo's in Maseru on Friday.)

3/23 and it’s 10:45 so I’m going to bed soon. My first clinical day at Motebang started with hearing that the baby from last night had died and ended with a few minutes of chest compressions on a 40ish-year-old woman who died. In between were patients who were all sicker than almost any patient I had ever seen prior. When I inexplicably lost my IP address and couldn’t communicate with America I could hardly keep from crying. I was more wiped out than I could even realize when I walked home with Ethel around 6:30 to borrow a big pot from Sister Lucy at the convent and start the barley mushroom soup project. Thank god we had beer in the fridge and Dr. Phil coming for dinner, because I might have just slinked into my bedroom and laid there until morning. Instead we had a really nice evening of planning our desert island belongings and researching Greek gods over warm, healthy tastiness.

Wow, overload on temporal wasting, though. Every one of these patients could be a “momentous really sick patient” whose social and spiritual history I will always remember from medical school. But, since the entire population of a small hospital is that sick, I don’t think I’ll have the chance to get to know them in such a personal way. On the upside – I’ll get to draw a bunch of blood, build autonomy, gain perspective on health and death, and will get to generally muddle through in ways the American system protects me from but which will make me a wiser and more independent doctor. Ahh! Profiting from the sick feels like such a moral paradox. But this is what the world is like, and here I am learning to help. And tomorrow I’ll be a little less overwhelmed and a little more effective.

I am so glad I have six weeks here, not ten days, not four weeks. I want to give a full picture of what I saw today but I don’t have that picture yet and I certainly don’t have the energy to try to write it down tonight.

I’ll leave you with a funny image, though. Each ward of the hospital is in a separate one-story brick building connected by cement walkways and in view of incredible, rocky mountains. Ethel and I were walking a blood sample to the lab building and walked out of the female medical ward to the connecting walkway. There we saw a three-year-old boy with his pants around his knees peeing onto the wheel of an empty wheelchair. He looked up at us with a vague smile of innocent greeting. Dumela abooti!

Good night.

Tomorrow I shall cover myself with a fig leaf.

3/22/09, 10:20pm, a Sunday evening at the convent B&B in Leribe. Physically, I should be tired but, again, I’m wired before bed. There’s been such an immense amount of important newness these last four days that I can’t put myself to sleep. I feel like I did when I was a kid lying in bed listening to the adult party continue in the living room of the Seneca Street house, wanting to be part of whatever was happening. I guess I still have a hard time leaving parties, but we all knew that… But nobody else is up. Our young doctor roommate from Zimbabwe was asleep when we got home from the hospital and Kevin and Ethel have retired, appropriately exhausted after our weekend. And here I sit in the kitchen listening to crickets and the occasional Zimbabwean cough (it’s just a tickle, it seems), and sipping a “refreshingly crisp” Hansa Pilsener brewed from “The kiss of the Saaz hop” in Maluti, down the road a fur piece (sp?). So let me fill you in, people I love and from whom I feel oddly separated:

First let me say that my welcome here could not have been better. Maybe I’ve said that before, but Ethel and Kevin are the perfect people for the job. They’re funny, gentle, and enthusiastic, smart and confident with wonderful awe, and appreciate my bursts of both thrill and overwhelmedness. On Saturday we made our way from Maseru to Leribe (the town is also called Hlotse and is within Leribe province/county, but most seem to refer to the town itself as Leribe). Sara and Josh had rented a car to get themselves to Jo’Burg, so I got to ride just with Sara and have the one-on-one catch-up I’d been waiting for. The ride took maybe an hour and a half and was my first glimpse of the roads outside the capitol. The entire way they were teeming with people: shepherd boys in oversized beanies, blankets, and wellies riding donkeys and carrying sticks, tons of cute kids on the way from Saturday school, a massive soccer tournament on a field in the middle nowhere, road-side tin-sided food stands selling veggies, chicken, grilled corn, or cell phone minutes, and all sorts of other people. Many of them waved and we waved back, me silently practicing my “Dumela mé” or “Dumela mdaté” so I’d be ready to greet women and men in person (I think “oussie” is “girl” and “abooti” is “boy”).

We all went to the Shoprite across the street from the convent and got dinner stuff, then Sara and Josh and I picked up my big bags, sent the day before, from the public health interns’ house in “Little America” and they dropped me home and went on their way… so sad to have such a short visit with a great old friend. Tapiwa, the young doctor I mentioned above, met us at the door. He’ll be our roommate until his organization finds him a house, since he’ll be here for a while secondary to having a real doctoring job here, as many young Zim docs do, nowadays. He’s a cool guy. He bites off bottle caps, laughs with a little embarrassment at raunchy jokes especially when told by me or Ethel, and explained the tragic hilarity of the Zim dollar by telling us that a banana from a street vendor costs 50 billion Zim dollars after 12 zeros were subtracted from the currency last year. And we call ours a recession!

