“GO BACK HOME AND TELL THEM OF THE BEAUTY OF AFRICA”

In my final wrap up of our Cape Town experience I want to share one of my most cherished memories of Cape Town- a conversation with a waiter at a local coffee shop in Sea Point. His name is Blaze and he comes from the Congo. A fascinating character who earned a scholarship to study Middle Eastern conflict in Switzerland while learning English, French, Italian and German. Ultimately he dreams of getting into politics and in between he is working in the tourist industry now. That’s what brought him to Cape Town actually, the lure of the great 2010 World Cup- the promise of clients, adventure and money. He was an absolutely brilliant, funny and humble man.

We got to talk about culture differences. He asked what it was like to grow up in the “world’s super power” (arms outstretching high in exaggeration as he said it). The question made me pause, I had never actually thought of it in that way before. It seems that I wouldn’t entirely be able to understand and answer that question without traveling outside of the States. How do I know the great things I have without the contrast of what a life without is like? Go beyond even the well-known super power benefits of freedom, politics and money that we have. Think about the simple things. Do we understand the comfort it is to have reliable water, electricity and toilets on hand? Are we conscious of the education available to us without censorship? The mere prospect of having career paths based on an individual desires and goals and not set tracks? It’s a beautiful and opportunistic, comforting blessing to be from the world’s super power. But I wouldn’t understand that as deeply as I do without experiencing what it would be like elsewhere.

Blaze later laughed because of the ‘silliness’ of American culture. Smiling and laughing with us he said, “Africans love to dance and sing and drink our tea. We are content with that- it makes us happy. I watched CNN last night. What are you concerned about? Jacko’s (Michael Jackson’s) doctor! You are so silly. I don’t understand the priorities of your culture!” We laughed with him realizing how silly we do look with our CNN headlines, People magazine attraction, and Bruno type movies.

We know the USA as much more than what the media portrays of us. We have our own rich culture and history. A myriad of people and experiences that are deeply meaningful but that are lost to outsiders who equate the USA with Hollywood. In the same regard how often do we generalize other cultures based on their media portrayal?

Africa is infinitely more than an area of poverty, hunger and safaris. It is a continent brimming with hope and the most genuine happiness I have experienced. A happiness that transcends circumstances and flows right from the core soul. It is a people alive with song, music, art and dance. Blaze told us to, “go home and tell others of the beauty of Africa!” I was told the same thing last year while in Tanzania. All over the continent, people are spilling over with happiness and a desire for the goodness of Africa to be known.

So I hope that through our experience you may see Africa as more than a place of poverty and need. Begin to see the people who have expressions of joy and an illustrious sense of hope in the greatness of humanity. Go and visit Africa and see it for yourself...

Few more Township Tour pictures

Bo-Kaap, a Muslim area as is known by the brightly colored houses- a tradition inspired by the Malaysian culture as a group of slaves traced back their heritage to Malaysian royalty. The palm tree in the back center is a protected site- the seeds were brought back from a Mecca journey and planted there. There are a number of these protected tree sites around Cape Town. 

Township Tour

Township shacks
A sign in the District Six museum
A street on District Six before it was demolished
The same street now. (see the three arches at the top of the stairs)

We were blessed with the opportunity of taking a township tour with the best tour guide, Colleen Knipe-Solomon of siyaFundisa Edu Tour. We were happy we did it at the end of our trip and not at the begining because we were able to understand the context so much better. During the tour we covered some of the historical/political/cultural/social contexts of the townships of Cape Town; Bo-Kaap (ex slave quarters); major contributions slaves and Muslims played in Cape Town communities; District Six (Apartheid Group Areas Forced Removals and its legacy); understanding the displacements of huge communities to the Cape Flats (aka townships), the formation of sub-economic Townships and perpetuation of their social crises; Langa (oldest township) how, why, when and events leading to Joe Slovo; informal residents- backyard dwellers and Delft residents; a drive through Bonteheuwel and Gugulethu- Guguletu 7 and Amy Biehl Memorials; Khayelisha- meeting with a local tailor and learn about her business and also what it is like for her living with HIV/AIDS; Philani Nutrition Centre; and the world famous Vicky's B & B in a township shack.

It was a moving, insightful experience and one of the highlights of the trips. I jotted down only a few of the interesting things we learned.

Township Tour Tidbits:

~ It was illegal to teach a black person math beyond the 8th grade. The government said there was no reason for them to have any math skills beyond that given their life course and they should not be given any kind of hope.

~ No houses were built from 1950-1978 as a way of keeping black people out of town (the houses were already occupied by whites after everyone else was forcefully removed). This began the chronic housing shortage.

~ Drugs only because a large issue after the forced removal. After forced removal, stay at home mothers had to get a job. Removing this nucleus of the family created a void of attention and care for the children. Gangs moved into the areas and took on the role as they recruited young boys into the gangs.

~ Afrikaans language is a mixture of languages including Dutch and Indonesian.

~ African culture has a hard time forsaking their liberator leaders even after they become tyrants. It’s difficult to let go of the original idea of the liberators as protectors.

~ Stadium workers (on the 2010 World Cup stadiums) make $2/day.

