International Medicine International Medicine Elective: BotswanaElective: Botswana

WelcomeWelcome

Global Health Programs

Greetings Are Very Important Greetings Are Very Important

► ““Dumela Rra”Dumela Rra”► ““Dumela Rra”Dumela Rra”

(Would be Dumela (Would be Dumela Mma if a woman)Mma if a woman)

► ““Le Kae”Le Kae” How are you? How are you?

► ““Re Teng”Re Teng” We are well. (Use of We are well. (Use of

plural shows plural shows respect.)respect.)

Partnership OverviewPartnership Overview

Botswana-UPenn Partnership Botswana-UPenn Partnership Mission Mission

To help build capacity in:Clinical CareEducationResearch

To offer opportunities in global health for Penn/CHOP trainees and faculty Botswana: Population 1.8 million

Democratic Safe Dessert

Penn CompactPenn Compact►The Penn Compact seeks to propel the The Penn Compact seeks to propel the

University of Pennsylvania from University of Pennsylvania from excellence to eminence in teaching, excellence to eminence in teaching, research, and service through:research, and service through: increasing accessincreasing access integrating knowledgeintegrating knowledge and engaging locally and globallyand engaging locally and globally

►Penn’s presence in Botswana is a model Penn’s presence in Botswana is a model for Penn’s future global engagement for Penn’s future global engagement initiatives. initiatives.

Botswana-UPenn Partnership Botswana-UPenn Partnership HistoryHistory

►Penn has been in Botswana since 2001. Penn has been in Botswana since 2001. ►First invited by ACHAP to have Penn First invited by ACHAP to have Penn

physicians assist in training local physicians assist in training local providers on the management of HIV providers on the management of HIV infected patients. infected patients. ARVS had just been made available at ARVS had just been made available at

lower cost in Africa.lower cost in Africa. Botswana has national healthcare, but did Botswana has national healthcare, but did

not have enough qualified providers to not have enough qualified providers to implement treatment.implement treatment.

4 Major Initiatives in Botswana

1. Clinical care: HIV, TB, Women’s Health. ~ 55 fulltime BUP employees in Botswana, including 15 doctors and researchers

2. Education in collaboration with new UB School of Medicine: Helped design internship and internal medicine residency curriculum, planning med library in new building

3. Global health opportunities for SOM Penn trainees: ~ 35 4th year med students and ~ 25 residents/fellows annually

4. Research

Botswana-UPenn Partnership in Botswana-UPenn Partnership in 20092009

► Med Students: Med Students: Penn 4th year medical students go for 8 week Penn 4th year medical students go for 8 week

electives (36/yr)electives (36/yr)► Residents and Fellows: Residents and Fellows:

Internal medicine residents (20/yr) Internal medicine residents (20/yr) Pediatrics, Dermatology, Radiology, Neurology, ID, Pediatrics, Dermatology, Radiology, Neurology, ID,

ER (~40/yr)ER (~40/yr)► Faculty: Faculty: ~ 6-12/yr ~ 6-12/yr ► Integrated services: We try to have interns Integrated services: We try to have interns

and medical officers from Botswana work with and medical officers from Botswana work with Penn trainees and faculty.Penn trainees and faculty.

► UB enrolled first class of medical students in UB enrolled first class of medical students in August 2009 so soon, Penn medical students August 2009 so soon, Penn medical students will work side-by-side with UB medical will work side-by-side with UB medical students.students.

