Nepal: Cleaning Up

I have some time to kill until a friend arrives from Pokhara...
 
With the lack of hot water (due to no electricity, mostly), I've become quite comfortable not showering every day. I've tossed aside western standards of cleanliness, and don't mind not showering daily, and when active (trekking or bike trip) if I smell, I smell. And since I'm not working, the dirt under my nails doesn't really bother me either.
 
But for some reason, the unruly hair around the back of my neck was just nagging me. The downfall of having closely shaved hair. [Oh, I shaved my head again in November, which is perfect for traveling]. You can't really shave back there, not without taking a chance and really making a really bad mistake and an erratic mess of a good hair line.
 
So, after lunch I decided to go get my neck shaved. I figured it would take all of 5 minutes and maybe 100 or 200 rupees... My only hesitation was making sure the blade would be soaking in some cleaning solution... flashbacks to the hepatitis C outbreak among uncleaned razors years ago.
 
So I popped into a HOLE in the WALL place, for a neck shave. Oh, and just to clarify, it is POURING rain outside. And I've been told all month that it never rains in Nepal in December. So if you think it sounds like an assinine waste of vacation time to get a neck shave, there really isn't much else to do beside drink coffee/tea, read, do email, and get a neck shave.
 
With bits of gesturing I think I get the point across that I need my neck shaved. So I sit down, and out come the clippers. And while I wouldn't mind a bit taken off the everywhere, I don't want to hassle with that now, I can do that in a week when I am back home in Jo'burg.
 
So he puts away the clippers, and moistens the hair around my neck and ears. Perfect, I think. I'll back to the coffee shop in 10 minutes, reading, and waiting for Dilip.
 
But I leave an hour and a half later.
 
Wow.
 
So, after a meticulous neck shave (with a new blade on an old style shaver), I got a scalp/head massage. Wow. And I factor in a few more rupees for the bill. And then the power goes out, and a candle is lit. And as the power went out, the rain went from a drizzle to buckets. And I'm dreading heading out in the rain. And I'm really enjoying the scalp massage, and I wonder if I have time to get a real massage (and more rupees flash before my eyes). As I think this, I'm now getting a neck massage, and then find myself leaning over the counter as I get a shoulder and back massage. And the paranoia in me wonders if this guy can read my thoughts (which would be embarrassing, because I'm thinking I wished this massage was coming from somebody younger and cuter). But I digress.
 
Wow. More rupees flash before my eyes.
 
It is still pissing rain. 
 
And now I get a facial-massage. This is a bit different, but I'm seriously taking this all in, and can't believe all I thought I would get in this TINY barber shop is a neck shave. Since the moment I arrived (and we made small talk about my trip to nepal and trek etc) he asks if I want my face shaved. Might as well. Though I am afraid, slightly, that he'll shave off the mole on my face and I'll bleed to death here. And of course I freak out forgetting that this guy can read my mind. I go to my buddhist mantra which I've been using since I learned it a month ago. He can read that all he wants.
 
My face is as smooth as a baby's ass after the shave. I notice he grabs another bottle. And then he paint (literally paints) something on my face, and he shows me and all I recognize is the word sandalwood. I'm cool with that.  But I don't know what it is. And I'm unsure if this is some kind of thick aftershave. But he hasn't undraped me, which I know is a universal sign that the business of salon stuff is over.
 
But now he is cleaning up. And don't forget, there is only a candle lighting the place. So I sit. What the hell, it is STILL raining out.
 
And that's when I realize I am getting a FACIAL. Whoa! [Bonus points for 'the card']. And now I'm really hoping that I get a manicure as well. The face mask dries, which is a bit of a weird feeling as well. I could get use to this, maybe wake up on saturdays, have porridge, apply face mask, read the paper, then shower?
 
The face mask is cleaned off. And I get aftershave on the lower portion of my face, and face cream on the upper portion.
 
And I'm sooo confused. How is it that I have thoroughly enjoyed this long pampering process (and now seem to have radiant skin), but also thoroughly enjoyed being smelly after a day of trekking, or getting to my hotel last night with mud covering various bits after the 40 mile bike ride back to Kathmandu???
 
I suspect, that in a nice salon, that would have been fifty dollars, maybe more...
 
 

Nepal

I find myself:

-kneeling in front of the Tibetan monk, who gives me a blessing "om mani padne hum" (which roughly implies long life and good luck), while he drapes a special cloth around my neck. He adds in a blessing for good health, every day. It's the every day part which I find touching, and secretly hope that it means I'll have healthy knees.. We finish our conversation about life, politics, and then head out. I still have the cloth.

-In the main part of Pokhara, asking my Nepali friend Dilip to please take me away from the tourist trap of Pokhara. We're eating dinner at a local place. I suspect I'm the only westerner that has been here in a long, long time. But am treated with great service, and a great meal. Dilip kindly leads me. We've ordered a variation of Daal Baat (the normal Nepali rice/lentil/curry meal) and are having Dhido, which is a soft polenta-like mash which is dipped in sauces. I know I'm off the tourist path when I don't automatically get offered silverware. So, I eat with my hands. Which is oddly gratifying. And I'm thinking back to the meal LR and I had at a superb Ethiopian restaurant in NY back in the spring, and thinking that silverware is slightly over-rated.

-Having breakfast with Dilip, watching Pokhara wake up. Shop keepers sweeping the stoops of their doorway. It seems odd that more shops aren't opening. We watch a mob trying to attack a taxi driver, as about 20 police officers show up to recue the taxi driver. It will be the last taxi we see that day... We're planning to head a bit out of town to the Tibetan Refugee center, I want to meet these people. We're also planning on seeing a bit more of the real city. But there are no busses. It's oddly quiet. It takes half an hour to figure out what's going on, and as it turns out, there is a one day strike, called by the students, in protest of something??? We spend the day walking up and down, up and down, up and down, the main tourist road. Having tea. Having coffee. Me trying to learn a bit of Nepalese. Learning about growing up here. Difficulties of daily living. We run into 4 or 5 people I met while trekking. We have dinner with a Danish friend I met, and her guide and her guide's wife and child.