~ South Africans were the only people in the world who didn’t know what Nelson Mandela looked like until he was released and made his first public speech. All pictures of him were banned in country.

~ The government did ‘culture tests’ to determine an individuals race. The most famous is the ‘pencil test’ where a pencil was placed in the hair and if it fell out you were classified as colored and if it stayed in you were classified as black. This is why beauty parlors were so popular in those days (and following to present day) as everyone wanted to get their hair treated, straightened or relaxed.

~ Other ‘culture tests’ included measuring the diameter of one’s nose and whether one had pink under their finger nail beds.

~ Speaking of apartheid, “What Hitler created in 15 years, we perfected in 50 years”.

~ One of the biggest misconceptions: South African slaves were of Asian descent, they weren’t native blacks.

~ There are 332 townships in Cape Town.

~ Government housing plans during the forced removals were done with no plans of urbanization. Houses were moved with out toilets or water.

~ Township has a Love Light Project focused on youths where youths have to take a 3-week course on sex education and HIV education before using the youth rec. facility. It’s been very helpful for the community.

~ In township, every child is sexually active by 12

~ S. Africa has the lowest abortion rules in world.

~ Projects around the township

· Restaurant training, Recycling, Youth Center, Storage units as stores

~ Khayletsha township residents are the most determined. They are proud and happy of their accomplishments and how far they’ve come. They are very ambitions.

~ 39% unemployment at the national level. 60-80% unemployment in the townships, of which ¼ are women with HIV/AIDS and 1/10 are men with HIV/AIDS

~ Swaziland has 59% HIV/AIDS rates, the highest percentage of total population in the world

~ South Africa’s HIV/AIDS rate is highest prevalence in the world

~ Townships are so tightly placed next to others that fires can spread rapidly. Record fire in December 2008 burned 500 houses in 8 minutes.

~ Government housing flats were promised at 25 Rand per month (roughly $3.20 US), but ended up being 750-1100 Rand per month ($96.15- $141.03). Only 1 family could afford to move in.

~ Cape Town offers the best hands-on medical training in the world because of its health disparity and problems.

~ Actor Danny Glover has a foundation that works in the townships.

~ The local cemetery is so full that bodies are three deep. The black community does not cremate. Bones are VERY important in the culture.

~ If the former president had not stepped down, Action Treatment Campaign would have charged him with war crimes for limiting ARV’s (HIV/AIDS medicine).

~ In the government forced removal, the government planned for people to live in very small areas and have different resources. This was in order to increase animosity between different races in neighboring townships. And it worked. It was called “Spatial Ethnical Engineering”

~ And most important quote:

· “Life is difficult but we never give up.”

Shark Diving!!!!

The sun is setting on our adventure in South Africa, but we'd like to think that we ended on a high note.  

Tipp, Ofer, and Valerie all came to town for a little adventure vacation.  Including Megan, Rusty and I, that made 6 travelers total.  

We first took a road trip along the Southern Coast for a few hours and stopped at the Arabella Hotel and Resort just outside of the city of Hermanus.  The Arabella was a St. Regis brand resort and the rooms were gorgeous.  The next morning we woke up early and went SHARK DIVING.

It only took about 30 minutes for the first shark to appear and take a nibble at the bait.  Shortly after, we had 15 Great White Sharks circling the boat for 5 hours straight.  

At one point, while I was in the cage, a great white made short work of the bait then in all his fury, he slammed into the cage, directly in front of me.  It was the most intense thing ever (see pictures)!!!

After a 3 day weekend in Arabella, we headed back to Cape Town and did a fully guided tour of the townships, including the history and oppression of Apartheid.  

To top it off, we drove the southern coast to the Southern most tip of the African Continent, where the Indian Ocean and Atlantic Oceans meet (Cape L' Agulhas).

I also worked a short shift today with the single goal of saying goodbye to the all the doctors and students at the ER.  However, right after I said goodbye, they put me to work for a few hours.  I surgically removed a bullet from a patient's leg, placed an intercostal drain (needle aspiration, for those of you who care), and did a lumbar puncture, all within 2 hours.  I love Africa!  

We will try our best to post one last concluding blog about our time in South Africa. It is difficult to end an overseas stay like this.  How can any of us fully describe this incredible experience?  This blog is merely the beginning of a great adventure that Megan and I were compelled into.  I will say for myself, that South Africa has been the deepest and richest learning experience of my life.  

Strikers

During our time here numerous sectors have gone on strike. I assumed it was in part due to the trump card these sectors held with the upcoming 2010 World Cup. South Africa is oozing over with 2010 pride and excitement. A single night would not go by without having TV commercials on, a car trip won't pass without seeing 2010 advertisements and the first thing you see leaving the airport is a large count down of days till 2010. South Africa is beaming about this honor. The second strike we experienced was the World Cup stadium workers. One of the nine stadiums in the country, The Green Point Stadium, is located 6 minutes from our apartment. The Green Point stadium workers showed up daily to protest and walk down the main road. Harmless and impressive to watch. They protest their salaries, if you could call it that. They make the tiny amount of $2 a day. 

