Chapter Seven- The Great Commission

The team has finally arrived. They go here on Saturday so Matt and I watched their kids, as the Village kids for a while, while they went to Joburg to pick the team up from the airport. They showed up late that night and things have been a little different since then. There are six people here for two weeks and it feels so weird having this many people around. However, it has its perks. For example, Matt's dad and sister are on the team and they came bearing gifts- and by gifts I mean candy, which I have not had in a while so it was a sweet surprise (see what I did there?) In addition, they schedule things for the team that we wouldn't do when its just us such as a trips to Thabong (the township where most of the poor live), mine tours, and a Fourth of July barbecue in the works.

Since they are here working on construction mainly, Matt and I are staying back from the hospital three days a week as well to help out. Work is moving incredibly fast and the house is now sheetrocked, painted, bricked around the outside, with mainly just interior touch-ups and furnishing left. They began building it in early May and it should be done in about the next week which is really awesome. Sometime very soon we will also be breaking ground on the foundation for the O'Tool's home here on the Village property. I have been working mainly alongside Louis and his brother Tim, who is here doing construction for 3 months. On a scale of 1 to 10 I know very little about construction so I have just been doing any labor that requires no skill (such as hauling bricks or digging holes) or whatever Louis tells me to, while we play games such as "guess the movie quote" or "how many S verbs can we think of". I may be unskilled labor but I like to think I'm worth my wages (think about that one for a second)

At the hospital, we continue to split our time between the medical wards and the ARV clinic. One day in the wards we were in a room of 8 patients and every single one of them had TB. If that doesn't make you hold your breath, I don't know what will. There was a man in the next room who had TB 5 times previously, which meant that he probably never took his medication and had a very high chance of MDR. We also saw a woman in the ward who we had ordered to be admitted when we saw her in Tshoanelo clinic. She had TB and a variety of other issues, so it was cool to see our efforts being worth something. There is an interesting phenomenon we've seen which I would like to do more research on when I get back home, HIV-induced vasculitis. Essentially, the virus attacks the walls of the vessels and they become inflamed which leads to poor circulation and possibly gangrene or stroke depending on where it is. This is what causes the number of young stroke patients to be so high here. The literature says that it is a rare condition but in just the last month we have seen more than I can count on one hand so clearly there is more to be learned. It is such a real treat being able to learn about these diseases so rarely seen in the US (HIV, TB, Meningitis, SJS, etc) and to learn them so in-depth and firsthand. I'm honestly going to miss having the chance to work with them when I get back home and stuck with boring old things like pancreatitis and broken fingers.

In the clinic, we have seen probably 75 patients so far overall. I would say about 90 percent of them we are able to take care of without consulting a doctor. Its interesting though how unique each case is and even with such a pointed focus we see different combinations of issues- high ALT, low Hb, pregnant, noncompliant, peripheral neuropathy, suspected TB, malnutrition, transfer, you name it. I really enjoy problem solving so it is actually a very fun experience for me. Some days we sit in with Dr. Nhiwatiwa in the teen HIV clinic as well and there is one case that specifically stuck out. He told us about a pair of twin girls that came in to him in 2003 when they were 9 years old. However, one was HIV-positive and the other not. The infected one was so small and sick that the other was carrying her in. The South African government wasn't allowing ARVs to be given then but he did anyways and now they are both 16 and doing better but the one is still so much smaller. It is a case where clearly HIV is the issue and not malnutrition or something else, and I wish HIV denialists could see what I see every day. With that specific girl though she now had TB and kidney issues which Dr. Nhiwatiwa missed until I showed him and so she was admitted. I look forward to reviewing her case.