-On the bus. Which is typical of what you expect if you think of the stereotype of what you've heard about if you think of buses in India. Except there are no chickens. I could write a whole blog entry alone on the bus. I marveled at the insanity of how the bus was packed with people, mixed with slight waves of anxiety thinking that if the bus crashed, it would be damn near impossible to get out easily. (and buses crash regularly). The bus ride is 17 hours, overnight to Bardia National Park.

-On a stopped bus, at 10pm. On the middle of the major east-west highway. I don't know why we stopped. I kind of don't mind, since it's likely more safe to be stopped at night. A fight breaks out on the bus (while we sit idle) at about 1am. I wonder why we're still stopped. The older women pray. But most people don't seem to care. The police show up. It's dark outside, and I can't see much. It's 8am, we're still not moving. I get out of the bus and se buses lined up and down the road. Seems odd, so finally I enquire. An unannounced strike has been called. the 17 hour bus ride has now been delayed 10 hours. We leave an hour later.

-On a Jungle Safari with Santa. I kid you not. Christmas is the furthest thing from my mind, given that I'm in a hindu/buddhist country, no signs of xmas, and no snow. It could be July for all I know. but meeting my guide, and learning his name is Santa (I asked twice) makes me realize that is is towards the end of December, and xmas is getting close. The Jungle is wet this am from all the dew. I get soaked. It's great fun, just me and Santa, tracking a rhino. I'm informed: If a rhino charges, climb a tree, if an elephant charges, run in a zig-zag. Santa doesn't mention what to do if bengal tiger charges. I'm putting all my faith that Santa will be able to beat the tiger with his walking stick. He has no gun. I think back to having been blessed recently for long life, and good luck. That must count for something. We do end up finding a rhino and an elephant. The tiger remains elusive.

-Riding an elephant through the jungle. Crashing through the underbrush. On the elephant as it pushes over trees in the way. That's impressive.

-On a raft trip. Ok, more like a float trip. But we are on a raft. It's fucking cold. cold cold cold.

-Sitting at dinner, drinking beer with Santa, and the other guides in the lodge. I'm hearing stories of what it was like when the Maoists troubles were going on. Bomb attacks. Constant harassment by the police, the army, the Maoists. Not knowing if the lodge would be bombed. Bad times. I read in the paper that 170 people are still missing from the area, all suspected to be dead, but nobody telling where the bodies are located.

-At the "Exact Spot" where Gautama Siddharta Buddha was born. Before he became enlightened and started buddhism. Being the skeptic, I look for signs of this. Maybe some amniotic fluid splash marks? Maybe the placenta? I was annoyed so I didn't pay the dollar equivalent to take photos there, and not it seems stupid to have balked over a dollar. Lumbini is the birthplace of Buddha. And it's not at all inspiring or peaceful. I've already booked to leave the following morning.

-Back in Kathmandu. 3 days earlier than planned. My hotel costs US$ 4 a night. You get what you pay for. :)

-Shocked that the price of a life is 17,000 Nepali Rupees. With is about US$ 250. This is the price a taxi driver has to pay to the family if he kills somebody.

I am booking a bike trip for the next 3 days, so will head out tomorrow on a bike trip for a few days. Then will be back here to finish exploring Kathmandu for a few days before heading back to warm Jo'burg.

From Nepal, I wish you a very happy and healthy holiday season, and a great 2009.


Brian

Nepal

Am alive and well in Nepal.
 
Happy Holidays, and more posts coming in 2009.
 
Thanks for following..
 
Cheers,
Brian

Nepal: Trekking

Namaste.
 
I am at a loss for words. If you've been following this blog, you know that often I can summarize. But I can't summarize the past 8 days.
 
How do you summarize:
 
-Spending an hour yesterday, under Tibetan Prayer Flags, looking at the Himalayan Range, completely undisturbed, the only sounds being the occasional hawk flying over head.

-Watching the sunset from Poon Hill yesterday evening, in front of me watching the sunset, behind me the moon rise above Annapurna I (the 10th highest mountain in the world).
 
-Going to bed at 9pm every night because you're beyond exhausted from a days trekking, but also because the only warm place is your sleeping bag.
 
-Hours, literally hours, walking (for me, alone) every day just mesmerized by the scenery, lost in thought, lost in the moment.
 
-Pure physical exhaustion (I made the trek in 8 days, but it's normally a 10-11 day trek) from dropping 1000 meters in a day.
 
-Pure mental exhaustion after a day of second-guessing if I was on the right trail.
 
-Dancing at a wedding celebration (uninvited, but welcomed), drinking the local wine (mulled millet), in the middle of literally, nowhere.
 
Other random things:
 
I've spent a fair amount of time thinking about poverty and life. Contrasting Soweto, Lesotho, Zimbabwe, and Nepal...
 
I did about a dozen medical consults in the 8 days... None of them on locals. I eyeballed the kids as I walked past, looking for the familiar signs of malnutrition (I didn't see any), listening for the chronic coughs (I didn't hear them), searching for those wasting from TB/HIV (I didn't see them).
 

I'm dying to get out of Pokara, Nepal's second largest city. I can't stand the noise. It's way too touristy here. But have decided to hole up here for 2 days of rest, need to give the legs a chance to mend, and also need to replete some glycogen stores, and consume some serious protein. Also, met a cool guy who wants to show me around for a day or so.
 
Headed off the grid again on Tuesday....
 
Cheers,
Brian,

Greetings from Pokara

Namaste (hello greeting)
 
 
Just a quick hello..
 
I started reading Dark Star Safari on the way here (Thanks AB and JS), and the introduction talks about going on this trip for a year and purposely staying away from internet/email, phone, fax, mail etc etc etc.. And that made me wonder how easy it is to stay in touch in this day and age. In fact, as S took me to the airport, we talked about mobile phones, and I had thought about getting a SIM card for my phone so I could have the luxury of sending text messages. Alas, after reading the intro, decided it wasn't necessary.
 
So, with the good graces of the travel gods, I arrived in KTM last night, zipped through immigration, was pleasantly surprised to see my bag, and ended up in a shabby hotel. Walked around, was just in love with the chaos in the streets at 10 pm, the dance that happens in the streets with taxis, motorcycles, pedestrians, cattle, kids. Managed to stock up on some last minute items, and went to bed after a cold shower. With the current power loading, electricity was off this am, so left things out to be easily loaded up this am.
 