Global Health Opportunities for Penn Global Health Opportunities for Penn Medicine Trainees & FacultyMedicine Trainees & Faculty

► Penn and UB collaborate on undergraduate and Penn and UB collaborate on undergraduate and graduate educational programs:graduate educational programs: Semester abroad (bilateral)Semester abroad (bilateral) Summer internships Summer internships Sabbaticals (UB at Penn)Sabbaticals (UB at Penn) HIV research (collaborative)HIV research (collaborative)

► Penn helping to develop curriculum for Internship Penn helping to develop curriculum for Internship and Internal Medicine residency in the new UB and Internal Medicine residency in the new UB medical schoolmedical school

UB-Penn UB-Penn CollaborationsCollaborations

Other American Universities Other American Universities Working in Botswana Working in Botswana

►Harvard Harvard Botswana–Harvard School of Public Health Botswana–Harvard School of Public Health

AIDS Initiative for HIV Research and AIDS Initiative for HIV Research and Education (BHP) Education (BHP)

►Baylor Baylor Baylor International Pediatric AIDS Initiative Baylor International Pediatric AIDS Initiative

(BIPAI)(BIPAI)►University of WashingtonUniversity of Washington

I-TECHI-TECH►VanderbiltVanderbilt

Sharing the expertise of a world-Sharing the expertise of a world-class university with our partners in class university with our partners in

Botswana to build capacity and Botswana to build capacity and excellence in clinical care, education, excellence in clinical care, education,

and researchand research..

BotswanaBotswana

► Land-locked countryLand-locked country► Size of Texas / FranceSize of Texas / France► The Tropic of Capricorn The Tropic of Capricorn

runs through it. runs through it. ► Kalahari Desert Kalahari Desert

occupies 87% of the occupies 87% of the territory.territory.

► Also home to the only Also home to the only inland delta in the inland delta in the world, the Okavango.world, the Okavango.

ClimateClimate

►Semiarid Semiarid ►Cool winters (June-August) Cool winters (June-August)

Average daily temps of 41 – 66F (but can Average daily temps of 41 – 66F (but can be colder at night) be colder at night)

►Hot summers (December-February)Hot summers (December-February) Average daily temps of 71 - 91F (but can Average daily temps of 71 - 91F (but can

be hotter and most buildings to not have be hotter and most buildings to not have AC)AC)

►Rainy season during their summer has Rainy season during their summer has intense rain and thunderstorms. intense rain and thunderstorms.

PeoplePeople

60% of countries’ population belongs to 60% of countries’ population belongs to one of 8 Tswana tribes one of 8 Tswana tribes (‘Ba’ means (‘Ba’ means ‘people of’)‘people of’) Barolong, Bakwena, Bangwaketse, Barolong, Bakwena, Bangwaketse,

Balete, Bakgatla, Batlokwa, Bangwato Balete, Bakgatla, Batlokwa, Bangwato and Batawanaand Batawana

Major Ethnic GroupsMajor Ethnic Groups► TswanaTswana► Kalanga (11%)Kalanga (11%)► Basarwa / San / “Bushmen” (3%)Basarwa / San / “Bushmen” (3%)► Other Newer Groups (7%)Other Newer Groups (7%)

HereroHerero► Bantu group originally from Namibia fled Bantu group originally from Namibia fled

to Botswana in 1904to Botswana in 1904 KgalagadiKgalagadi WhiteWhite

► PennPenn

ReligionReligion

► 70% are Christian70% are Christian► 7% have indigenous 7% have indigenous

beliefsbeliefs► 20% have no religion20% have no religion

► Many Batswana mix Many Batswana mix some African Traditional some African Traditional Religious or Badimo Religious or Badimo beliefs into their religious beliefs into their religious practices (e.g. consulting practices (e.g. consulting medicine men for medicine men for advice). advice).

LanguageLanguage

► English is the official language.English is the official language.► Setswana is the national language. Setswana is the national language.

It is used by the very young and the very old. It is used by the very young and the very old. G is nearly always pronounced as H and TH as T and E G is nearly always pronounced as H and TH as T and E

is rarely silent.is rarely silent.► Gaborone pronounced “Ha-bor-ron-ee”Gaborone pronounced “Ha-bor-ron-ee”

The people of Botswana are called “Batswana.”The people of Botswana are called “Batswana.” One person from Botswana is called a “Motswana.”One person from Botswana is called a “Motswana.”

