Chapter Ten- Meet the Kids

For those of you who have read my last post you now know about the general conditions in South Africa. However, neither I nor Restoring Hope are here for that reason, we are here for the people. In their case that is brought out in the largest part of their ministry, long-term care for orphaned children. I would like to introduce to you the kids and their stories as well as their personalities in the way that I know them:

Motshidisi Karreebos- Age 17- Motshidisi and her sister Dieketseng were both living in a small tin shack in Thabong with their grandma, four other children, and occasionally an aunt. Their grandmother was HIV-positive and was often in need of as much care as the children. The aunt was a prostitute and was more harmful than helpful when she was around. In 2006 the situation came to a head and the children were all moved to the Pines (the organization the Niehoffs and O’Tools previously worked at). Now they are both happily living at Restoring Hope and doing well.

Motshidisi is the oldest of the children and often serves as a caretaker to help the housemothers handle the load. She is often shy and softspoken but is a wonderful girl and opens up once you know her. She is very obedient and as I mentioned earlier, extremely helpful and willing to serve. This makes sense, as she told me that her name means “supporter” although I later learned it is more accurately translated “road”. Well we are what we believe we are, right? For all her experience taking care of kids though, I watched her perform her first diaper change and I would say that her and her gag reflex have a way to go! Due to her background she was significantly behind in school when she began, but she works very hard and last term she made honor roll (which means she completed all her school work with at least 80 percent). As of Saturday she is still deciding what she wants to do when she is older because I had to explain to her that paramedics, her previous ambition, had to work with blood and possibly dead people. As you can tell she is a very funny girl. She knows Jesus Christ as her savior and along with her sister attends Bible Study on a weekly basis and enjoys it.

Dieketseng- Age 15- You have already been introduced to her story so I will do my best to capture her personality. She is a very outgoing girl and I wouldn’t say she is stubborn but she is definitely confident (even when she maybe shouldn’t be). Never one to let you miss what is going on in her mind, which makes her a prime target for me to pick on. Don’t worry though she is quick to dish it back! She is very bright and made honor roll this last term, finishing a week before the end of the term. Her hobbies include playing netball, watching movies, and dodging work (especially with “uncle Brian”). She has lots of ideas about what she wants to do when she grows up, but topping the list right now is a musician. She loves High School Musical but still has to overcome the obstacle of learning an instrument. She would very much like to visit America and after so much interaction with the Niehoffs, O’Tools, and team members I think she could fit in well. This is something which hasn’t escaped her classmates attention as they call her “America” because she speaks such good English. Although Dieketseng is attempting to fight this image- she recently requested new soap because the current one is “making her skin too light”. She is very lively but is a sweet girl and she also loves and follows the Lord Jesus Christ

Lerato Ramakhale- Age 9- Lerato and her sister Monica were the first two children at Restoring Hope Village when it opened. They were living with their uncle in the township as a means for him to get a child care grant every month. They were often locked inside while he went to the bars and there were often times other men living in the house. It was a dangerous situation for them so in December 2010 social services got them moved to the Village. When they came, neither of them spoke English but I could hardly tell by the time I arrived in May. At that time Monica and Lerato were the first and only children at the Village. They attend Dunamis Christian school and both of them achieved honor roll this last term.

Lerato is a sassy young lady but very good-natured. I can always expect her to spot me when I get back home and yell my name so that she can come running over and climb on me. She is definitely not shy and when the children sing in church her voice is always audible above the rest. She is a good big sister to Monica and I expect she’ll be a good leader some day after seeing her take the role of interpreter/crowd control for me when I was in charge of Sunday school. My attachment to baby Tumi hasn’t escaped her attention and so whenever I head down to the kid’s home to visit them she will carry him out to me (which I assure you is no small task). She may be bold but I can definitely see the soft side she has when dealing with people. However, when I asked her what she wanted to do when she grows up she told me, “I’m not old like you I don’t have to decide that yet”. Like I said, she has no problem asserting herself.