Jumped on a plane (small 20 seater) for the flight to Pokara (20 minute flight), and got a magnificent view of the himalayas. Wow.
 
Wandered the town, found a hotel (US $ 7 a night) and then headed off for a small day hike to the World Peace Pogoda in Pokara.
 
It's overcast and a bit cloudy now.
 
Pokara is interesting. Pretty touristy, but have a great vibe to it. I'm slightly envious, I must admit. There is a cadre of folks here who have obviously been her a bit. That transient-wander-around-trustafarians who are all in their 20s, and seem to be totally care-free. Why didn't I do that when I was in my 20s?? But, of course, this sounds absolutely fucking ridiculous now that I have written this down, because I am aware that I'm doing a similar thing this year. And I feel incredibly lucky to have been in Zimbabwe a week ago at this time, and am now in Nepal. The trick will be escaping tourist hang-outs and repeating the feat from last weekend of being the only 2 foreigners in the bar.
 
So, I'm taking off trekking tomorrow... More posts down the road.
 
Oh, some prices..
2L bottle water US$ 0.60
Latte and croissant US$ 2.00 (DOUBLE latte too)
Fake North Face baseball hat US$ 3.00 (and I had to trade in my fake bilabong hat)
 
Cheers,
Brian

 
PS-re: cholera in Zim, it's likely DOUBLE what the UN is reporting, according to the docs in Harare. Don't believe the news...

World AIDS Day (and Zim)

It's World AIDS day.

 

I suspect there are things going on in Jo'burg, but haven't really paid much attention. There are charity events as fund-raisers for orphanages, hospices, clinics. I've seen more red-ribbons today as well.

 

World AIDS day to me, in the past, has been a day to think about the impact, the lives lost, usually spent attending some kind of speech, or service, or candle-light vigil. But here, every day seems to be a World AIDS day. It's a part of life.

 

And I don't feel like partaking today. I don't feel a desire to do anything different today to mark this day (though I am going to dinner with a Hopkins Infectious Disease resident, he husband, and also David-my ID doc friend). I feel like every day since I've been here has had stories of HIV/AIDS, and I feel like I've written about these issues (sometimes passionately) and today I don't see the need to do anything special...

 

But, I have to throw this out there. As I was driving, I heard a broadcast from Zim, where a radio presenter is doing a 24 hour radio-thon to raise awareness of HIV/AIDS in Zim. Which, of course, made me think back to the conversation from this past weekend, as Myr and I tried to get some insight into the HIV/AIDS situation in Zim. Both of us thought the rate if infection was likely on the lower end, not too sure what this is based on.. But I heard on the radio that 1 in 7 are infected, or 15%. Much less than here in South Africa. But there is a set up for disaster. What's going to happen to HIV/AIDS as the medical care system lays in shambles. Is there PMTCT (Prevention of mother to child transmission)? There was mention of HAART (AIDS meds) by a few, but sketchy details on if they were really available anywhere.

 

Last week I met with the Professor of adult Infectious Disease medicine, which is where I'll start in January. Most of their work is taken up by HIV/AIDS/TB, and less by other infections which are seen on the in-patient wards. Clinics are Wed, Thurs, and Fri. They have approximately 6,000 adults on HAART (double what the pedi clinic has), but estimate they need to get 4,000 more on treatment.  There is a backlog of people waiting to get on treatment... The drugs are here.

 

I doubt there are drugs in Zim. And I need to look into this issue further so I don't report inaccurate info, but for now I think it's pretty safe to say that Mugabe is killing Zimbabweans much like Mbeki killed South Africans.

 

Thanks for listening.

More from Nepal

 

 

Luggage-Notes on Zim and Vic Falls

"Where's your luggage?"

 

As it would happen, I arrived back to Johannesburg at the same time S&S were returning from Cape Town, which was fortunate because I couldn't figure out exactly where I had left my car in the airport, so I called them to meet up.

 

Oh, and I didn't have luggage. I was carrying a plastic laundry bag, from the Victoria Falls Hotel, which had my boxers, socks, running jacket, and running shorts. Those were the only possessions I decided to keep. The rest of my clothes, aside from what I was wearing, had been given away to mostly street kids in Zim. And my backpack as a gift to a friend.

 

I couldn't write when I got home from VF yesterday. There was just too much stuff to process. The beauty of the falls, the beauty of the land, the absolute friendliest people I've ever met, the desperate conditions under which people are living, the luxury of being in a grandiose hotel. I'll just present snippets here, in no order.

 

The Falls:

Spectacular, and it's not peak season for the river, which means were were seeing the falls at maybe half capacity. The deafening roar. The first view of the falls was the mist coming about the canopy of trees in the distance. Rainbows everywhere. We arrived on a day in which there were few tourists in the park (and there are way too few tourists period in the area). At times we'd be the only ones having a view to ourselves.

 

Currency:

The Zim currency is basically worthless. As most know, Zim has the highest inflation rate in the world, prices go up constantly. Thus, most things are priced in US dollars, and that's the preferred currency, with the Rand and Euro being used as well. Though, the conversion rate doesn't match exchange rates, so you do lots of negotiating for prices. For example if something is 10 US dollars, and you want to pay in SA Rand, the price should be 100 Rands, but often we found we'd be asked to 120 Rand and we'd have to negotiate back down to as close to the 10 rand as possible. I have included a pic of my 100 BILLION dollar bill. I'm rich.

 

The Banks:

Zimbabweans can only withdraw 500 Zim Dollars a day, a limit set by the government. Bank are closed on Sundays. 500 Zim Dollars will buy a tomato. A single tomato. One must go to the bank daily to get enough money for a loaf of bread. Obviously, people don't keep most their money in the banks. But one of the hotel workers was explaining how his money is directly deposited into the back, which makes it very trough for him and his family to survive. It's not good.

 

Shoes:

"I like your shoes"

Not a compliment. Rather a subtle line to ask if you're willing to part with them. Maybe trade the shoes for some souvenirs? What shoes are for sale (and we couldn't find many, even in the market) are far too expensive for most. On the final day, when Myr and I were walking through town distributing some clothes and food, we easily were met by at least 10 people who for days had been eyeing our shoes.