► Other languages include Khoisan languages Other languages include Khoisan languages (“click languages” of the San and Kalanga in the (“click languages” of the San and Kalanga in the north)north)

Political HistoryPolitical History

► British colony known as British colony known as the Bechuanaland the Bechuanaland Protectorate (Protectorate (1885-1885-19661966). ).

► Obtained independence Obtained independence in 1966.in 1966.

► Longest continuous Longest continuous multiparty democracy in multiparty democracy in Africa with 4 Africa with 4 democratically elected democratically elected presidents:presidents: Seretse KhamaSeretse Khama Ketumile MasireKetumile Masire Festus MogaeFestus Mogae Ian KhamaIan Khama

19661966

►Botswana ranked as one of the Botswana ranked as one of the world’s poorest countries with per world’s poorest countries with per capita income of $70 USD capita income of $70 USD

►There was only one 12 km paved There was only one 12 km paved road in the entire country at the time road in the entire country at the time of independence.of independence.

DiamondsDiamonds

► In 1967, diamonds were In 1967, diamonds were discovered in Orapadiscovered in Orapa

► Debswana, largest Debswana, largest mining company, 50% mining company, 50% owned by the owned by the government and 50% government and 50% owned by DeBeers, owned by DeBeers, generates half of all generates half of all government revenues. government revenues. (These are NOT “blood (These are NOT “blood diamonds.)diamonds.)

Current EconomyCurrent Economy

► Mining: Diamonds, copper, nickel, coal, methane gasMining: Diamonds, copper, nickel, coal, methane gas Diamond mining accounts for >1/3 of the GDP and 75% of Diamond mining accounts for >1/3 of the GDP and 75% of

export earnings. export earnings. Jwaneng diamond mine is the richest diamond mine in the Jwaneng diamond mine is the richest diamond mine in the

worldworld► Tourism Tourism

Tsodilo Hills (UNESCO World Heritage Site), Chobe elephants, Tsodilo Hills (UNESCO World Heritage Site), Chobe elephants, Okavango Delta, Kalahari DesertOkavango Delta, Kalahari Desert

Large nature preserves & good conservation practicesLarge nature preserves & good conservation practices Expensive park admission fees geared towards high-end Expensive park admission fees geared towards high-end

tourismtourism Big game hunting on private reservesBig game hunting on private reserves

► Cattle / BeefCattle / Beef► Financial servicesFinancial services

GrowthGrowth

►Botswana has had one of the fastest Botswana has had one of the fastest growth rates in per capita income in the growth rates in per capita income in the world. world.

►Per-capita income was $5,680 USD in Per-capita income was $5,680 USD in 2007, the highest among non-oil-2007, the highest among non-oil-exporting African countries. exporting African countries.

►Life expectancy soared from 49 at the Life expectancy soared from 49 at the time of independence (1966) to about time of independence (1966) to about 70 by mid-1990s.70 by mid-1990s.

A Great SuccessA Great Success

►According to Transparency Int’l, According to Transparency Int’l, Botswana is Africa’s least corrupt Botswana is Africa’s least corrupt countrycountry

►Botswana has steadily employed a Botswana has steadily employed a sound fiscal policysound fiscal policy

►National educationNational education►National healthcareNational healthcare

But…But…

►Large gap between rich and poorLarge gap between rich and poor►High unemploymentHigh unemployment►Women head half of householdsWomen head half of households►Mining hit hard by worldwide economic Mining hit hard by worldwide economic

downturndownturn►HIV / AIDSHIV / AIDS

HIV & TBHIV & TB

HIV EpidemicHIV Epidemic

UNAIDS Global Report 2008

HIV Epidemic: Sub-Saharan HIV Epidemic: Sub-Saharan AfricaAfrica

HIV / AIDS in Botswana, 2007HIV / AIDS in Botswana, 2007

► Second highest HIV infection rate in the world Second highest HIV infection rate in the world (after Swaziland)(after Swaziland)

