Groote Schuur Hospital-HIV Neuropathy Research-

Neurology Department-Nick Faunce-

GSH foreground. Devil’s Peak Background.

Personal Goals• Immersion in a foreign setting• Deconstruct preconceived biases• Adapt to new cultures• Learn historical context• Find independence• Explore a new landscape

• Develop clinical research skillset• Data gathering/ documentation

methods• Follow-up/ specimen registry

process• Data management tools• Statistical analysis techniques• Statistical Packages

• Appreciate tools of neurology• Neurological physical exam• Electroencephalography

testing/reading• Electromyography testing/reading• CT/MR/XR

• Observe advanced pathology• Strokes• Duchennes• Guillian-Barre syndrome• Myasthenia gravis• Charcot-Marie Tooth syndrome• Huntington’s….etc.,

Groote Schuur Hospital - University of Cape Town• Home of the 1st Heart Xplant• Tertiary (quaternary?) Public Hospital serving >3.75M (Cape Town pop.)• 893 beds

• Substantial NIH Funding for Infectious Disease Research (TB, HIV, etc.,)• Folder Research Elective (4 or 8 wks) – Apply 1 month advance• Clinical Elective (4 or 8 wks) – Apply 1-2 yr in advance (6 month min)• Amidst a Critical Crime Post (US State Dept.)

Background Information• 11 official languages (tribal origin)• History steeped in turmoil

• Dutch East India Trading Company stopping post in Cape Town • 1652-1795 a.d.• Established Boer pop. (became Afrikaaners)

• French Huguenots fearing Napoleon’s persecution settled 1685-ish

• British Overthrow• 1795 a.d.• Returned to Dutch 1803• Anglo-Dutch war 1806-1814

• Dutch regained control

• Apartheid 1948-1994 • Nelson Mandela

• Imprisoned 1962-1990

• President 1991-1997

• Resources• Agriculture rich• Aquaculture rich• Mineral rich

• Gold, Platinum (78% WW), Diamonds, Coal, Chromium

• Current• Stabilizing from effects of apartheid• High crime rate (3rd WW)• High Pollution rate (Johannesburg 7th WW)• Incredible tourist attractions

• Stellenbosch vineyards etc. (Hugeonots)• Great White Shark diving/Su• Kruger National Park• Cape Colony Penguins• Table Mountain

Health Issues/Challenges• Systemic• Underfunded public hospitals/public health organizations

• Resources, clinics, diagnostics, drugs, vaccinations, awareness• Technological inefficiencies• Patient Overload

• Inconsistent health professional training (Overall not at GSH)• Emigration of health professionals

• Nurses/physicians• Language/Cultural (home remedies/drugs)

• Pathology• HIV 17% of adult population (US ~0.3%)• TB ~80% latent TB• Everything is late stage• Trauma!!

Learning Curve• Resourcefulness• Implications of diagnostic tests on clinical management• Returning used assistive devices/unused drugs• Physician independence—triage, blood draws, US, BP, EKG, IV’s, Monitor relays• Physical Exam

• Communication• Inter-collegial diplomacy• Accurate interpretation of patients words

• Histories, symptoms, drugs-list• Personalizing treatments based on patients described responses• Objectivity with sensitive issues• Proper emotional responses

• Sterility/Sanitation

Conclusions/Suggestions• Hospital is comprised of incredible physicians who see extraordinary

pathology and treat with minimal resources• They manage to get along

• Profound diversity of race, religion, culture, language, and background • DON’T BE AFRAID. TRY IT!!

Profound Clinical/Academic Experiences

• Clinical: • Textbook mumps orchitis• Post-MI status dystonicus—group of students watching a convulsing body while a

nurse performed supportive esophageal suction.• Locked-in syndrome—post-posterolateral thoracic stab wound. Students unaware

of the impact of giggles while assessing clonus.• Severe sepsis and Heart Failure pt—triaged as a yellow (2-5hr waiting time)

• Academic:• EEG reading—Consultant sitting with me for an hour describing the theory of EEG

and the nuances that make it so difficult.• Learning sessions—Students required to assess patients and report findings in a

group setting. Incorporation of physical exam and direct input from consultants on methods or findings.

Cultural Experiences• Tuning my ear—for one accent getting caught off guard by another• Listening to my guide in Kruger Park describe how he learned about

animals and astronomy so he could become a park ranger and not die in the mines like his father.• Driving from Phalaborwa Gate to Johannesburg—observing the extent to

which people have to wait/walk to travel between work and home• Observing the maids and workers walk towards the suburbs at 7 am from

the train stations as we departed for the hospital.• Listening to a fresh marimba band at Marco’s African place.• Rugby Matches at Paul Ruus boys preparatory school

Professional Takeaways• It instilled my desire to treat everyone with dignity• I’ve kept an open mind about my professional direction but it gave me

tools to excel when I get there.• It exposed me to an array of pathologies that have given meaning and

depth to my studies.• It prepared me for what to expect with the resource-limited work I do in

the future.• It presented me with uncomfortable situations which exposed my

prejudices and biases, and allowed me to grapple with their relevance and origins.

Cape Town

Mitchells plains township

South African National Gallery, Cape town

Devil’s Peak, Overlooking the Western Cape

Waterfront Mall, Cape Twon

Simonstown

Cape Penguin Colony

Hermanas/Haans Baai

Great white shark diving

Hermanas en Aarde, wine vallley

Hermanas Beach, Southern Right whale mating grounds

Kruger/Johannesburg/Blyde River Canyon