 

Bike Riding:

Saturday we rented bikes, and headed out into the surrounding areas, went along the Zambezi river, and ended up at this amazing Crocodile farm, which has 40,000 crocs, breed in captivity for food and skins, but also some re-introduced in years past (apparently there are now too many crocs along the Zambezi river). It was great. Got to hold a 2 year old croc. Observe a feeding. Lost a finger. Kidding.. It was great being back on a bike, and made me wonder how it is that I haven't had a bike since leaving Dublin. We were about 3Km from town when her bike chain broke, and it was actually hysterical and we just had to laugh at the situation. We had a HORRIBLE flight to Zim, which included a very tough landing (the pilots didn't come out of the plane) so we just had to assume that this was a continued string of problems with transport. We weren't able to fix the chain, so we rode back with her holding onto a rope tied to the back of my bike.

 

The People:

Fri night we walked into town to seek some dinner. Met a guy along the way who took us to a small house that served some food. We ate Pap (a maize-polenta) served with some chicken. The chicken on my place was a single drumstick, which had barely any meat on it. I suspect that this chicken was rather paltry when it was alive. The food was decent, the price was inflated, but pap is very filling. It's a staple, so not as nutritious as one would like, and given the cost of vegetables and meat, I suspect it's the major diet. Anyway, we ended up having a few beers in a local bar, and that's where we met Jackson. Decent guy. From there we went to a club which wasn't happening and so we went back to the hotel to sleep. The next night, we went back to the club, expecting to hear a band from Harare. We confirmed the time with Jackson and a few others, but of course when we arrived, there was nobody there, yet. We were sitting off in the corner, and were literally about to leave when Kvee (or Vincent) joined us. He's the main DJ of the club. We talked for almost 2 hours about conditions in Zim, and at the end of the 2 hours we had easily met 10 more people. I don't know how it happened, but we ended up leaving the club at after 4am. It was just so enjoyable to meet so many amazing people, dancing, drinking, having mini-discussions about life and politics. What I'm not explaining well is that these people really not only don't have much in the way of basic needs, but can't even get the goods. Kvee and I swapped shirts, check out the pics.

 

Healthcare: Home to Die 

We were trying to figure out what's going on in the area with healthcare. There is a public hospital. But it's basically closed. There may or may not be a doctor there. Which doesn't really matter since there are NO supplies. People don't even think about heading there. There is a local private doctor, but he charges something extraordinary for just a consult fee (something astronomical, maybe US$ 50), and if you get a script for meds, will they aren't available or affordable, so when I asked Ebert people do when they get sick, he said "we go home to die." Pretty bleak. Kvee has to take his 2 year old daughter to a sangoma (traditional healer) which is not what he would prefer to do, but feels compelled to do something when she is sick. Kids are no longer vaccinated.

 

The Grocery Store:

Myr and I went into the local Spar grocery store. Most the shelves were empty. There were some staples like cereal, biscuits, and bottles of water. The meat that was in the freezer looked very old. We were the only 2 people in there. And when we were in town, never really saw people going inside either, as most people were shopping at the market.

 

I have to wrap this up, have a lot to get done before leaving on Wed.. But I'm really bothered by what I saw. In contrast to the people of Soweto, the people in Zim were absolutely delightful, have just as little possessions, without the prospect of really getting more (and we're talking clothing, food stuffs here), but seem to keep struggling on. For comparison, mobile phones are everywhere amongst Sowetans, but I heard 1 mobile phone ring in the entire time we were there..

 

We were fortunate enough to be able to discuss politics with some people, and really most seemed to acknowledge that Mugabe must go.

 

 

How to Help:

We didn't have time to really put together a great plan...

I have a contact in Vic Falls who will distribute goods which are sent to him. The list is endless, but the practical things would be any clothing, (for any ages), shoes, pens (I was able to almost buy things with pens), paper, simple food stuffs, It doesn't have to be a big box, and more ideal would be smaller packages send distributed throughout the year. Luckily, packages are not opened by Zim authorities, and there is no import tax on goods. Please email me (javamania75@hotmail.com) if interested and I will email you the information and instructions.

 

Next post likely from Nepal.

 

 

BPB

An Open Letter, An Update, And Heading Off the Grid

Dear Blog Reader,

 

I wish you a Happy Thanksgiving.

 

I hope that you're able to celebrate with the company of friends and family. To me, Thanksgiving is the last pure holiday, and really the most important annual celebratory event (aside from my birthday, which hasn't been declared a national holiday, yet).  I was fortunate enough last year be able to celebrate with my immediate family in Colorado, and a few years ago to celebrate with my family in Chicago. In times past, I've also celebrated with coworkers, classmates, and occasionally random strangers (in Dennys). There is something wholesome about cooking a good meal and enjoying the company of those who are close to us, be they friends, family. But also taking a moment to remember what we're thankful for. Yes, the painful tradition of going around the table, verbalizing what we're thankful for...

 

The past 5 months have been quite eventful. I've had the great fortune to have been graciously given a leave from my residency program to come here to Jo'burg. I came here to learn aspects of medical care that I am not exposed to back in the US. In my short time here, I've certainly learned a lot of medicine, but it's been the other lessons learned which have been equally, it not more, rich.

 

I feel like I've learned about a human spirit or drive which I never knew existed, demonstrated by a population whom I get to care for every single day at work. This is a culture which, even in the midst of lacking essentials, seem to be thankful regularly for health, for family, for the care provided to them.

 

And that's something I'm learning, to be thankful regularly, be it for my health, my friends, my family (even if they voted Republican), my job. The idea of sitting around a nice meal with family and friends to celebrate what we're thankful for is very inviting, but perhaps it should happen more regularly than once a year? Perhaps if we spent more time thankful for what we have, we'd be less pre-occupied about the things we don't have.?.

 

I will admit that I am failing to live up to my Expat duties in spreading this event amongst my friends and family here in Jo'burg. I tip my hat to Randall who is hosting Thanksgiving in China, where Turkeys and canned pumpkin are non-existent, whereas both are in the store here in Jo'burg. (Ah, flashbacks to the first Thanksgiving in Dublin). I will celebrate Thanksgiving by having a nice quiet dinner with David, and maybe a few other. Sadly, S&S are out of town.