► Adult prevalence (age 15-49 yrs): 24% Adult prevalence (age 15-49 yrs): 24% ► Infant mortality increased to 45 deaths/1,000 live Infant mortality increased to 45 deaths/1,000 live

birthsbirths► People living with HIV: 300,000People living with HIV: 300,000

Adults (age 15yr and older): 280,000Adults (age 15yr and older): 280,000 Women (age 15yr and older): 170,000Women (age 15yr and older): 170,000 Children (age 0-14yr) living with HIV: 15,000Children (age 0-14yr) living with HIV: 15,000

► Deaths due to AIDS: 11,000Deaths due to AIDS: 11,000► Orphans (age 0-17yr) due to AIDS: 95,000 Orphans (age 0-17yr) due to AIDS: 95,000

2008 UNAIDS Report on Global AIDS Epidemic

Batswana Life ExpectancyBatswana Life Expectancy

►49 yo (1966)49 yo (1966)

►70 yo (mid 1990s)70 yo (mid 1990s)

►48 yo (2005)48 yo (2005)

Why is HIV / AIDS so Why is HIV / AIDS so Prevalent?Prevalent?

► Concurrent PartnershipsConcurrent Partnerships Average number of lifetime sexual partners in Botswana Average number of lifetime sexual partners in Botswana

is lower than in the US but Batswana are far more likely is lower than in the US but Batswana are far more likely to have concurrent sexual partnersto have concurrent sexual partners

Some long-term girlfriends, “little house” mistressesSome long-term girlfriends, “little house” mistresses► Highly Mobile Society Highly Mobile Society

Husbands and wives living and working apart (mining, Husbands and wives living and working apart (mining, cattle, tourism) people go where the work iscattle, tourism) people go where the work is

With mining and migration of labor, HIV spread from With mining and migration of labor, HIV spread from girlfriends or prostitutes to wivesgirlfriends or prostitutes to wives

► Lack of Male CircumcisionLack of Male Circumcision► Income Inequality & Gender DynamicsIncome Inequality & Gender Dynamics

►People who want children do not wear People who want children do not wear condoms.condoms.

►Family is an important part of Family is an important part of Batswana culture.Batswana culture.

►Children have historically signified Children have historically signified wealth and were insurance for old age.wealth and were insurance for old age.

►Women who are mothers have higher Women who are mothers have higher stature in Botswana society.stature in Botswana society.

Botswana’s Response to HIVBotswana’s Response to HIV► Government mandate to have no Government mandate to have no

new infections by 2016new infections by 2016► Free ARVs to all Botswana CitizensFree ARVs to all Botswana Citizens► Prevention campaigns to address Prevention campaigns to address

cultural issues and stigma of HIVcultural issues and stigma of HIV► Free formula for HIV exposed infantsFree formula for HIV exposed infants► Health care capacity and Health care capacity and

infrastructure buildinginfrastructure building► International financial and technical International financial and technical

assistanceassistance

HIV / AIDS – Some SuccessHIV / AIDS – Some Success

► 32% of pregnant females were HIV positive 32% of pregnant females were HIV positive as of 2006 (sentinel surveillance) down from as of 2006 (sentinel surveillance) down from 38% in 200338% in 2003

► 90% of citizens eligible for ARV therapy are 90% of citizens eligible for ARV therapy are on treatmenton treatment

► Prevention of Mother to Child Transmission: Prevention of Mother to Child Transmission: 40% down to 6%40% down to 6%

Tuberculosis in BotswanaTuberculosis in Botswana

► One of the highest TB notification rates in the One of the highest TB notification rates in the worldworld

► Total number of new TB cases rose from:Total number of new TB cases rose from: 5655 in 1995 5655 in 1995 10,228 in 200510,228 in 2005

► Proportion of TB patients who are co-infected Proportion of TB patients who are co-infected with HIV in Botswana ranges from 60-86%with HIV in Botswana ranges from 60-86%

► TB responsible for 13% of adult deaths and TB responsible for 13% of adult deaths and 40% of deaths among people living with 40% of deaths among people living with HIV/AIDSHIV/AIDS