When we got here the doctors were on strike. Doctors here make less than teachers, they protested. (Now that's something to think about- why are the salaries of doctors and teachers always compared to each other as justification of poor salaries?) We worked one night in the ER during the strike. It was eerie to walk in, there was only two patients inside when normally there would be at least twenty-two. Doctors during the strike would either not come to work, or in the case of the ER where doctors could not be absent, they would only treat immediate emergencies. During the negotiations, a caller called into the local radio station and said not to buy in to the promises in the negotiations. That, for instance, officials were promising a 12% salary increase to doctors, but in the fine print they would also be given a 34% tax increase on any overtime or they could also lose part of their benefits. So in the end it was a wash. Tricky tricky!

Since then, the municipal works have gone on strike: those workers responsible for service delivery (i.e. garbage collector). And in the news today the telecommunication workers are striking. 

At least 4 sectors in 6 weeks! Here's to your 2010 trump card, hope it lasts post 2010.....

Robben Island

Robben Island is a bit off the coast of Cape Town. It's a prison that the government used during the apartheid era to put all their political prisoners- activist, demonstrators, etc. It was made most famous by housing Nelson Mandela during his imprisonment. It's a big deal to go see- think the sights of Alcatrez + tons of historical significance. 

We have tried going numerous times already. First time sold out. Second time closed to a holiday (the ONLY holiday of the year they close it for- one coming out of the Soweto Uprising that is considered to be beginning of the end of apartheid). We started to go early in the morning to get tickets for a later ferry..... Third time closed for rough weather. Fourth time sold out. And final time to go was today..... Fifth time sold out. 

The comical part of the experience, and why it is funny enough for me to blog about personally, is our friend Ofer has been staying with us for 2 weeks. The first day he went down late in the day and got a ticket on a ferry that was leaving in 20 minutes. Some people are just lucky... and others are just unlucky! See you next trip Robben Island. Instead there will be wine tasting today!.......

Pictures from weekend trip to Hillcrest Berry Farm. On our way back took some pictures of the wine valley and some passing pedestrians, such little monkeys! (Which picture!!?:D)  There was a big troop of them. 

DAY TO DAY

Before coming here we were all uncertain what our day-to-day life would be like. What we did know was that we had 500 charts of patient’s who had a chest tube (ICD) placed from GF Jooste hospital to review, those charts had to be cross checked with the tuberculosis (TB) database, all the data had to be inputted into the computer, and a statistical analysis of the data would be done.

Let me explain now how that has played out. The culture here is either very trusting or very lax, which ever you prefer! And all the records are paper copies, nothing is electronic. When a patient comes into the Casualty (ER) they go to the admission window and get a folder handed to them with preprinted labels. They bring that folder with them into the casualty room, which is an open pit. There is supposed to be a clerk by the door ‘checking’ patients in from admission but most of the time no one is there. So the patient comes up to anyone they see who looks like they work there and hand them their chart. We have had charts handed to us many times while we are doing chart reviews (naturally anyone reading a chart should in fact be a doctor). The patient finally finds a nurse who will do intake vitals on them and get them situated in the casualty. The nurse then registers the patient into the casualty registry book, a hand written log with patient name, patient folder number, reason for visit, and doctor assigned to the patient. Patients are then seen by the casualty doctor for treatment and referrals to an in-patient ward or other hospital.

Patients who need an ICD put in are sent to the surgical ward (10 feet away) and are registered into the surgical book. A chest tube is placed when there is risk or evidence of a collapsed lung from trauma. For our project we are only looking at penetrating trauma requiring an ICD, like that of a stabbing or gun shot wound.

Step one of our project was then going through the surgical registry books looking for all patients with an ICD placement. Our study protocol called for any patients with an ICD from 2004-present. From two registry books (the size of a very large yearbook) we had over 500 ICD’s. We made one complete list of all 500 of the patient folder numbers associated with the ICD patients. These happened to be all from 2006 and 2007.

Step two was going to the records department and pulling our charts. The first week or so we did it ourselves. I explained myself once the first day to one of the staff and they were okay with me coming in there. After we did two overnighters however we were told we must call the Director of Records and explain who we were and what we were doing. After that phone call we set up a wonderful system of the staff pulling 50 charts at night and 50 charts in the morning and just keeping them stacked up for us. (There is a sign saying “These charts are for a research project for doctors”.  That reminds me, in order to get access I am registered as a ‘visiting medical student’. I have a student ID card and everything. Who knew you could get a medical degree as a student at DU!) For the last 4 weeks that is what we have been doing. We had pulled 448 charts of 500 as of this Monday.

The first week or so we did our chart review at a tiny coffee table sized table in the records office. There were no chairs so we would either stand or end up sitting on the tile floor (not the cleanest!). When that got too much we moved out the casualty room and squeezed onto the side of the table in the center. There wasn’t’ ever a really conducive place to sprawl out with our folders. Through a series of events we eventually found the research resource room that has a conference room sized table. We have happily been using this room ever since.