I came in to this trip with a slight inclination towards infectious diseases and needy populations, but these experiences have put almost any question out of my mind that this is what I want to be doing. I have seen such a need in the population here and I know that there are places like it all over the world. I also went along with Louis today for a Bible study that he holds in Thabong. On the way we discussed missions and I explained to him where my passions lay. He told me about the things which drew him here and the amazing areas where God has been able to use him in ministering to the kids and many others. The great commission in Matthew 28:18-20 says, "And Jesus came and said to them, "All authority in heaven and on earth has been given to me. Go therefore and make disciples of all nations, baptizing them in the name of the Father and of the Son and of the Holy Spirit, teaching them to observe all that I have commanded you. And behold, I am with you always, to the end of the age." In poor and uneducated places there is a huge huge need for not only the gospel to be preached but for discipleship to take place. In South Africa, Christianity is actually pretty widespread but the people are so susceptible to the winds of any strange teachings and the addition of superstition and things like ancestor worship. The Lord is the greatest passion in my life and medicine is near the top, and I see so many reasons why missions would be the best place for me satisfy both of them.

.The children's cemetery near Thabong. They add approximately 20 graves a week just for infants and kids under the age of 5.

Chapter Six- A Day in the Life

Since I know you are all DYING to find out what its like to be in a South African hospital, here is a glimpse from one day out of my medical journal. We do take extensive notes so its kind of long and for that I apologize. If you find yourself reading it and being confused by the rapid progression and heavy use of medical jargon, then I have done my job. Now please sit back, relax, and try not to get TB from simply reading it:

Monday, June 20

This morning we missed ICU rounds with Dr. Colene because he showed up half an hour early. So we don’t know the meeting topic on Friday or what was discussed but we will find out then. We made our way to C-mix where we saw quite a few patients because Dr. Matika wasn’t there and Dr. Camps had to cover the whole floor.
The first patient had COPD as a result of smoking. He was a very typical smoking patient, having claimed to have quit “about two weeks ago” which is code for “about the time I realized I couldn’t breathe and needed to go to the hospital”. His x-ray showed that he had large lungs with a flat diaphragm which is typical of COPD. Rhonchi were heard in both lungs upon auscultation. We discussed lung sounds a bit according to the way Dr. Camps explained them. “Rales” is the name for all abnormal lung sounds collectively. Crackles/crepitation indicates alveolar problems and sounds like sandpaper being rubbed. Wheezing is usually a problem with the small bronchi, and rhoncus is large bronchi. There was a patient with a herpetic infection on his lips so he was given Aciclovir. He also had streptococcal pneumonia which is very often concurrent with herpes infection.

There was another room which had two recovering stroke patients, one young and one old. The younger one was beginning to regain some speaking ability and was ready to start physiotherapy to learn to walk. His ECG showed a left bundle branch block (LBBB). The outcome for young stroke patients is much better as far as regaining functionality. The older man was conscious and able to sign to us but in worse condition overall. He appeared to be embolizing which was causing his left foot to develop early stages of gangrene. It will likely be amputated but they wait for demarcation to show up so that they can determine where to cut it off. In addition to that he was demonstrating Cheyne-Stokes breathing pattern (deep, heightened rate alternating with periods of shallow or normal breathing). This is a sign of cardiac failure in addition to the peripheral circulation issues and likely embolism. An ECG was ordered to confirm and a D-dimer test for blood thickness. He was currently receiving aspirin but it didn’t appear to be enough so he switched it to Clexane.

The next large room began with a 21 year old man who was fitting and suspected to have organophosphate poisoning, but he turned out to be an epileptic. He was given a toxic screen and a Cholinesterase test, which was high (would have been low for poisoning). He exhibited no signs of meningitis, which is more common to develop in epileptics. He also had a cough and slight indications of TB on his x-ray. All seizure cases are given x-rays in case they aspirated vomit which could get into the lung, usually the right. He also had slight leukocytosis, but fitting can cause that in addition to infection and he had no fever. A sputum will be done to check, otherwise he will just be stabilized and discharged. The next patient was possibly a case of acute Parkinson’s, but was likely the result of a drug reaction. He had been experiencing tremors for three days and then began being confused. He now had “cog-wheel rigidity” which was stiffness in the joints that caused them to move in jumps. However, he had psychosis as an underlying condition and was taking Etamine and Haloperidol (anti-psychotics). Haloperidol was the likely culprit and can cause extrapyramidal reactions which would lead to the tremors. The next man was a possible new diabetic. He was admitted with hypoglycemia which was now under control, but was also HIV-positive and hypertensive. He was on ARV’s (3TC, D4T, EFV) and pharmapress (for hypertension). Dr. Camps said that ARV’s can cause pancreatitis and lead to diabetes. The patient also had severe peripheral neuropathy which can progress to numbness in the legs, so the patient had an ulcer on his leg but it didn’t seem to bother him. As he often does as a quick inquiry to nutrition, Dr. Camps asked the man questions like, “are you working?” or “how are you eating?” This man was not working and so the hypoglycemia could have been a result of malnutrition. Because he had no money he also had stopped taking Diflucan for cryptococcal meningitis which he had. It was very important to check his CD4 and do an India ink test to see if the infection was gone or not.