Your Clinical RotationYour Clinical Rotation

Botswana: What you SeeBotswana: What you See

► TuberculosisTuberculosis ExtrapulmonaryExtrapulmonary

► Cryptococcal Cryptococcal meningitismeningitis

► Pyogenic meningitisPyogenic meningitis► Pneumonia/lung Pneumonia/lung

abscessabscess► EmpyemaEmpyema► DiarrheaDiarrhea► HepatitisHepatitis

► Rheumatic heart diseaseRheumatic heart disease► CHFCHF► Malignant hypertensionMalignant hypertension► DKADKA► Renal failureRenal failure► Multiple malignanciesMultiple malignancies► AnemiaAnemia► COPD( mines)/asthmaCOPD( mines)/asthma► Hepatic disordersHepatic disorders► Neurological disordersNeurological disorders► Dermatological disordersDermatological disorders► SeizuresSeizures

Botswana: What you SeeBotswana: What you See

► More unusual More unusual diagnosesdiagnoses TetanusTetanus PellagraPellagra Cobra BiteCobra Bite Scorpion stingScorpion sting MalariaMalaria CysticercosisCysticercosis Cardiac tamponadeCardiac tamponade Unusual drug Unusual drug

overdosesoverdoses

► ProceduresProcedures Lumbar punctureLumbar puncture ThorocentesisThorocentesis ParacentesisParacentesis PericardiocentesisPericardiocentesis Bone marrow Bone marrow Chest tubeChest tube Peritoneal dialysisPeritoneal dialysis

Botswana: Living ConditionsBotswana: Living Conditions

► In GaboroneIn Gaborone Fully furnished flatsFully furnished flats Pretty cushy – flats have maids that do laundry and Pretty cushy – flats have maids that do laundry and

clean, swimming pool…you won’t be sleeping in a clean, swimming pool…you won’t be sleeping in a hut with a dirt floor (although these exist in hut with a dirt floor (although these exist in Botswana)Botswana)

Walking distance to the hospital (NOTE – Students & Walking distance to the hospital (NOTE – Students & residents are prohibited from driving in Botswana.)residents are prohibited from driving in Botswana.)

Communal living and learningCommunal living and learning Low cost of living (groceries and entertainment Low cost of living (groceries and entertainment

about half the cost of Philadelphia)about half the cost of Philadelphia) Plenty of activities in Gaborone: Gyms, Restaurants, Plenty of activities in Gaborone: Gyms, Restaurants,

Malls, Movies, University of Botswana, Soccer Malls, Movies, University of Botswana, Soccer Games at National Stadium, etc.Games at National Stadium, etc.

Botswana: FinancesBotswana: Finances

► We pay for:We pay for:► Plane fare to Gaborone and backPlane fare to Gaborone and back► Flats / Housing while in BotswanaFlats / Housing while in Botswana

► You pay for:You pay for:► FoodFood► EntertainmentEntertainment► Recreational travel Recreational travel

Plan for either before or after after rotation…students are expected Plan for either before or after after rotation…students are expected to work fulltime during rotation to work fulltime during rotation

Travel is usually expensiveTravel is usually expensive Vacations people plan: Camping in Kalahari, safari in Okavango Vacations people plan: Camping in Kalahari, safari in Okavango

Delta, Chobe, Tuli Block; visits to Victoria Falls, Namibia, Cape TownDelta, Chobe, Tuli Block; visits to Victoria Falls, Namibia, Cape Town► Travelers insurance (highly recommended)Travelers insurance (highly recommended)

► We have full-time faculty and administrators in We have full-time faculty and administrators in country to help with orientation and problem solving.country to help with orientation and problem solving.