Kevin and Ethel took me to the local hotel restaurant for a chicken curry take-away dinner. Somehow in the hour it took them to prepare our food complete with three follow-up conversations about our order, they ended up adding a steak to our take-away bag. Funny, because nobody had ever mentioned a cow at all. The stars are ridiculous here, like blue-water sailboat under a new moon ridiculous. None of the street lights work, so light pollution is minimal. Of parental importance, the streets feel very safe even at night, with lots of friendly people about. During the day, everyone agrees that running the main roads is completely safe.

I fell asleep to the tachy rhythm of my oxygen-deprived heart (we’re high up) in my ear-plugged ears and tried to calm my thoughts and balance the need for air with my sleeping bag’s ability to keep away mosquitoes. I can’t believe that word has an “e” in it, spellcheck!

This morning Dr. Phil came over to trade in the borrowed Bourne Identity for All About My Mother and to take us on a sight-seeing and hiking adventure day. Phil is a family doctor from coastal Maine (just below Acadia) who recently retired and was hired by LeBoHA with his Nurse Practitioner wife to work at Motebang. Sandy, his wife, is out of town, so we snagged him for the day as our tour guide and (my) new friend. We drove first to Bokong, a park (indistinguishable from the surrounding landscape, except I guess there weren’t any huts on this part of the land) with a nice flat out-and-back hike to the top of a lovely waterfall. There was a bizarrely fancy “conference center” (“bizarrely” because nobody goes there; Phil had the last three entries in the guest book) with panoramic views of the mountains beyond mountains (to borrow a phrase borrowed by Kevin from Tracy Kidder) and stuffed local animals in decent condition. There were about 15 steps from the conference center, built into the stone wall, up to the trail and my quads were immediately flooded with lactic acid and I ceased being able to complete full sentences. I considered doing the old Daddy running trick of asking a thoughtful question on the uphills, but then things flattened out. The four of us walked in t-shirts on a quite nice path made of local stones to the top of the waterfall and sat there chatting for a nice half hour, basking in the warm sun and listening to the water fall. We three students in the group are still adjusting to getting awesome placements in the residency match, and Kevin and I, having hinted for months with our fingers crossed about both ending up together in Seattle, started planning our Pacific Northwest adventures inside and outside of medicine. I can’t wait to buy a good road bike, plant some edibles in a small garden, live near KP, Toby, Pete, and Soph, and explore the mountains and waters, not to mention the West Seattle Big Band and the 826 tutoring center for kids. ‘Cause I’ll have PLENTY of free time…

After returning to the truck we pressed on, often going 15 mph on the switch-backing, vertiginous, Canary-reminiscent hills (though, sadly lacking in snack stands, and much more lush) for another almost 2 hours until we reached a really impressive look-out populated by a cute gang of impossible relatives of the elephant, the Hyrex. There’s a picture in the last post and it looks like a guinea pig with a tapered nose.

A whole bunch of switch-backs and hundreds of road-side waving children later we reached the Katse dam from above. The gate was closed (though the guidebook had predicted a tour at 2:00) so we paused for peanut butter sandwiches and plums and drove to the base and walked in the last half mile to the base of the 185m engineering feat. We threw a bunch of rocks into the river (I thought about my recent rock-throwing fun with Nicholas in Aurora), many of which were embedded with shiny quartz, scrambled along the river bed, said “Dumela” to some fishermen, and then climbed willow trees to try to cut down a couple abandoned dangling birds’ nests for Phil’s porch decoration. By the time we were back in the car (and Kevin’s finger blood was staunched; ooh, I should clean my Leatherman) we were all on the verge of sleep (except Phil; he drove very well). I read a handful of poems aloud from Phil’s Garrison Kieller Poet’s Almanac and then we all gave up on verbal communication. Back at the convent we thanked Phil for the adventure and headed out to get dinner at the Pelican bar down the road and visit the hospital for a quick email check before bed.

Ethel, however, happened upon a crying mother holding an eerily lethargic and tiny one-year-old boy whose skin was retracting between his ribs and above his clavicles with the effort of breathing, and whose lungs sounded like serious crepital crap. The child had been ill for ten days and, due to some sort of money and transportation obstacles, had not been to the hospital yet. There were no doctors or nurses to be found so, after a quick exam in the computer office, we carried the baby up to the pediatrics wing while Kevin called in Christopher, the resident on call. Since I don’t know my way around the hospital workings yet, I manned the open office while Kevin and Ethel got the little boy oxygen and a bed in the ICU/trauma ward. It looks like the poor little guy won’t make it and, as he was severely volume depleted from diarrhea and vomiting, even as we left, nobody had been able to get IV access in arm, foot, or scalp to infuse replacement fluids. In the best hands available, we left the baby for the night. We’ll find out in the morning if he is pulled through.