We then went to the ARV clinic and afterwards came back to C-mix as Dr. Camps was finishing rounds. The second time we saw a man with right upper lobe pneumonia, which could be TB because it usually attacks the upper lobes. He also had a chronic cough, night sweats, and cavitations on his x-ray which are all classic TB symptoms. In addition he had high neutrophils (indicative of bacterial infection) and high CRP. CRP is an acute phase reactant which binds to phagocytotic cells and aids in fighting infections so when it is high it indicates likely infection. There was a CCF patient with high BP, which is unusual because usually once the heart starts to fail it is unable to circulate blood well enough to remain hypertensive. He had a lot of distention-abdominal, scrotal, lower limb, and face, so he was given a high dose of Lasix. Normally it is given 40 or 80 mg bd but since he was so swollen he was given 120 mg bd. Another man had empyema (pus in the pleural cavity) in the left lung. On the x-ray, a meniscus of fluid was visible even with the chest tube, and the lung was shrunk and did not entirely fill the pleural cavity. The last patient was the most severe case of Stevens-Johnson Syndrome we have seen here. SJS is a drug reaction that occurs with TB treatment and affects the skin, causing systemic rash and epithelial necrosis (cell death). It covered his entire body, with the appearance of a burn and his skin was just drying out so he was beginning to recover. Once the drugs are removed, SJS is treated just like a burn with fluids and blankets to keep them warm and hydrated. I was surprised he was not in the burn unit or a more sterile environment because he had no first line defense against infection and was more or less a burn patient.

In the ARV clinic, we saw about fifteen patients today. We were in our own room without even Dr. Makhakhe supervising us, but we had almost no troubles (besides language). The first woman was on HAART since this March so she was not suppressed but was showing signs of TB (cough, night sweats) but was only on INH as prophylaxis. We did not change or do anything but sent her for a chest x-ray and she will come back tomorrow with that. There was a man with resistance to first line, shown by suppression with his first two and a half years on ARV’s and recent increase in viral load even with compliance. He was on 3TC, AZT, and EFV. We moved him to 3TC (always keep it), TDF, and Aluvia after checking his lipid profile. One woman had already had an initial consultation and all we had to do was look at her blood results and decide which ARV’s to place her on. She was slated to get 3TC, TDF, and NVP but she had Hep B and her ALT was high so we used NVP instead. There was a patient who, after exactly 6 months of treatment, was not suppressed. Since that is the borderline for determining resistance, we referred him for a checkup in 3 months to reassess then. There was a man who was supposed to be taking 3TC, D4T, and NVP but he was mistakenly taking 2 doses of D4T rather than 3TC. Stavudine is fairly toxic with lots of side effects in a single dose so of all the ARV’s it is the worst to make that mistake with, and the noncompliance makes resistance likelihood greater. Four or five more patients were routine checkups and doing well on their treatment and others had minor non-ARV related complaints which we referred to the clinics. It was good practice being fully on our own. After the patients were gone at the clinic, we went to D ward to look at patient charts and then went home.