Step three was cross-referencing our data with the electronic TB registry called ETR.net, which we have been trying to get access to since day one. That has been quite the fiasco and we have been given a bit of run around with it. In the mean time we have also been hearing varied stories of the reliability of TB data at Jooste. Apparently TB tracking has only really been happening within the last year - year and a half. Even then it also has low compliance because it relies on the doctors calling the research center and referring a patient for TB testing/counseling/treatment. Of all the hospitals in the Western Cape, Jooste has the poorest record for TB compliance.

On Tuesday we finally spoke with a women at the Department of Health who could get us access to ETR.net, kind of. We can’t access it ourselves as we thought, but we can give her a list of all the patients we need and she can pull a master report for us. That was time saving news to here. Also on Tuesday, through another source, we ultimately came to realize that a very, very small percentage of our ICD patients from 2006-2007 might in fact be in ETR.net due to the lack of records. Without the cross referencing capability there would be no way of confirming TB and/or HIV in our patients. Thus we could not test our study hypothesis that TB and/or HIV patients experience greater morbidity and complications associated with ICD placement. Not good news to hear after 4 weeks of work! But thankfully our team is pretty resilient and dedicated to this project.

We decided to recreate our list of ICD patients using only patients from 2008-2009, when ETR.net was ‘regularly’ used. We created a new master list of 500 patients, dropped it off at records Wednesday and started “Project #2”, as we are now calling it. We have a week left in our project/internship. It’s crazy to think about restarting the project that had taken us 4 weeks before, with only 1 week left. However there are some great learning lessons in this. We definitely feel that we worked out a lot of kinks in Project #1 including consistent data collection on our part, and learning more about the charts and thus adding a few items to our data collection forms for Project #2.  As our fearless leader back in the states said, “We have perfected this to a science”! Two eight-hour days with only tea breaks have already give us 200 charts.

Step four is data entry, the fun stuff. We just finished inputting the data from Project #1 last night. We are focusing on getting the charts reviewed now given our time crunch and then will do data entry for Project #2 next week. Then will turn around and give a report of patients to our Department of Health contact of all our patients and see which ones exist in ETR.net. All by next FridayJ

Step five will be the data analysis and I’ll do that back in the states. We are all every interested to see what results we get. Even looking at our current data regardless of TB status- see the ratio of men to women, mean age, whether there are more complications from ICD’s placed at the day hospitals than at Jooste, etc. And because we have Project #1 and Project #2 with two distinct time frames we can also look at differences over time. So all is not wasted here and we are all about slaphappy with exhaustion over it. 

REFERAL SYSTEM

In working, discussing or understanding South African health care it is important to understand the referral system. Like most other referral systems, i.e. HMO’s, a patient must go to his primary care doctor and get a referral to a more specialized doctor for any complication or procedure his/her primary care doctor cannot perform.

As we’ve explained to some of you, a patient who needs an ICD (chest tube) is required to go to a local day hospital/community care center (aka his primary care doctor). The day hospital can place the ICD but they do no further ICD treatment. The patient is then referred up to the local secondary hospital, like Jooste. On referrals a patient is transported between referrals via ambulance and ‘porters’. (That is good news; we had thought it was the patient’s own responsibility to get from referral to referral.)

Patients transferred to Jooste are admitted into the casualty (ER) from the day hospital. The casualty doctor’s evaluate them and once the patient is stable the transport them to the ICD ward at Magnolia hospital. The ICD has physical therapist there to assist in breathing exercises and rehabilitation. After the patient is ready for discharge, they are transported back to Jooste for discharge where the ICD is removed, the site is sutured and the patient leaves. From our research, it appears most patients only stay about 3 days.

The general consensus of the referral system is that it’s a bit frustrating and better in theory. The theory is that when there are such few resources, they must be maximized as greatly as possible. So day hospitals are pretty common and have only the basic care resources. Moving up the referral system chain, the next level health care facility will have a bit more resources to treat a few more complications. And ultimately the highest-level health care facility in the referral system has the most advanced technology for the area. This way the Department of Health does not have to have machines at every hospital, only at the perspective secondary, tertiary, etc.  (For instance there are only 3 modern ultrasound machines in the Western Cape region and they are all at the higher referral hospitals). The referral system follows South Africa’s general sense of hope, as it was said to me. It’s a system based on hope that there are no complicated patients. That a patient with a cold can simply go to the day hospital for treatment. And that the cold is not in fact a complication from ARV’s and a sign of system failure that would require more advanced treatment than that available at a day hospital.

We can all understand the frustration with referral systems with our own understanding of the HMO system. Now just think about this in an emergency situation, when you can’t wait 2 weeks for a new appointment. In the states a patient would arrive at the ER and be rushed to surgery if needed. In this referral system a patient must go to the day hospital first, then get referrals to more advanced treatment. Of course if a patient arrives at Jooste without a referral letter from a day hospital he/she will still be treated. In that regard I don’t quite understand the consequences a patient would face if he/she just arrived at the highest-level care requesting treatment. 

The Full Moon of Cape Town and the 4 travelers

Camps Bay at Sunset

Sunset and Moon Rise from the Top of Lion's head

The moon rising over Table Mountain. 