Botswana: Who ThrivesBotswana: Who Thrives

► Personal characteristics for a successful Personal characteristics for a successful experience at PMH:experience at PMH: Ability to handle inefficiency and frustrationAbility to handle inefficiency and frustration Willingness to pitch in and do “scut” as part of a Willingness to pitch in and do “scut” as part of a

teamteam Flexible with ability to improviseFlexible with ability to improvise Ability to focus on what you can accomplish in an Ability to focus on what you can accomplish in an

environment with limited resources rather than environment with limited resources rather than lament what can’t be donelament what can’t be done

► Diagnoses are often not confirmedDiagnoses are often not confirmed► Patients die of things that they would not die of in the USPatients die of things that they would not die of in the US

Botswana: Who ThrivesBotswana: Who Thrives► Personal characteristics for a successful experience Personal characteristics for a successful experience

in Botswana:in Botswana: Common sense and street smarts Common sense and street smarts

► Need to be willing to negotiate market prices and missed Need to be willing to negotiate market prices and missed flights, and thwart would-be pickpockets.flights, and thwart would-be pickpockets.

Adventurous spirit and curiosityAdventurous spirit and curiosity► If the idea of killing a roach with your flip-flop, or watching If the idea of killing a roach with your flip-flop, or watching

others eat caterpillars (a delicacy in Botswana) horrifies you, others eat caterpillars (a delicacy in Botswana) horrifies you, this may not be the best fit. this may not be the best fit.

Friendly and easy-goingFriendly and easy-going► If you can’t imagine a day without Starbucks, or sharing a If you can’t imagine a day without Starbucks, or sharing a

bathroom with 7 other people, this might not be a good fit.bathroom with 7 other people, this might not be a good fit. RespectfulRespectful

► Batswana value respect for elders and superiors, and Batswana value respect for elders and superiors, and successful students learn how to follow local conventions.successful students learn how to follow local conventions.

Rotation ResponsibilitiesRotation Responsibilities

►Work as part of team!Work as part of team! Your role may vary according to the Your role may vary according to the

dynamics of your teamdynamics of your team

►Clinical careClinical care PMH wards M-F 7:30am-5pm PMH wards M-F 7:30am-5pm

►EducationEducation►Professionalism: respect for Professionalism: respect for

colleagues, staff, patients and familycolleagues, staff, patients and family

Rotation Goals: Patient Care and Rotation Goals: Patient Care and Medical KnowledgeMedical Knowledge

► Patient CarePatient Care Understand management of common medical Understand management of common medical

complaints presenting in Botswanacomplaints presenting in Botswana Basic diagnosis, care and management of HIVBasic diagnosis, care and management of HIV Provide care that is appropriate, Provide care that is appropriate,

compassionate and effectivecompassionate and effective► Medical KnowledgeMedical Knowledge

Enhance HIV and infectious disease knowledge Enhance HIV and infectious disease knowledge base base

Attend teaching rounds, conferences and Attend teaching rounds, conferences and discussions hosted by PMHdiscussions hosted by PMH

Rotation Goals: Communication Rotation Goals: Communication and Professionalismand Professionalism

►Work effectively with a patient care Work effectively with a patient care teamteam

►Effective communication with patients, Effective communication with patients, family, staff and teamfamily, staff and team

►Carry out ALL expected dutiesCarry out ALL expected duties►Demonstrate altruism and respectDemonstrate altruism and respect►Adhere to ethical principalsAdhere to ethical principals

Rotation Goals: Practice-based Rotation Goals: Practice-based Learning and Systems-based Learning and Systems-based

PracticePractice► Integrate knowledge from medical Integrate knowledge from medical

journals and research into patient carejournals and research into patient care►Assimilate feedback from supervisorsAssimilate feedback from supervisors► Identify knowledge and skills gaps and Identify knowledge and skills gaps and

develop individualized learning plan to develop individualized learning plan to address these gapsaddress these gaps

► Identify resources and barriers to Identify resources and barriers to accessing health and HIV care in accessing health and HIV care in Gaborone, BotswanaGaborone, Botswana

The Facts of The Facts of LifeLife

Breaking down the Breaking down the day at Marinaday at Marina

A Few Basic FactsA Few Basic Facts

► 525 bed hospital, usually has > 600 pts in house525 bed hospital, usually has > 600 pts in house► Separate Male & Female Medical WardsSeparate Male & Female Medical Wards