This is half of one of the rooms in the wards. There are 8 patients and about 4 rooms per wardThis is the foot of the man with Stevens-Johnson Syndrome

Chapter 5- Dr. Hircock

So aside from the fact that Matt and I get called doctor half a dozen times a day, this week was the first time I really felt like one (only six years premature). On Tuesday we spent the whole day actually seeing patients in the ARV clinic prescribing their HIV medications. We were under the supervision of Dr. Makhakhe for a lot of it but soon enough we'll be pretty independent. We fill out the prescription forms ourselves and he told us to write MBCHB as our qualification, which is the equivalent of MD. His reasoning was, "You're training to be doctors anyways". We saw about 20 patients and surprisingly enough changed the regimens on about half of them because they were improper or experiencing side effects or something. We know almost everything we need to about the drugs we are just getting familiar with the clinics operations, which are a mess. Essentially the patients have scheduled blood draw and checkup dates which they come in on, then wait for their file, then wait for a sister to fill out a paper, then wait for a doctor to see them, and their files are improperly filled out about half the time so we end up doing error checks for a good chunk of the consultation. Dr. Makhakhe told us all the changes he would like to make but doesn't have the power to, especially getting a computer to keep track of blood work and things. One of the patients was resistant to the first line so we switched to her to the second (and last) line of treatment. Several had problems with side effects, almost always from Stavudine, so we changed them if we were able and prescribed them other medications if we weren't. The last patient we saw was wearing a goat skin because she is a traditional healer. I found it ironic that she was coming into a hospital to be treated.

The rest of our time at the hospital has been pretty good too. Matt and I have dubbed this 'Diversity Week' because we started in the ARV clinic, yesterday was oncology (cancer) clinic, and tomorrow we are doing rounds at the MDR (multi-drug resistant) TB clinic. Lots of interesting stuff and it has put my medical notes up to 30 pages. In the oncology clinic we say our first cases of Kaposi's Sarcoma, which is a type of cancer that shows up as blueish ulcer-like lesions around the body in immunosuppressed patients. She also had a 6" diameter fungal lesion on her back so they were not able to give her full chemo until that is treated and gone otherwise it could get worse. There was another patient with an abscess near his waist which was severely infected and draining pus. He had to be admitted for antibiotics and surgery because gangrene was spreading across his abdomen. And for those of who are curious, HIV and TB has not been eradicated in the last week by any means.

The Village is now up to six kids so it is starting to be more lively around there, and the car is a bit more packed on the morning ride to the school and hospital. The Neihoffs and O'Tools met with another couple this week to discuss partnering to build a church in Thabong and start an outreach ministry there. A lot of things are still up in there but it is an area in huge need so it would really be amazing on all sides if it worked out. For church now we are still meeting at the school and this last week Matt and I led Sunday School for the kids. I've been a camp counselor before so I thought I had it under control but I never had to keep track of 20 kids before, several which didn't speak English. It still went just fine and we learned about being "fishers of men".

Today was a national holiday so we stayed and worked at the Village. We painted the container so it is no longer the evergreen lodge, but it looks much better. The second children's home is coming along nicely and the drywall is nearly finished. The kids were even helping plant new stuff in the garden (winter in SA and they still manage to grow plants). When the team comes in a couple weeks we'll be staying back several days a week and working at the Village. Everything is going pretty well around here except that one of Louis and Amber's dogs got hit by a car before Bible study the other night which was a little sad. Bless their hearts though, they've still invited me to supper so I have to go eat now. Tsamaya hantl! (that's Sotho for goodbye)

Chapter Four- Bonecrusher

That's what I would call myself if I was an orthopedic surgeon. It's also a possibility for the name of my first son.

[Insert impeccably smooth transition here]

I realize its only been a little while since I last updated, and you're thinking "What could this kid have possibly done in the last week that is worth me reading?" I watched a guy get his knee sawed off, that's what! On Tuesday we got to go to St. Helena, a private hospital in Welkom, to watch orthopaedic surgeries for the day. Brian and Lois proved themselves useful connections yet again and hooked us up with their surgeon friend Dr. Van Sittert. We put on scrubs and masks and got to stand in the operating room at a safe distance (1 meter = outside spray range). The first surgery was a knee replacement which was a real treat. For an hour and a half he sawed, drilled, and hammered on this guy's knee. On a scale of 1 to a water-skiing squirrel, it was pretty neat. I'll spare the more squeamish among you the details, but anyone who wants to hear a good story should ask me when they get a chance. The next two surgeries were arthroscopic, a shoulder repair and meniscus removal. It wasn't as visual but it was sort of like an in vitro sewing and welding lesson put together.