Tales from the Casualty

Today's fun fact is the South African term for Emergency is "Casualty".  Therefore EM docs are Casualty doctors here.  

We know that we haven't done an update in 2 weeks, so I thought I could do a little piece I like to call "Tales from the Casualty".  

Rusty and I have worked every weekend night shift in the past 2 weeks, which has made for some intense stories.  I don't need to go into all of the victims of violence that we see here, but I just wanted to share a few highlights (for lack of a better word).

Two weekends ago, I was standing in the Resuscitation Room (aka Trauma Bay) and I glanced over my shoulder and there was a young man who was just wheeled into the ED and he looked at me through the glass doors of the resuscitation room, then his head dropped and he died.  So I jumped up, ran over to him, and immediately noticed that his shirt was completely covered in blood.  By the time I got to him, the nurses and doctors did as well.  So we grabbed him, threw him onto the gurney and attempted to resuscitate him. I cut off his clothes and saw the wound--he was stabbed fatally in the axilla (armpit) and his axillary artery was severed.  Rusty and I got his IV started and simply did chest compressions.  20 minutes later, we got his heart rate and pulse back, then the surgeons took him and he died during surgery.  

The next day, and a few resuscitations later, an older man was brought in on stretcher in respiratory arrest, so I intubated him while Rusty did compressions and got his arterial blood gas.  Again, we got his pulses and heart rate back, and he died later in the ICU.  

The night was finished off with a young girl, 6 months pregnant, whom was hit in the face with a brick and fell onto her abdomen.  The girl and the baby ended up fairing well, and I got to do my 2nd fetal ultrasound (and stitch her face).

Then, last weekend, we were told that all the action happens on the first weekend of the month, because the government checks get sent out and people party, get drunk, get high, etc and as a result, Casualty is crazy.  This proved to be true.

Last Saturday, there were two rival gangs walking around the neighborhood and assaulting anybody in the street.  The police ended up arming themselves with machine guns and drove around the city streets arresting anybody outside, for any reason.  Sure enough, the victims of the gangs, would come in, one after another.  In addition to the typical busy Saturday, we had about 15 extra people who were bleeding from stab wounds and head injuries from gang violence.  So Rusty and started sewing these people back together.  We got through about 6 patients and we realized that we had run out of suture kits.  After a hospital wide search, we found out that the entire hospital had run out of suture kits and that the bleeding patients just had to stand in the corner and bleed on the ground.  After about 3-4 hours of watching these people moan and bleed, we finally got some Debridement kits (not suture) and separated out the tools in the Debridement kits that we could use for suturing.  Eventually, 6 hours later, we finally got all of their lacerations sewn up.  T.I.A.  

One couple that I treated had been out drinking with a "friend".  At some point, during the night, the "friend" hit the female over the head with a beer bottle a few times, until the bottle broke, of course, then took the jagged end of the bottle and stabbed the male in the face.  The friend then put the female and the male in his car and was driving them to the countryside where he was going to murder them.  The male finally regained consciousness and jumped from the moving car, the female followed him, breaking her leg.  

Another 3 people that we treated were all family.  A gang member just broke into their shack and attacked the whole family in their sleep.  He stabbed the teenage daughter in the face, he stabbed the 60 year old mother in the chest and he stabbed the brother in the back. These 3 people all ended up surviving, but in my opinion, the teenage girl got the worst of it, because her face will be scarred for life.  Rusty did a great job on suturing her face, with our make shift kits.  I sewed the mother, who had an arterial bleed that sprayed in my face a few times (I wore goggles).  

Lastly, Rusty and I work the Casualty Department, so that we can teach the doctors and residents how to use the ultrasound machine in a trauma situation.  Sure enough, we had a young man who was stabbed in the chest, just anterior to the heart.  The doctors and surgeons were voting on whether to take him directly to surgery, or watch and wait, because they couldn't tell if his heart had been stabbed, or just his lungs.  Rusty and I grabbed the ultrasound machine and scanned him.  We immediately picked up on his pericardial effusion (meaning that his heart had in fact, been stabbed).  The surgeons immediately took him to the OR.  Later that night the surgeon came out of surgery and thanked us, because the patient had a right ventricle stab that they saw during surgery.  As we like to joke here, "Another life saved".  Haha. 

Rusty and I have also had the opportunity to do several lumbar punctures (spinal tap) on meningitis patients.  Additionally, the doctors here have promised us the chance to do all the chest tubes that come in while we are working (how many CU students are doing that??)!! 

As for fun stuff.  Ofer got here a week ago and we have been trying to entertain him by showing him around a bit, between shifts.  The four of us (Megan, Rusty, Ofer and I) got a chance to climb Lion's Head at sunset and watch the full moon rise over Table Mountain.  We then climbed down in the dark and went to our favorite 2 for 1 burger joint!   It was amazing!  

Right now we are in our final push to finish the research portion of our time here.  We have had some major set backs, but we think it is possible to finish the research project. Wish us luck!  

Latest and Greatest

Hello....a few updates for you!