Supply Closets, RN Room, MD Room, Procedure RoomsSupply Closets, RN Room, MD Room, Procedure Rooms Isolation rooms for patients with MDR TBIsolation rooms for patients with MDR TB

► Patients can also be on the Eye & Private WardsPatients can also be on the Eye & Private Wards► There is There is technically technically an ICU (but it is a Surgical ICU an ICU (but it is a Surgical ICU

only)only)► Staffed by:Staffed by:

Specialists = AttendingsSpecialists = Attendings Medical Officers = ResidentsMedical Officers = Residents Interns = InternsInterns = Interns Medical Students from everywhereMedical Students from everywhere Nurses (mostly from Botswana)Nurses (mostly from Botswana)

Resources at Princess MarinaResources at Princess Marina

Resources at Princess MarinaResources at Princess Marina

►NursesNurses►RadiologyRadiology

►LabsLabs►MicroscopyMicroscopy►ComputersComputers

Nurses Nurses at Princess Marinaat Princess Marina

►Head NurseHead Nurse In charge of floor mgmt, In charge of floor mgmt,

ordering meds & supplies, ordering meds & supplies, administration, etc.administration, etc.

►Floor NursesFloor Nurses 1 per 8 or more pts1 per 8 or more pts

►ClerkClerk Check vitals, help gathering materialsCheck vitals, help gathering materials

Approaching the NursesApproaching the Nurses

►Not so different than anywhere else Not so different than anywhere else (but you will receive a lot of coaching (but you will receive a lot of coaching on it)on it)

►Be friendly, considerateBe friendly, considerate►Do not lose your temperDo not lose your temper►Realize they have been doing a very Realize they have been doing a very

hard job for a very long time. Keep hard job for a very long time. Keep perspective!perspective!

What to Expect…What to Expect…

►Nurses will:Nurses will: Administer drugsAdminister drugs Update family membersUpdate family members Co-facilitate family Co-facilitate family

meetingsmeetings Write separate admission Write separate admission

notes (very helpful)notes (very helpful)

What to Expect…What to Expect…

►Nurses will Nurses will notnot:: Place IV’sPlace IV’s Perform phlebotomyPerform phlebotomy Give IV meds if no IV in placeGive IV meds if no IV in place Deliver/retrieve labs, X-rays, Deliver/retrieve labs, X-rays,

etcetc Bathe patientsBathe patients Always administer PRN Always administer PRN

medicationsmedications

What to Expect…What to Expect…

►Nurses will Nurses will notnot:: Place IV’sPlace IV’s Perform phlebotomyPerform phlebotomy Give IV meds if no IV in placeGive IV meds if no IV in place Deliver/retrieve labs, X-rays, Deliver/retrieve labs, X-rays,

etcetc Bathe patientsBathe patients Always administer PRN Always administer PRN

medicationsmedications

Radiology Radiology at Princess at Princess MarinaMarina

Radiology Radiology at Princess at Princess MarinaMarina

►Studies Available:Studies Available: X-Rays (can be done the same day)X-Rays (can be done the same day) CT Scans (1-2 days)CT Scans (1-2 days) Ultrasounds (2-3 days)Ultrasounds (2-3 days) Echos (variable)Echos (variable)

Radiology Radiology at Princess at Princess MarinaMarina

►Studies Available:Studies Available: X-Rays – Read by Medicine housestaffX-Rays – Read by Medicine housestaff CT Scans – Read by Medicine housestaffCT Scans – Read by Medicine housestaff Ultrasounds – Read by tech (you get the Ultrasounds – Read by tech (you get the

report)report) Echos – Read by Specialist (you get the Echos – Read by Specialist (you get the

report)report)

Labs Labs at Princess Marinaat Princess Marina

►No phlebotomyNo phlebotomy►No daily labsNo daily labs►No notification of critical valuesNo notification of critical values►Not all lab tests are available (even basic Not all lab tests are available (even basic

ones)ones)►Labs are picked up 1-2 times per dayLabs are picked up 1-2 times per day►““Stat”(ish) labs should be hand-deliveredStat”(ish) labs should be hand-delivered►Results are posted in the computerResults are posted in the computer►Labs are lost with some frequencyLabs are lost with some frequency