Monica Ramakhale- Age 7- Pint-sized Monica is about as cute as they come. She’s just a little thing with a gap-toothed smile and a near constant giggle. She loves to be around people and has no hesitation in attaching herself to someone. During the day when people are working down on the house she likes to make a game out of trying to distract them to play with her. Rosina and I are probably the most susceptible to this but let’s be honest, what won’t Rosina do to get out of work? I don’t think I’ve ever been around Monica without seeing her smile or laugh and so she is a very cute, very fun girl to be around. Her favorite activities include singing, giggling, and getting piggy back rides. Despite her age and small stature I have seen her exhibit monumental feats of strength and cunning. For strength she can carry Tumi for a good 20 feet which is impressive because he’s half her size. For cunning she has fooled me in a game of soccer in which she fell and promptly turned on a very convincing waterworks display only to stop abruptly and make a break for the ball when I turned to help her. She’s like a sour patch kid in reverse- first she’s sweet, then she’s sour.

Tumisong – 9 months- More commonly known as “Tumi”, “Sumi Tumi”, or “Chunker”. He is a little (or should I say big) roly poly plumpster, which has led to him taking the brunt of many a fat joke. Don’t feel too bad for him though, for one thing he is only a baby so he doesn’t understand anyway, and he also gets his fair share of attention. When he came to the Village at the end of May he began staying at Brian and Lois’s house so I saw plenty of him (and believe me there is plenty of him to see) and for some reason I was just drawn to him. I began taking care of, playing with, and feeding him whenever I could so we established somewhat of a connection. This did not make him any less hesitant to spit up on me as often as possible though. He was brought to the Village because his mother is on her way through the court system and most likely to jail. We don’t believe she was a great caretaker anyhow (despite his “well fed” appearance) and he has spent most of his young life laying in his crib on a steady diet of sugar water. As such he is a bit behind in development although I claim personal credit for teaching him how to sit up, click with his tongue, and shake his head violently back and forth. He is coming along well but it would be nice if we could get him to crawl rather than just lay on his stomach like the beached whale that he is (there is no end to the joke material that he provides)

Amohelang Oliphant- 3 months- I honestly can’t tell you a whole lot about this little chiclet because she likes to spend most of her time within the confines of her swaddling cloths. I can assure you that she is quite the opposite of Tumi in size and when she arrived at 6 weeks old could nearly fit in the palm of your hand. What she lacks in size though she makes up in hair as she has a veritable jungle on the top of her head already. In what I suspect is likely due to her tiny hands and quiet demeanor she has become a popular attraction amongst the ladies visiting here. She was brought to RHI because her mother was discovered to abandon her on more than one occasion and is not emotionally stable enough to be caring for a child. She arrived in May about three days before Tumi and has probably grown more than him in her time here which is good progress. Her favorite hobbies to my knowledge are sleeping, pooping, and chilling with Mama Lizzar.

So that is just a quick introduction to the kids here and after spending two months with them I absolutely love them and it will kill me to have to leave. It has been a great blessing to experience firsthand the fruits of this ministry and see the lives these kids are getting in comparison to the ones I know they would be getting otherwise. I have seen glimpses of life in Thabong and I assure you the love, opportunities, education, and spiritual influence they get at RHI is beyond measurement in comparison. I hope that through this you have gotten a small feeling for the individual personalities they each bring to the table. If you are interested in helping sponsor any of these children (and I personally recommend all of them) you can contact RHI at childsponsor@restoringhopeint.org

Chapter Nine- South Afripedia

So it has come to my attention that living in a place for two months enables you to learn certain things about a place that you can’t find out on Wikipedia. I know this because I’ve checked. I figured that I would fill you in on the things I have learned about the culture, medical treatment, and Restoring Hope’s ministry here in Welkom (pronounced Vel-kome). I do not claim to be an expert, but some information is better than none for the curious mind. Please bear in mind that when I use terms such as blacks and whites, it in no way is a racist thing, that is just the way things are here. It is very important to remember that their racial history is very recent and the outcome of that is a large separation of things in many regards along racial lines.