1) We have been very busy with the research project. Research in a developing country is a unique experience- most steps take much longer than in the states, but T.I.A. (this is africa). It seems that we are continually working on the project with half a result to show for it by the end of the day: getting approval or access to vital items, getting patient charts pulled, etc. It all takes more time than we were expecting. I have found that research reminds me of writing a term paper- the research and writing are actually quite boring but you just hope for an exciting final result! It has been more and more exciting the longer we do it (and more of a headache!) And I do enjoy my time more when the guys are doing charts with me (they are spending half their time with patients and half doing this research) 

2) I am blown away with the realities of the limited resources hospitals in developing countries face. To begin with, the lack of computerized records. Kalen and I have discussed many times recently that if we won the lotto we would want to buy a computerized records software. There are so many benefits of having computerized records (including the help it would have been for us in this project!). Other limited resources are a lack of individual rooms, blankets, staff, lab results, medical equipment, outdated ultrasound machine, TV's or any sort of entertainment (a patient just stares at the nursing/doctors center desk all day- the ER is just one big open room with gurneys lining the wall and the center desk 2 ft away for doctors to write notes, talk, etc). 

3) For our research, we go through the surgical admissions registry to look for ICD's (intercostal chest drain). Some days, of 30 admissions, 17 of them will be ICD's! It's staggering how many chest tubes (and thus stabbings) they have in this area. Equally, or more, shocking is that by far the number one surgical admission I have seen is for ICA (incomplete abortions). From my development/health graduate courses I have a new understanding and belief about the lack of resources available to women all over the world. 

4) Exciting story- Two nights ago Kalen and I went to sushi for a date night. We were driving down our street to the main road "Beach Rd". I'm driving and turning right onto Beach. To my left I see a man shaking pretty violently laying half in the street and half on the sidewalk. It was dark and I couldn't tell if he had leg braces on or if there was something else by his legs. I am telling Kalen to look, look and we make a u-turn to help him (after I have Kalen give me his wallet and cell phone in case it is an elaborate robbery attempt!) By this point a local jogger and hotel manager have come over to the gentleman on the ground. Kalen jumps out and I stayed in the car. I just see Kalen crouching down talking to this man and the other people. Then Kalen pulls up the genlteman's pants leg and gives him a shot of something from the gentleman's bag. The group continue to help the gentleman for about 10 minutes longer and then help him get up. The hotel manager helps him walk back to the hotel and we see the gentleman has a very bad limp. Kalen gets back and it turns out the man was diabetic and his blood sugar was too high. As he was walking across the street he got dizzy and either passed out or just fell over. He seemed to have some hip problem too which hindered him from getting up. He had been shaking and reaching for his insulin when Kalen came up and Kalen figured out what was happening. But he was also deaf. Before Kalen realized this the gentleman kept signing to Kalen 'thank you' and Kalen was asking "are you hungry?". The gentleman finally pulled out his clip board from his rolling brief case (which I thought were his leg braces when I saw him laying there) and wrote to Kalen that he was deaf. As we were getting ready to drive away the police pulled up behind us (mind you we are on the side street, which is not busy itself) I assume because I had my hazard lights on. We explained why we were pulled over. I assume that our American accents proved to him we weren't up to no good and we weren't lying. I was really impressed that without calling the police, they showed up because of my hazards within about 15 minutes. There may be some very dangerous places in this country but apparently our apartment is not in one of them! I was really impressed with Kalen in this situation. The community's little knight in shining armor.

5) It has been VERY cold this week. We posted pictures from the storm that came through. Buildings have tile floors and no insulation so it's just as cold inside as out, if not colder. The hospital is absolutely freezing. Yesterday I had 4 t-shirts on and a fleece to make me not cold. I feel for the patients who are in hospital gowns with one blanket. 

6) Since the desk we work at is in the middle of the ER, we are in the middle of all the action. Sometimes it is heartbreaking. Yesterday there was an elderly man who was crying for hours. It was difficult to see this man, who I respect for his age, in such a vulnerable position. I felt like his sense of respect was diminished some how by being in the resource limited hospital, with hospital staff that couldn't give him much time because there were so many patients. I wanted to look at him and give him a look of comfort, that I heard him crying and I knew he was in pain- give him even that basic level of understanding from one person to another. But I didn't, because I didn't know what else to do for him. As if looking at him would make him think I was a doctor because I sat at the table. It feels like the wrong decision but I didn't know how else to respond. It's these tiny, little experiences that leave the biggest imprint on my day. 

7) There is MAJOR sports fever here. The Confederations Cup is a world wide soccer tournament that was chosen to play here as a warmup for the 2010 World Cup. (Yeah for US upsetting Spain in soccer!!! We ended their 35 winning streak and Spain is ranked #1 in the world. We will play Brazil on Sunday for the Confederations Cup Championship, Watch it!).  Additionally, South Africa just lost to Brazil in the semifinals and will play Spain for 3rd place.  The ICC Cricket world championships in London was all over the TV here because South Africa made it through to the semifinals!  Lastly, the British and Irish Lions (a selected team of the best rugby players in the UK) came through South Africa and played at venues all over the countryside.  In the end, South Africa's Varsity squad made short work of the Lions (GO SA!).  