 

 

 

And for an update...

 

This is the conclusion of my Bara Pediatric Experience. I'm wrapping up with Cardiology, and headed to Vic Falls on Friday. It is pretty incredible to think about the children that I have taken care of the past 5 months. I remember so many faces and names. I have a special fondness for many of the kids, including the one child I wished would have been adopted, as well as a special recollection of the children whom I took care of who died these past months. I've learned about HIV/TB in kids, as well as how to manage the malnutritition states. I've become adept at drawing blood, starting IVs and other nasty, but necessary, procedures. I'm aware how my management style has changed, be it for better or worse, I'm not sure yet. I set out to accomplish a list of goals for my pediatric experience, and all of those goals have been met.

 

 

And heading off the grid...

 

I made a list of priorities for this year which didn't include medicine. One of those was to visit Vic Falls. And so I will depart on Friday to Vic falls and then return on Sunday. Many months ago when I booked this trip (along with Myrrith who is this amazing Dutch Ob/Gyn Resident who is friend of a mutual friend), I only considered visiting the Zimbabwe side; as it is the more impressive side to visit. This was to the objection of certain friends here who felt I should boycott Zim and see the Zambian side. Nevertheless, I didn't even consider it. Until Friday. When taking care of Baby T and hearing the awful stories that her mom and aunt relayed, I wondered how I could enter this country knowing that revenue from this trip will likely trickle into the evil bastard Mugabe's bank account. Of course, the competing emotion was to find a way to work in Zim for the next 6 months. So anyway, on Friday I'm off to Vic Falls... I'll make sure I get a blog post up as well as some photos before:

 

 

And further off the grid...

 

On December 3rd, I'm flying to Nepal. For a month. In a string of random coincidences, I booked a flight to Nepal for my December break. And then in September I made some arrangement to extend the trip for the whole month. I know there is a regular cadre of readers, and it's been motivating to know that people have keenly followed me on this experience. I don't anticipate regular blog postings, but am sure I'll pop into a net café and just drop a note to say hello.

 

 

One Last Note...

 

As for the upcoming holiday season, I'd like to make a plug for reducing material needs, and consider making a donation to a charity which will improve the quality of life of those less fortunate.  Consider one of these, or some other charity, be it local or global which addresses the health needs of the less fortunate.

 

http://www.46664.com/donate/

http://www.msf.org/msfinternational/donations/

http://pih.org/youcando/donate.html

 

 

 

Again, I wish you a fantastic Thanksgiving, may the turkey be moist, may the company be enjoyable, and may we truly remember that most of us have many things to be thankful for.

 

Cheers,

Brian

 

 

Paeds Synopsis

The other reg and I went to one of the wards this afternoon to do a cardiology consult. Our normal fashion has been to get as little information as possible from the referring reg, and just go see the kid, examine them, then look at the chest xray (if there is one) and the EKG (if there is one) and the labs, and come up with a diagnosis.

 

So today we went to evaluate S, a 5 year old. Part of the diagnosis was easy. He's a malnourished, sickly looking 5 year old. Who doesn't smile-at all. He had clubbing (the shape of the nail beds changes) and was anemic looking. He had swollen nodes, enlarged parotids, as well as oral thrush. He liver was 5 cm enlarged, and his spleen was sticking out by a cm. Not only was it evident that he was HIV positive, but also that his immune system was faltering. The only piece of the puzzle was which lung condition was causing the clubbing-was it TB or LIP?

 

Examining his cardiovascular system, which is what we were to focus on, was rather unimpressive. Slightly displaced apex indicating a generous heart size, slight parasternal heave (enlarged right ventricle), but normal auscultation. We examined the rest of the data. The EKG showed some a slight right axis, but more of an enlarged left ventricle, than the right we were expecting.. The CXR showed significant lung disease, likely TB, likely LIP. And the reason for the consult was cardiomegaly, based on the chest xray, which when reviewed carefully was not enlarged.

 

This boy is unwell. He's not on HIV treatment having missed his intake appointment at the pedi HIV clinic. He has had a partial work up for TB, but is not on treatment.

 

And it was clear to me exactly what needed to be done. He needs to be immediately started on steroids (for the impressive adenopathy surrounding his bronchi) and TB treatment (3 or 4 drug, it's debatable an abdominal ultrasounds to rule out TB in his abdominal cavity (which will change his treatment course for TB). What he really needs is to get on HIV treatment as soon as possible, which won't happen for 2 or more weeks (the time he needs to be on TB treatment before starting HIV treatment). There isn't an isolated cardiac issue. We'll do an echo tomorrow, but we'll have no recommendations for his care, other than to fix his medical issues.

 

And sitting there in ward 33, writing up his note, I realized that things had finally clicked. It no longer bothered me that I don't have "proof" that he has TB. I was no longer naive to think that maybe his malnourished state was because he didn't get enough to eat, but knew it was related to his HIV.

 

I have acquired a fund of knowledge which I didn't have before coming here 5 months ago. If (or rather, when) I find myself  being the sole pediatrician in an environment that is rife with malnutrition, TB, HIV, I'll know what to do, or at least where to start.

 

In the past five months I have not treated an asthma attack. I have not treated eczema. I have not treated "reflux" (which I am beginning to think is a diagnosis created by the pharmaceutical industry). I have not treated constipation. If I really thought about it, I'm sure I could come up with a list of 10 more "common" things that I have not seen here. Not to say that they don't exist, as common outpatient stuff is dealt with in the clinics..

 

In the past five months, I have written more prescriptions for ampicillin/amoxicillin, gentamycin, vitamins/iron/zinc (ps-every child with diarrhea back in America should also get zinc) than I have written in my 3 previous years. I have not written a SINGLE prescription for azithro, clindamycin, cimetidine...

 

What I'm realizing, is that I am developing two skill sets. One set of skills for the practice of medicine in resource rich environments (like back in the US), and one in resource poor environments And what I'm finding is a misconception about how my knowledge is changing... I don't expect to return to my program in the US being any "smarter" than when I left, and in fact, I suspect I'll be a bit rusty on things that I use to know off the top of my heard. I expect to return to the US, having a fund of knowledge which I won't use, and I already find myself dreading questions of "well, what would you have done in South Africa?"  It's apples and oranges. Different bugs, different drugs, different standards of care...

