Thursday, November 16, 2006

What am I up to? (5 Nov – 12)

In the interest of sharing a few more of the day-to-day details of my life here in Swaziland (as requested by a few of you), I offer to you this update:

The past week began and ended with travel. I returned from Malawi on Monday afternoon and saw patients in the clinic--i.e. the Baylor Center of Excellence (COE)--Tuesday through Thursday.

My three clinic days were typical clinic days. I arrived at the COE at 7:30 or so, waved as I walked in through the waiting room, and headed to the kitchen to prepare a cup of instant coffee. This ordinary entrance is followed by a “quick” check of the emails I received while sleeping, not-so-"quick" connection speed permitting.

[As foolish as it might sound, I still have conceptual difficulties with the undeniable fact that my today is somebody else’s yesterday, and that when I arrive to work on Tuesday, Monday is simultaneously out there somewhere. In any case, I tend to receive email messages in the middle of the night, and check them when the senders are just entering REM.]

The instant coffee helps me clear this up inside my head, and, once situated in time, I grab the first patient chart, usually around 8:00. Some time between 9:30 and 11:00 I happen to pick up the chart of an English- or Portuguese-speaking patient and the SiSwati translator goes to tea. A mid-morning break is a foreign concept to many, but I can assure you that if it is one’s job to accurately and tactfully translate the things that come out of my mouth, she deserves tea.

Patients continue to come and go throughout the morning. Some are very sick, and some are not. All, with rare exception, are HIV positive. (Those that are HIV negative are able to see a physician on the day they are screened, but are then referred to the local general pediatrics clinic, as it is our mandate to care for HIV-infected children and their families.)

On a typical day, lunch comes at around 1pm and ends shortly thereafter, when I pick up the next chart.

An average day’s patient volume will be around 12-16 patients per physician (similar to subspecialty clinics in the US).

Patients usually come in groups of 2, but some are seen individually, and families of three or four not uncommon. Two-thirds to three-fourths of the patients I see are children, and the rest are adults. There is always an available internist or family practitioner if I find myself inundated by complaints of lower back pain, hypertension, etc, and need to consult an old-person-doc.

Approximately half of the patients seen are on antiretroviral medications. The other half are being monitored and treated until their CD4 counts drop to the range where ARVs are indicated. Most patients come in for scheduled visits (routine labs, adherence checks, clinical follow-up, nutrition/social worker counseling, med refills, etc), but a handful drop in because they are ill and need to be seen without an appointment.

On a typical week, I admit one (maybe two) children to the hospital. This process is well-known to any outpatient physician, but here in Mbabane there is one significant difference—the hospital often has fewer resources than the COE. To minimize the effect of this disparity, we do as much as possible for the child before the child is transferred, and we communicate directly with the doctors receiving the patient at Mbabane Government Hospital. To ensure adequate follow-up and to help address some of the hospital’s unmet needs, we also assign at least one Baylor Aids Corps physician to round during the week at “MGH”. (I will be there next week, so stay tuned for more on this.)

Patient care usually wraps up between 3:30 and 4pm, at which time we typically have informal meetings, review labs, or continue working on other projects (PMTCT, improving clinical protocols, nutrition program development, training preparation, etc.)

This, in summary, is a typical clinic day. I hope this description answers more questions than it generates. If not, let me know and I will elaborate further.

Friday was filled, as usual, with administrative and academic meetings. We discussed TB protocols, a recent patient death and its most likely causes, the Malawi COE network meeting, and more.

As I stated, last week ended with travel. A mere 4 hours southeast of Mbabane, there is a beautiful bay (called Sodwana) that is also a South African national park. They say that the diving there is second only to the Great Barrier Reef. This has to do with the diversity of fish and coral, the visibility, and other underwater details. For such details, ask one of those people with that rectangular red and white scuba sticker on their back windshield. They will know.

I went to simply spend a day on the beach, and I did just that. We left for the beach Saturday at 6am, and came back early Sunday.

Sunday evening, I read some of Sachs's “The End of Poverty” before closing my eyes, jealous that everybody in Texas was just sitting down to Sunday brunch (a tradition I would trade for morning tea any day), and hopeful that the book on my nightstand was correct and that the world was indeed on track to change for the better.



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