8) Along those lines- the marketing budget for 2010 World Cup must be ginormous. They have billboards, bumper stickers, every 3rd TV commercial allocated towards the World Cup. 

9) They also have every 5th commercial and every episode of the local soap operas targeting HIV/AIDS awareness. The commercials are hilarious, I wish I could tape them somehow. And the soap operas are educational (see, they teach you something, they're not all trashy)

10) Leaving the best for last- between the sushi and the wine, I am in heaven.......

Pictures! 1) Megan at Boulder Beach at sunset, hanging with the locals 2) Ostrich at Cape Point 3) Kalen at Cape Point- farthest south point in Africa 4)Storm this week that came through- waves 9 meters high and sea spray as high as the light post!! Pictures from the boardwalk that is one block from our apartment

1) We went to the Two Oceans Aquarium today (Saturday). Kalen took this amazing photo of the clown fish. 2) Another picture from the storm this week. 3) Sunset at our favorite watering hole "La Med"- 4) View from La Med looking up to Lion's Head. This is the bar that after paragliding off Lion's Head you land in the rugby field in the bottom left, unclip and walk up to La Med and order a beer "A man's greatest dream!" 

Picture from Cape Point- looking into the Atlantic Ocean

Kalen and I at Cape Point- False Bay and the Indian Ocean behind us

Kalen's perspective.....

This place is unbelievable. We are 1 block from some of the most beautiful beachfront I have ever seen. Its so amazing. There are literally mansions in my neighborhood. There is a Bently parked across the street from our place and there is also a Lamborghini dealership about 1 mile away.

In contrast, every morning we drive about 40 minutes East, to a city called Manenberg. It is a giant township of 1 million people. Townships are areas of "black" and "colored" people that are basically the poorest people in the entire world. They live in these self-constructed shacks made of metal scraps from the landfills. They are about 10X10 and sleep 5-10 people and are pretty much built on top of one another. There are also government built dorms in the townships and unfortunately the gangs take over the dorms and use them to traffick meth and other drugs. The hospital sits in gang territory and sees some of the most horrific violent crimes. These gangs won't simply rob someone, they will beat you to death for fun, or light you on fire, etc. We are instructed to never leave the hospital after sunset.

The emergency room is  chaos. It's basically this large open pit. Patients admit themselves, most of which are walk-ins, or by ambulance. There are no rooms, the beds are just out in the open and patients just scream or moan all day, you sometimes can't hear yourself think. Literally, everybody has TB and MDR-TB and HIV. I have only seen 1-2 patients who are not infected. Most of what we have seen so far are AIDS complications (that are really horrible), TB complications (i see one person per day whose lung has 100% turned to pus and goo) and violence. Everybody here would be considered homeless by US standards. Some of these poor people haven't showered in weeks, and that is the norm. The ER smells something awful. The doctors here only have the bare necessities. We don't even have gauze pads. There are only 4 mechanical ventilators, so if they are being used and a 5th patient comes in with respiratory compromise, they are simply left to die. Resources are limited and the diseases are ridiculously severe.

It has only been 3 full shifts and my first patient was a guy who walked in with a stab wound in his leg. As I was stitching him, he told me that he likes to smoke heroin and meth simultaneously and then he immediately asked me to hurry because he left his young child at home. Yesterday a 25 year old guy walked in with 3 stab wounds. He made it to the desk and passed out onto the ground bleeding everywhere. I got his IV started and gave him fluids. He finally woke up and Rusty and I stitched his wounds closed. He then told me that he got into a fight with his girlfriend and she stabbed him three times. The last patient I saw yesterday was a 76 year old woman who was left in the care of her son, who neglected her so poorly that 90% of backside was a bedsore/pressure sore that, when I looked closely past the festering wound and the smell of rotten flesh, was bone deep. Only God knows how long she was left lying in that position.

There are officially 20 beds and a holding area with 6 beds and a bench where patient just pile up. Once the beds are filled people just start sitting/laying anywhere and we haven't even worked a busy weekend yet (we are going to work a graveyard this Friday/Sat)!

Then, we leave the hospital, drive home and live in the lap of luxury. It is very very very difficult to wrap my mind around. We have been doing some sight seeing and touristy stuff. I am finally comfortable driving on the left side of the car (shifting with my left hand) and driving on the left side of the road. Even parallel parked last night! We have gone out twice...the nightlife is non-stop. The clubs don't close until sunrise.

Reading reflections

I am reading the book “No Future Without Forgiveness” by Archbishop Desmond Tutu. It reflections on the Truth and Reconciliation Commission of South Africa, which was formed after the abolishment of apartheid. It was a court-body created so any victim of apartheid violence could be heard and perpetrators of violence could give their testimony in return for request for amnesty. It was obviously a very sensitive endeavor. I have been struck with the power of reading it while being here- I can’t begin to understand the true forgiveness and strength encapsulated in this place. Here, in a very moving piece, Desmond Tutu is discussing judging the perpetrators….