 

 

365,000 people killed in South Africa

Literally killed by a neglectful government...

 

"The new government is now trying to hasten the expansion of antiretroviral treatments. The task is urgent. South Africa today is home to 5.7 million people who are H.I.V.-positive — more than any other nation, almost one in five adults. More than 900 people a day die here as a result of AIDS, the United Nations estimates."

 

Read More: http://www.nytimes.com/2008/11/26/world/africa/26aids.html?hp

So Much To Say

A lot has happened since I left for work Friday morning, and tonight (Sunday) I arrived home at just before 10pm, having been away all weekend. While I was driving home, the lyrics from "So Much to Say" popped into my head...

 

Friday Work: Baby T is a 7 month old male brought by his mom and Aunt who have trekked from Harare, Zimbabwe and have managed to make their way to Bara hoping, desperately to get medical care. He has a congenital heart defect, and was told the only hope for his survival was to get a heart operation, in SA. Inside the echo room, medicine was put on hold while, circles around Baby T, we listened to the absolutely nightmare conditions and quality of life that they experience in Zim. Forget what you might read in the papers or hear on the news (though there isn't much news coverage at this point given DRC, Obama, Economics), things are deplorable in Zim, and only hearing this first-hand account made it tangible how bad things are. The room was filled with a mixture of despair and anger. I ask you to please visit this web page (Thanks LR) and sign this petition: http://actnow-phr.org/campaign/zimbabwe?rk=XpeTF361rJatE

 

Friday Night: S&S generously hosted a going away party for a friend who works for the UN, and will be headed to Panama soon. It was a spectacular party, meeting great people from all over, but also being surrounded by many ex-pats from many countries. Having the chance to be surrounded by many people who have built their careers travelling away from home to help others is re-affirming.

 

Friday Late Night: The party winds down, with only a handful of us left, retiring to the patio couches and engaging in fairly deep conversation, as one would expect after that much wine.

 

Saturday, EARLY morning: S comments that the sun is coming up as he loads the dishwasher with the umpteenth load of wine glasses. The house is mostly put back together. I jokingly mention to the other S that our plan was to run Saturday morning, and he suggests we run, now. I say sure, thinking he'll cave, he doesn't. We decide to run before going to bed, and run for an hour and a half. Which isn't really recommended after drinking wine and eating all night. We see the sunrise of JHB.

 

Saturday, Brunch: S&S, myself, and the guest of honor from last night enjoy what will be the last meal together. It's a perfect afternoon (it was after 12noon), we sit outside for hours eating and discussing life, politics, travel, relationships, and gossiping.. When the second bottle of wine is gone, there is a group hesitation, realizing that the time has come to part ways, and wishing the guest of honor safe travels and continued journeys.

 

Sunday: I wake up expecting to have a cup of coffee and head home. After brunch I expect to head home. After an afternoon nap outside, I expect to head home. I end up at dinner with somebody from the party on Friday. I am finally on my way home.

 

And there is so much to say, so much to say, so much to say...

 

"So Much to Say"

Dave Matthews Band

 

I say my hell is the closet I'm stuck inside
Can't see the light
And my Heaven is a nice house in the sky
Got central heating, and I'm alright
Yeah, yeah, yeah
Can't see the light
Keep it locked up inside
Don't talk about it
T-t-talk about the weather

Yeah, yeah, yeah
Can't see the light
Open up my head and let me out, little baby
'Cause here we have been standing for a long, long time
Treading trodden trails for a long, long time

I say my hell is the closet I'm stuck inside
Can't see the light
And my Heaven is a nice house in the sky
Got central heating and I'm alright
'Cause here we have been standing for a long, long time
Treading trodden trails for a long, long time
Time, time, time, time, time, time

I find sometimes it's easy to be myself
Sometimes I find it's better to be somebody else

I see you young and soft, oh little baby
Little feet, little hands, little feet, little feet, little baby
One year of cryin' and the words creep up inside
Creep into your mind, yeah

So much to say, so much to say, so much to say, so much to say
So much to say, so much to say, so much to say, so much to say

'Cause here we have been standing for a long, long time
Treading trodden trails for a long, long time
Time, time, time, time, time, time

I find sometimes it's easy to be myself
Sometimes I find it's better to be somebody else

So much to say, so much to say, so much to say, so much to say
So much to say, so much to say, so much to say, so much to say
So much to say, so much to say, so much to say, so much to say
So much to say, so much to say, so much to say, so much to say

Open up my head and let me out, little baby

 

F&F

[For HW]

 

The highlights of today do not relate to work (but work was great today).

 

Highlight #1:

I took the bakkie to the mechanic on Wed morning. Some new sounds emerged Saturday as I was driving back from my mini-weekend trip. Sounds which didn't sound great, but also didn't sound like the car was going to fall apart or spontaneously combust. I thought about ignoring the sounds for a few weeks, until it was more convenient to take the car in to the mechanic. I had the car in the shop 2 weeks ago for its 120,000 Km inspection, and it apparently got a clean bill of health, after getting a new ball bearing. So I was a bit annoyed that the clean bill of health only lasted 2 weeks, after costing me a pretty Rand (SA currency). Anyway, amusingly the mechanic is a local buy who has a shop right next to a gas (petrol) station. He wasn't at the shop on time, and I was afraid he wouldn't get there in time before my ride showed up to take me to work. The guys who pump gas said I should just leave the keys inside the shop, and head to work. Which, honestly, would likely have been fine. Not my usual MO, and a bit of leap of faith that the bakkie wouldn't disappear, but I knew full well the limits of my auto insurance for theft, and that had the bakkie gone missing, it wasn't going to be covered under my insurance for this. I imagined the conversation in my head, and hearing the agent say something to the effect of: "So, let me see if I have all the pertinent details. You left the keys to your vehicle with the petrol station attendant, and at this time the anti-theft system was disengaged so the mechanic could work on the car, but the mechanic wasn't there. And now your car is gone. Ah-hah. I see. The good news is we've decided you're a moron, the bad news is you're screwed. And we suggest next time just leaving a sign on the bakkie which says, TAKE ME."