There’s a remarkable calm that I felt, despite the flurry of action. When we walked into the pediatrics building it was immediately clear to me how different a game this is. There were many family members around the children there but no medical staff anywhere. Can we try intraosseous access? We don’t have IO needles here. What does the ICU have that the ward doesn’t? The nurses can give more attention to the baby. I imagine that some people reading this might expect me to feel frustrated or angry or desperate to try something. But all I felt was sad and calm and awake in a way I haven’t felt since ambulance work. I have more experience getting IV access than most of my classmates at home thanks to my paramedic years, but the resident here is better than I am, I’m sure, and Kevin and Ethel have been honing their skills for a solid month, so I had nothing to offer except a hand on the back of the weary and frightened mother. I couldn’t even explain anything to her, the fall-back student offering at home, as my Sesotho vocabulary includes only greetings and “thank you”.

Tomorrow I’m going to shadow Ethel in the male medical ward to start getting a feel for medicine here. Two of her patients died over the weekend so there are only five men under her care, one of whom has TB and one of whom is in the ICU; I’ll find out why tomorrow. I’ll bring in my donated goods, try to give out some stickers to kids, and start learning the limited formulary (drugs available) and treatment regimens. Ethel and Kevin have been super generous in sharing their medical experiences here with me, so I know I’m about to start seeing as normal the complications of AIDS and tuberculosis that I’ve only read about these last four years. Since I’m still up at 11:30 after a tiring past several days, I know I must be nervous. But mostly I just feel the preparations for becoming sponge-like for new knowledge, and for retraining myself for Basotho medicine. What will my role be? How can I figure out how to write prescriptions for new medicines for new diseases in this new (to me) depth of poverty in this new and beautiful country? What does this mean for my next 40 years of doctoring? How can this direct my next four years of training to be a family doctor? How will I learn to adjust my expectations and counsel myself through so much death and suffering? And how on earth will I put myself to bed when this sad and exciting party is going on ALL THE TIME just down the road? I guess I’d better start trying.

Photos finally - READ THIS BACKWARDS so it's in order

Beautiful lake on the drive home.
Why is my attending in a willow tree? Is he harvesting aspirin? Would he like to be a swinger of birches but has the wrong species? He was actually trying to recover an abandoned hanging birds' nest to no avail. K, E, and I got a couple for his porch across the river with only a little blood spilt...
Dam! This is Katse, one of the two big dams built by South Africa and Lesotho to harness some of the potential energy inherent in the only country entirely above 1,000m. Four more are planned to be completed by 2020. According to Lonely Planet there's been prosecution for corruption in the big companies in charge, there's been a decrease in the already scarce arable land, but there's been a great increase in roads and power supply to many rural areas in Lesotho. Wedrove down a dirt road to about a quarter mile from the base then walked in. We got sprayed, threw rocks in the river, examined rocks, saw a lizard, saw banderiki (Amanda, Mike: did that mean "bird shit" or "Americans"?), theorized about turbines, and walked back to the car fantasizing about obtaining birds' nests for Phil.
A man in nature.
Pointing at the guy pointing... who is Phil, out attending. He took us on an epic tour today (Sunday) in his great ol' diesel Toyota pick-em-up. We went to Bokong park to hike (pictured here) at 3090m above sea-level, then on to Katse dam, the tallest dam in Africa at 185m.
Would you believe this cute little guy is related to the elephant. He didn't respond to my elephant call. Maggie, want to give it a try? I believe, though I'm not sure, that the hyrax is NOT one of Africa's "big five".
Almost all of the rural villages have these round thatched huts. One hell of a backdrop, eh?
Home, sweet home. Ethel and Kevin are leading me through the Garden of Sweden (a little joke because Kevin and I both matched at Swedish programs in Seattle... hah hah, thanks for laughing).
Sara Hoffman, Kevin Kless, Ethel Wu - convent in background, our house out of sight and beyond some gardens to the left. Sara was about to leave to play in Jo'Burg before heading home. Booo.... I love her!
AIDS ribbon painted on a hillside between Maseru and Leribe. Taken from the car while Sara was driving.
Kevin, the sketchy butcher. Remember him? Stiiiilll sketchy!
With a pint and some narrative medicine reading at the Sun Inn in Barnes. Barnes Pond just out of eye shot behind the hedge.