Microscope RoomMicroscope Room

► In the Male Medical WardIn the Male Medical Ward►Has reagents for Gram StainingHas reagents for Gram Staining

Methylene Blue, Iodine, Decolorizer, Methylene Blue, Iodine, Decolorizer, SafraninSafranin

►Ask about this…Ask about this…

Computers Computers at Princess at Princess MarinaMarina

►Used for:Used for: Lab order entryLab order entry Lab result retrievalLab result retrieval Internet access (slow)Internet access (slow)

►Often unavailable (only 2 per ward)Often unavailable (only 2 per ward)►SlowSlow

A Day in the Life…A Day in the Life…

Basic Daily ScheduleBasic Daily Schedule

►7:00 – 7:307:00 – 7:30 Get up, walk to workGet up, walk to work►7:30 – 8:307:30 – 8:30 Morning ReportMorning Report►8:30 – 12:008:30 – 12:00 AM RoundsAM Rounds►12:00ish12:00ish LunchLunch►1:00 – 2:301:00 – 2:30 Family TimeFamily Time►2:30 – 5:002:30 – 5:00 Afternoon workAfternoon work►5:00ish5:00ish Walking homeWalking home

07:00 Get Up & Walk to 07:00 Get Up & Walk to WorkWork

07:30 Morning Report07:30 Morning Report

07:30 Morning Report07:30 Morning Report

►Hear about Overnight Admissions Hear about Overnight Admissions Call for your team starts at 7AM, lasts 24 Call for your team starts at 7AM, lasts 24

hourshours A nightfloat admits overnightA nightfloat admits overnight There is a lifelong bounce-back policyThere is a lifelong bounce-back policy

►Hear about patient deathsHear about patient deaths►Review radiologyReview radiology►Teaching & PresentationsTeaching & Presentations

08:30 Rounds08:30 Rounds

08:30 Rounds08:30 Rounds

►The team rounds on all patients, The team rounds on all patients, usually with the Specialist (Attending)usually with the Specialist (Attending)

►All labs are drawn, IV’s placedAll labs are drawn, IV’s placed►Check the computer for new lab Check the computer for new lab

resultsresults►Progress Notes written at bedside Progress Notes written at bedside

(they are brief and to the point)(they are brief and to the point)►Admissions may arrive during this timeAdmissions may arrive during this time

12:00 Lunch12:00 Lunch

13:00 Family Visiting Hour13:00 Family Visiting Hour

13:00 Family Visiting Hour13:00 Family Visiting Hour

►Not like Visiting Hours in the US. Not like Visiting Hours in the US. There are A LOT of family members!There are A LOT of family members!

►Family members bring food, bathe Family members bring food, bathe patients, and sometimes additional patients, and sometimes additional medicationsmedications

►Not a good time to draw labsNot a good time to draw labs►A very good time for A very good time for family meetings family meetings

……

Family MeetingsFamily Meetings

►Ask the nurse to set them upAsk the nurse to set them up►The nurse must be presentThe nurse must be present►Find a quiet spaceFind a quiet space►Plan ahead, think about:Plan ahead, think about:

Breaking bad news through a translatorBreaking bad news through a translator Cultural differences in expression of griefCultural differences in expression of grief There is still stigma around HIVThere is still stigma around HIV Not all your patients are Motswana, be Not all your patients are Motswana, be

aware!aware!

14:30 Work Time14:30 Work Time

14:30 Work Time14:30 Work Time

►Family MeetingsFamily Meetings►Lab Draws, IV placementLab Draws, IV placement►ProceduresProcedures►PaperworkPaperwork►AdmissionsAdmissions►Dealing with the unexpected…Dealing with the unexpected…

14:30 Work Time14:30 Work Time

17:00ish Head Home17:00ish Head Home

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