 

So, they didn't get the car fixed in one day. I'm not even going to go into what was wrong with it, since they essentially had to replace the part that the dealer had to replace, plus fix the brakes.. The important issues was that I was sans car this morning. And not wanting to ask for another ride, decided I'd figure out how to get to the hospital on my own.

 

Options:

Bike. Don't have one, but that would have been ideal, perfect morning for a ride to work.

Walk. Doable, but a bit far.

Bus. Not possible.

Hitchhike. Totally doable.

Taxi. Doable, but a bit tricky.

 

So, I chose Taxi... Now, taxi isn't NY or Dublin stand on the road, hail down a car and get to work. Taxi is a 12 seater van, which usually drives a set route for a set price, which requires some complex hand signals to get the right taxi.. They are often very full. For a while the Taxis were death traps, as most were not road-worthy. Sometimes being held together by tape and string. But, there has been a campaign to get the road-unworthy ones off the street, and deaths from taxi accidents have declined. Literally. I called S because I had to get some of the basics on how to go about taking a taxi. He gave me an over-the-phone tutorial on how to get to work on the taxi.

 

So, this morning, I left ridiculously early. Was on the street corner, and as I saw approaching taxis I did my hand signal (finger pointing to the ground, with a wagging circular motion to indicate I needed a local taxi) and the third one stopped. I hopped in, and verified it was the local to Southgate (the mall where I would go to change taxis). As I mentioned a minute ago, most taxis are now road-worthy. This one wasn't. But it was early morning, and I didn't have far to go so I felt a bit invincible.

 

The taxi driver was kind enough to show me where to go to grab the next taxi to the hospital. I jumped out at a busy intersection, made my way to the next taxi, and was at the hospital in under 20 minutes! All for the cost of an equivalent  US$1.25. Not bad.

My coworkers were fairly impressed that I'd take the taxi to work. To be blunt: white people generally don't take taxis. And white tourists certainly don't take taxis. The joys of  being the outlier!

 

Highlight #2:

The folks at my favorite Jo'burg coffee house held a cupping tonight. Cupping is the coffee equivalent of wine tasting. It's a pretty systematic way of tasting coffee. I've been looking forward to it for WEEKS! And one of the attendings I'm working with is also a coffee addict, so I'd told him about it. My landlord and her family came along as well. It was fantastic. The guys really had the place set up well for the event. They had some local musicians playing, who apparently usually play next to the pay station at one of the local malls. The coffees weren't labeled, and identities were only revealed after the cupping was over. I must say, the Rwandan was superb, though the coffee is coming from the region that borders the DRC, and I guess the supply may be interrupted for a while. The Kenyan was as to be expected, and while I haven't been a fan of the Ethiopian it grew on me a bit. I've uploaded a few pics.

 

On a small aside, the new barista has spent a few winters working in CO, and is headed back for a week of skiing. Made me a bit jealous!

 

Well, the coffee buzz is finally wearing off...

 

Cheers

 

Humble Applesauce

I bought some apples last week that were on-sale. They looked ok, but of course they turned out to be mushy within a few days. No big deal, it cost me the equivalent of a buck for a dozen of them.

 

So tonight I made applesauce with them. While waiting for the apple sauce to cool down, I decided to make my daily pilgrimage to the ATM. While the exchange rate is good, I try to go daily and am stockpiling money. It is perfect outside, a very cool breeze, and the sunset is spectacular.

 

As I walked to the ATM, I walked past a woman still selling her wares. Often containing sandwich bag size portions of snacks, but also pieces of candy and cigarettes. I see the kids in clinic with the bags of snacks, and also the kids walking to school often have a bag or two in their hands, but I've never really discovered what was in those bags.

 

So, walking back from the ATM, I asked for a bag, which cost a 1 Rand, and also got a bag of peanuts for 1 Rand as well. ZAR 1. So I gave her a 10 rand, and as she reached for change, told her I that was ok, to keep the 8 Rand. And the way her face lit up was tremendous. Thank you thank you thank you.

 

Humbling how the equivalent of 80 cents appears to have made this womans day.

 

 

Take only pictures, leave only Blood.

Ok, I didn't really leave blood on the trail. It was really only a trickle down my shin, and my arm.

 

The original plan had been a weekend away taking a rock climbing course. But the rains Friday were non-stop, and it didn't looks like they were going to stop on Saturday, so instead I cancelled, and decided to explore part of the Mpumalanga Province. I headed to an area just west of the famous Kruger Park, and spent the night in hostel in Sabie. My room had a tin roof, and the rain was still coming down heavy, so I fell asleep to the rain.

 

I woke up early and was outta the hostel by 7:30 am. Headed out to explore the area. It's a unique area in that there are actually a lot of waterfalls in the vicinity, as well as a the Blyde Canyon and some small towns (like Pilgrims rest and Gaskop). I stopped in both those towns, while hoping the sun would burn off the morning mist..

 

There is a view point, called God's window. And so I headed up the pass hoping to beat the crowds and get some time by myself to sit and do what ever one does at God's window. But as I took the turn off from the pass, I realized I wouldn't be seeing much (we're talking literally here, not philosophically), as the fog was very dense. But nevertheless, I went up the path anyway, thinking that maybe God would part the clouds for me and give me a view. And of course, there was nothing to see. The folks selling their crafts seemed to be somewhat amused that I actually went up the path and looked anyway..

 

I left God and headed on to the canyon. The plan at that point was to get some serious hiking done. I had read mention of a hike down to the bottom of the canyon, which went to the old Belvedere Power Station, which off the top of my head said something about how this was one of the largest power stations at one point, and that apparently the town of Pilgrims Rest had electric streetlights before London due to the Power station. I was more interested in getting to the bottom of the canyon. At the entrance to the canyon there were some potholes (which was the main attraction). These are circular divots carved into the rock by the water. Interestingly, there are potholes in Shelburne MA as well, which is the town I would live in if it were possible. Anyway..