A rough statistic about South Africa in general: about 90 percent of the population here is black or colored, with the other 10 percent being whites. For a long time, the whites dominated the country, leading to Apartheid, the legalized segregation and racism policy from the late 1940s to 1994. Many of you may be familiar with Apartheid and Nelson Mandela as the face of its end. Essentially it was originated to separate the racial groups to keep them from fighting each other but led to horrible policies based in racism. Blacks and colored people were not allowed to vote and relegated to poorer areas and general living conditions. Even since the end of Apartheid though things have not fully improved. Due to longstanding inequality , blacks are still socioeconomically crippled and poverty is rampant. The ANC (African National Congress) is the party of the blacks which has been in power since 1994, but despite their promises of change the country is still in poor shape and the party is known to be full of corruption. In addition, it is common practice and policy to hire blacks before whites, regardless of qualifications. Just by observing the healthcare, education, and other areas it is clear that things are not being run well, but I certainly don’t agree with the prior regime either. This country still has a long way to go politically.

As for culture, there are many ethnic groups making up this country and 11 official languages. Generally, each province (similar to our states) has its primary black ethnicities with their own language. Afrikaans is spoken amongst the whites and taught in most schools, and English is also very common amongst whites and many of the blacks. I’ve mentioned before that Christianity is the major religion of South Africa, but tribal religions are also so embedded into the culture that most “Christians” have additional beliefs added in such as ancestor worship, demonic activity, and various other superstition or false teachings for the sake of money. Suffice to say, the depth of Christianity here is lacking and a solid Christian is fairly difficult to find. Superstition and tradition are very deeply rooted into the black culture and beliefs are very hard to change in the people. For example, even in the hospitals the doctors struggle with patients that take herbal remedies or methods of treatment from “traditional healers” which do more harm than good. Many also believe in the mythical Tokoloshe, which is more or less an evil gremlin which torments people, usually while they are sleeping. Some churches will capitalize on this and tell people that they have to give a certain amount of money to have it removed. Not to say the culture is entirely negative (they have beautiful music) but the presence of such immorality and depravity has really dragged them down. Now only the gospel can truly save these people, but education is another key to lifting them out of the lifestyle. The problem is that schools take time, money, and effort from children and families who cannot or are not willing to commit that much, which in poorer areas such as Thabong creates a viscious cycle shown by the 60% unemployment rate in SA and nearly 80% in Welkom alone. These people are hurting because they are in a place and condition that is bad enough to not allow them to leave it.

Statistics will probably tell you that the HIV prevalence in SA is somewhere near 10-15%, but this is a gross underestimation. Due to the huge social stigma, people almost never get tested unless they are pregnant or very sick. Doctors wouldn’t hesitate to tell you they believe its more like 30-50%. This prevalence coupled with their unwillingness to face it or even talk about it creates a huge problem in attempting to treat it. When patients are admitted to hospitals with TB, pneumonia, wasting, meningitis, and other various conditions they are often tested, but must have counseling just to take the test. Most doctors know based on the patient’s condition but because of the stigma they must jump through hurdles and use words like “retroviral-infected” or “immunosuppressed”. AIDS is only a word used on government scare tactic posters and has lost its true medical meaning. Still, once they are placed on treatment (ARVs) and receive counseling, they almost always drastically improve and are able to live a more normal life. I can’t tell you a lot about general health other than that it is mostly not good, especially when it comes to nutrition. What I can tell you about is the entirely different atmosphere of medicine here as opposed to a developed country. With so many immunocompromised patients, which make up the majority of admissions, you see such a whole new and more potent set of conditions than anywhere else. Starting with TB, 70% of HIV-positive individuals will contract TB in their lifetime. Slightly under half of the patients I see have confirmed or suspected TB, and I see it in a variety of ways. There’s not time to cover all of them but meningitis, pneumonia, stroke, lung infection, Kaposi sarcoma, and so many more conditions relating to infectious diseases are common here at an unparalleled level. The government healthcare here is affordable for the hordes of poor, and though it is not top notch and waits may be long, it is effective for treating the flood of potent diseases mostly resulting from HIV and the conditions I’ve already mentioned. It seems cliché to come to South Africa and focus on HIV, but its not really avoidable. And I’ll be the first to tell you about the loads of other issues, but most roads will lead you back there.