Back at Bongani the last couple of days, we spent more time actually talking to the doctors and asking them questions about diseases and treatments and drugs. If you'll humor me, I'll cover some of the more interesting ones here. One patient suffered from Stephen Johnson's syndrome, a severe skin reaction to either the ARV's or antibiotics she was being given for her HIV and TB. Its a dark, blotchy rash and can progress to their skin falling off which is obviously very serious. The only thing they can do for her is to remove the drugs and hope she recovers. Another thing we have seen several times is patients in their 20's suffering strokes, because the HIV virus attacks their blood vessels and causes them to become inflamed and stop blood flow. There was a case of neurocysticercosis, which is a parasitic tapeworm entering the brain which causes seizures and vomiting from increased pressure inside the skull. These are the more interesting ones, but HIV, TB, pneumonia, and meningitis are still by far the most common. We have learned how to spot TB and pneumonia on x-rays and are learning the drugs they are given. My goal is to be able to know how to diagnose and treat these common conditions on my own by the end of my time here. I have so much information and I'm hoping to be able to make a medical presentation when I'm done. We are also finishing up our lessons with Dr. Makhakhe and will start seeing patients in the ARV clinic next week.

Back at home things are going well. We have had rice for probably 75 percent of our meals which I'm perfectly content with. In addition to the bitter cold (it drops below freezing about half of the nights) it has been raining the last three days which makes me regret leaving summer back home when I remember, this is way cooler! Two new girls, whose names I will not try to butcher, are coming to the Village today which is exciting.

Chapter Three- Grand Slam!

Another week gone by in South Africa, and my notebook has plenty to show for it. At the hospital, we are still being bombarded by all kinds of interesting patients and cases. I've taken to bringing a small notebook with me which I affectionately refer to as "Notey". In it I write down everything we see as we go along. We have gotten to know most of the doctors well so we are free to roam the hospital and follow any of them whenever we want. We have been observing the sisters doing blood draws and will probably start doing them ourselves pretty soon. We've seen stroke patients, tons of diabetics, gangrene, ulcers, cardiac arrest, lymphoma, and nearly any infectious disease you can think of. As a short lesson, there are 4 main types of meningitis: viral, fungal (cryptococcal), TB, and bacterial. As of the end of last week, we have observed every single one, a grand slam! In the US, a patient with bacterial meningitis is placed in a sterile room with anyone entering required to wear a mask (maybe two). Here they are placed on the bed closest to the window. It speaks volumes about the endemic of infectious diseases here.

Matt and I are both interested in infectious diseases and missions to some extent in our medical futures, so this has already been an invaluable trip. We have been in the laboratory, taking ARV lessons with Dr. Makhakhe when possible, and doing rounds with Dr. Nhiwatiwa and the rest of the medical ward doctors. We are scheduled to go to the oncology unit in a few weeks, and tomorrow are spending our day observing surgeries. My expectations for this trip have been far exceeded and we are only two and a half weeks in.

The other side of things here has been great as well. Our container home is now fully furnished and so we have started cooking for ourselves, which usually consists of rice or whatever we can do with a potato. We spend a good amount of time out there now and watch movies most nights. I enjoy talking to Brian and Lois about their ministry and finding out more details of how it works in practicality. Recently they have been bombarded with requests to take in children but they just don't have the facilities or personnel just yet, especially any more babies. There was one 13-year old girl who had been raped by her sister's boyfriend and needed a temporary place to stay, but the social workers never brought her to the Village. South African children can't be adopted to the US and there are few other places here for them to go so it is a very vital ministry. I like to play my own small part by taking care of baby Tumi whenever I can.

Yesterday we went four-wheeling onto the mine dumps, which are huge dunes created by mixing the leftover ore with a cocktail of other chemicals, which makes for an ugly sight but great riding terrain. I am definitely starting to miss American food, especially the snacks. In my opinion, that would be the largest sacrifice of a life in missions to South Africa. However, I will say that the pop here is delicious. After going missing for over two weeks, Matt's bags finally arrived at the Village today which has made him a happy man. The Village has a phone line now and will get internet whenever the workers get around to it, which is anybody's guess.

I hope you all enjoy hearing about the trip, and if you have any questions feel free to email me at thircock@mchsi.com. Thanks!