“There is a salutary counter to our tendency to push blame onto others in a book by the Harvard theologian, Harvey Cox, with the lovely title, On Not Leaving It to the Snake. This helped me to be a great deal less judgmental and to avoid gloating at the misfortune of others. It was particularly important in the commission’s encounter with the perpetrators of some of the most horrendous atrocities. So frequently we in the commission were quite appalled at the depth of depravity to which human beings could sink and we would, most of us, say that those who committed such dastardly deeds were monsters because the deeds were monstrous. But theology prevents us from doing this. Theology reminded me that, however diabolical the act, it did not turn the perpetrator into a demon. We had to distinguish between the deed and the perpetrator, between the sinner and the sin, to hate and condemn the sin while being filled with compassion for the sinner. The point is this, if perpetrators were to be despaired of as monsters and demons, then we were thereby letting accountability go out the window because we were then declaring that they were not moral agents to be held responsible for the deeds they had committed. Much more importantly, it meant that we abandoned all hope of their being able to change for the better. Theology said they still, despite the awfulness of their deeds, remained children of God with the capacity to repent, to be able to change. Otherwise we should, as a commission, have had to shut up shop, since we were operating on the premise that people could change, could recognize and acknowledge the error of their ways and so experience contrition or, at the very least, remorse and would at some point be constrained to confess their dastardly conduct and ask for forgiveness. If, however, they were dismissed as being monsters they could not by definition engage in a process that so deeply personal as that of forgiveness and reconciliation. …..

None of us could predict that if we had been subjected to the same influences, the same conditioning, we would not have turned out like these perpetrators. This is not to condone or excuse what they did. It is to be filled more and more with the compassion of God, looking on and weeping that one of His beloved had come to such a sad pass. We have to say to ourselves with deep feeling, not a cheap pietism, “There but for the grace of God go I.”

First week done....

We are beginning to feel acclimated with Cape Town- jet lag is over, we’ve mastered left side driving, gotten lost a few times and now know our way around, and visited all the hospitals we will be working at. Cape Town is a stunning place. On our flight on the pilot said, “welcome to Cape Town, the most beautiful city in the world” and it definitely ranks high on the list. It is much more modern than I was expecting. There are very wealthy individuals in parts of the area- it reminds me of Laguna Beach, California to give some perspective. We have seen Bentley cars around.  On the other hand, the townships are very intense. Millions of people crammed into tin shacks. The city, in preparation for the 2010 World Cup, has begun to build government housing in front of the townships to block the view of the townships from the highway leaving the main airport. The government housing is a nice gesture still but none-the-less it will not mitigate the problem and is only to hide the problem.

My first visit to GF Jooste hospital was overwhelming. GF Jooste services a local population of 1.1 million, primarily from townships. As a non-medical student it was a sensory overload, even as a global health student with hospital experience. The smells, the patient load (168% capacity), the patients (TB, HIV, stabbing, an old women was locked (from the outside) inside her township house for days and basically non-responsive still when we saw her)…. It was a lot for a first day. Continuing to visit more hospitals has helped ease the shock of it for me. Today we came back to Jooste and I felt much more ‘present’ and capable of taking in my surroundings.

There have been some delays in getting approval for me to start my research study. I expect to start that by weeks end. I am very much looking forward to starting my work. I am getting jealous of the medical students as they shuffle around Jooste helping the physicians and patients.

For a bit of entertainment, I’ll tell you we have done our fair share of sightseeing in the week we’ve had. We drove down to Cape Point Sunday. Postcard perfect huge crashing waves along the massive, empty shoreline. Something right out of Pirates of the Caribbean or any other ship wreck scene. On our way back we stopped to check out the Penguins at Boulder Beach. I was expecting it to be the ‘off season’ and maybe seen one penguin. Not the case! And they come right up to you as you sit on the bench. There was some wine-tasting another day. I am in heaven here! The beach and world-class wine: tell me what could be better?!

Hope to post pictures later. Until then- wish me luck with continued safe left-side driving!

What we're doing in Cape Town.....

Hello from Cape Town!

Kalen and I are spending the summer in Cape Town (or winter here) along with two other medical students, Rusty and Shannon. I am working on a medical research project evaluating the morbidity associated with the placement of a chest tube in trauma patients. Chest tubes are inserted into the chest and lung to help a person breath and reduce the risk of a collapsed lung, these are almost always inserted into a trauma patient (someone with a stabbing or gun shot wound) as the risk of a lung collapse then is very high. However the lead doctor (Dr Richards from Denver Health at home) hypothesizes that patients with TB and/or HIV are at a greater harm for complications, and possibly death, because of the chest tube. Basically the patients are either so sick that they are at a very high risk for deadly infection or their lungs are so gunked up from the TB that the lung probably wont' collapse and so putting a chest tube in them is harmful. I will be doing a retrospective chart review on chest tube patients and then statistically evaluating the data to test the hypothesis. I will be working out of GF Jooste Hospital. 

Kalen and Rusty will be spending 50% of their time helping me on this chest tube research study and then 50% of their time helping the physicians treat patients in the local hospitals.  They will be working from about 5 local hospitals. 

Shannon will be doing data collection for a hospital capacity study looking at the hospitals capacity rates this summer and comparing them to next summer when the 2010 World Cup is here in South Africa.