Restoring Hope has taken an interesting angle on addressing the situation. They know they can’t come in and fix this country’s problems. So they have come to fix the lives of the victims of those problems. They are building a community of children’s homes for orphaned kids affected by the AIDS crisis. They are rescuing the kids from poor futures either alone in the township or with elderly grandmothers, uncles, and cousins who are often unable or unwilling to raise them in a proper, healthy manner. If it was just that though it wouldn’t be enough. They place the kids in a family environment with a housemother as well as older Christian mentors. They recognize that all the world, in poverty or not, is lost and in need of saving. After they have rescued these kids physically they show them the gospel, that Jesus Christ died for their sins to save them. They teach and disciple these kids with spiritual truth and do this in a loving environment. As I mentioned earlier, it is so hard to find a solid believer here due to the conditions and the culture. But they are bringing them up so that they can be a light to the people and influence those around them in order to change the heart of the culture. In addition to Restoring Hope Village, they are actively engaging the culture by making connections with people in Thabong and doing outreach. Several Bible studies have been done and a number of young men, now at university are living testaments to the power of God and the influence that personal discipleship has had on them. They hold church in a schoolroom in Thabong and are looking to purchase land and build nearby. These people have a passion for loving the children and people and are seeking to begun change on a personal level and through the most powerful tool available- the Gospel.

The missionaries serving here are Brian & Lois Niehoff and Louis & Amber O'Tool. You can learn more about their ministry here: http://restoringhopeint.org/
If you feel led to support them you can contact them through that page. Any other questions, you can come to me- I highly recommend and support this ministry having seen and experienced it firsthand

Brian, Lois, Lindie, and Liam

Louis, Amber, Drake, and Meredith

Chapter Eight- Please Don't Blame Tim

No one should ever dare to embark on a journey to Africa with the expectation of having any expectations. Things always have a way of surprising you, often times at your expense but at the benefit of a great story. This Tuesday I had my own little adventure which has definitely spiced up my trip. For those who haven't heard, on my first trip overseas I managed to get my first broken bone. To protect the dignity of all those involved I will leave it to your imagination to come up with any number of heroic scenarios you desire to explain the following outcome. At first I thought everything was fine because I had heard collar bone fractures were extremely painful and I was not in that much pain. I don't consider myself as someone with an astounding pain tolerance so things were looking good. However, I then felt something just south of my neck moving around and noticed there was an unnatural lump. Still convinced it wasn't painful enough to be significant, I had now decided that it was dislocated. With the gracious help of Timothy O'Tool- who is in no way responsible, at fault, or liable for this tragedy- I made it back inside and attempted to finish our game of Ticket to Ride. The group was apparently concerned about me so Brian drove me into Medi-clinic, the private hospital im Welkom, for x-rays. Once they had finished taking them I sat in the waiting area and my jaw dropped when I spotted this hanging up in the radiologist's office:

In an ironic turn of events Dr. van Sittert, the orthopedic surgeon who Matt and I observed for a day, was the one we called to come and consult on it. He said that I could either choose to have surgery and end up with a scar or just use a sling for 4-6 weeks and have a permanent bump and a bit more pain. Never one to back down from a chance to prove my manliness (or to avoid getting surgery in Africa) I chose the second option. The only reason I regret this decision is that if they would gave operated I could have had Matt attend and record the surgery which would have been beyond sweet. Due to the nature of this trip I never pass on a chance to investigate the medical side of things, so here is the radiologist's report on my x-ray:

"Comminuted fracture with overriding at the fracture site was noted in relation to the junction between the middle and distal third of the clavicle with suboptimal alignment. Associated soft tissue injury not excluded"

For those of you unfamiliar with medical terminology, thats a pretty intense fracture. There was complete separation of the bone between half and two-thirds of the way down my clavicle with a few smaller shards as well. This is right on the border of where they typically decide to operate or not. There is a lot of soft tissue and blood vessels in that area so surgery can be delicate and tricky with a high risk of sepsis (blood infection). In addition, its possible that the tissue can get between the bone fragments, impairing them from healing properly at which point surgery would be necessary. After about three weeks it should be obvious whether they are coming together properly.

It is a little disappointing that I can't help as much with work but ever since the incident I have been at the heels of everyone in probably annoying fashion, trying to make up for my lack of ability with effort. I have been glad at the chance to scrub floors or just hand people tools because I want to know I'm of use. So things are going well and I'm taking it in stride. I just wanted to share my little adventure with all my faithful readers.

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.