 

The hike was great. Fairly primitive trail, meaning that there were occasional marking, the trail was mostly visible (and when I realized I was following a game path, not the trail, it was easy to pick up again). Came across some unfriendly baboons, realized I have baboonaphobia. Took a bit of a beating on the trail, as there was a type of tree/large bush that has well hidden spikes, and given the lack of groomed tail, required a bit of bushwhacking. So am a bit afraid what will be said at work tomorrow when I show up with cuts on my arms, thankfully they are higher up and should be partially covered by scrub tops. Anyway, stopped to take a photo on the way back and that's when I saw the blood oozing down my leg, and in that proud moment, I felt like this had been a real hike.

 

The best part... I was the only one on the trail. And when I was walking back to the parking lot, muddy, bleeding, and smelly, people looked at me with slight fright, and I had to reassure them that the potholes were on a paved walked, and that I had been out hiking.

 

So, I decided to give God a second chance, in part because I had decided to head back to Jo'burg instead of hostelling for a second night. Which meant backtracking instead of exploring more of the canyon and surrounding area. And, by now, the sun was in full force, and the clouds had vanished. So I drove back the way I had come, and took the road up the pass to see God, and wouldn't you know it, just a little way down the road I found myself back in the fog. I didn't even bother turning into God's parking lot, instead I had a few choice words for him/her, and vowed to return sometime before I leave SA.

 

Driving somewhere around 600+ miles in 2 days left plenty of time to think (and to sing in the car). This is such an amazing country. Again I found myself a few hours out from Jo'burg-home, and thoroughly enjoying/loving the area. But what was striking was the contrast. Clarens, The Drakensberg, and this area are all different mountains. This weekend was full of coniferous trees (and gross tree farms and logging, but I looked past that bit). And I haven't even hit the desert and ocean areas. It was so gorgeous driving home, that I though about stopping the car and jumping up and down out of sheer excitement. Though I was worried I'd look like a madman and that I'd have some weird explaining to do... I also thought about stopping, jumping over fences (past don't trespass signs) and hiking to the tops of random mountains. But, having almost gotten in trouble before for trespassing, I'm a little hesitant to do that again, and also I figured that the bakkie would get broken in to while I was going up the mountain.

 

Anyway, I came home wrecked, smelly, and very content. A hot bath and Chinese take-away sounded great to me, but S&S called, invited me out to dinner at The Local Grille, which has some of the best steaks, ever. Couldn't pass that up.

 

As for work... Friday I popped into the high-care ward to check on KB. He's the kiddo I mentioned a while back who has Trisomy 9, and who was in the cath lab last Monday. He was extubated in the ICU mid-week and was holding his own. On Thursday when I popped in to see him, he actually looked a bit better than he had the day before. But when I saw his bed empty Friday morning, I knew that he had died in the night. And I confirmed this with the Reg taking care of him. He died across the hall from the bed which he occupied for his first few days in Bara, back when I admitted him in August. His mom, who is 17, hasn't fully understood the severity of the situation. And many people have tried different approaches to help explain that it was likely to come to this end. So, mid-morning when we were rounding in HC, I saw her. I approached her, and was about to express my condolences when something happened. I was literally about to say I was sorry he had died, but instead what came out was "good morning, how're you?" Something at the last second had registered that I should be careful about what I said. "Where's my baby" was her reply. I don't know what cue I picked up a the last minute which made me realize that she didn't know that he had died. And here she was now, mid-morning, not aware that he had died during the night. Which is, of course, horrific as well. I didn't know the full details, and excused myself to call the Reg to come and talk to her. I hadn't really been connected with his care since August, and it didn't seem right for me to break the news. And for those who wonder.. this doesn't happen regularly. Parents are called when children die, as one would expect. I would guess she didn't have credit on her phone, and had assumed that he was well, and didn't call to return the message, but rather showed up that morning as usual.

 

 

There are PICS up, click under my mug shot over there to the right of the screen where is say PICS.

Prop 8

A slight deviation from the normal blog posting, which is kind of weird, because I'm no longer sure who reads this thing, and how many people are reading it that I don't know, so often I save the more personal stuff for private conversations, or emails...

 

I wish I could say I was surprised by the outcome of Prop 8, but maybe I'm too much of a pessimist about what the average American believes...  I didn't really think that the majority of people in CA (as well as the two other states which passed anti-same-sex marriage ballots and Arkansas who passed adoption legislation) would really set aside their own moral judgments and allow the passage of bills/props/laws etc which would offer the same "benefits" or "rights" to those that they themselves likely enjoy, or can enjoy. I am really unsure how allowing same-sex marriage threatens a person, a society, or a country.  

 

I'm kind of bothered with the emails going around which seem to now target religious orders which may have illegally acted to help pass these bills. I'm bother that there are some/many religions don't promote unconditional tolerance, or even acceptance. And I've been unsure what to do about signing the petition. To me it seems to be a retaliatory action, and I wonder if it will really get at the heart of the matter. Though I guess we could debate what the real "heart of the matter is."

 

So anyway, I submit these two links below.

 

http://www.youtube.com/watch?v=hnHyy8gkNEE

 

http://www.mormonsstoleourrights.com/

 

 

 

Ward 18

I was in my old ward today, Ward 18.

 

I've known for a few weeks that S was "adopted" by family, not his parents who never came to collect him. But I found myself walking through the ward looking for familiar faces. If he wasn't there, was K there? Or O? None of the regulars were there. The nurses were very happy to see me, which is always a nice feeling. And they asked when I would be back on Ward 18.

 

"Please come back."

"Seriously?"

"Seriously!"

"But Sis, seriously, didn't you find me to abrupt?"

"Eish Doctor Brian, we got use to you," she laughs, and gives me a big hug.

 

I grin.

She insists they enjoyed working with me.

 

I will miss ward 18. And I promised that I'd go back and visit through the spring.

 

I booked my return flight home last night. Found a killer fare, and decided to jump on it. And all of a sudden my time here seems soooo short. There is now this sense of finality to this year. "This Year Off" has been more of an abstract than something concrete. I don't know how to explain it all that well, but up until this past week I was feeling like I would be here forever. I'm always conscious that I have to be back to my home hospital on July 1, but that seemed soooo far away. But now, it seems so close. As I hit the button to pay for the ticket last night, I kept trying to think what that day will be like. I can see the send off here, the sadness at leaving the close friends I've made thus far, but also the excitement to see my dear friends back home.

 

But it also brought a new perspective. A little Carpe Diem to the experience. To really enjoy the present moments while I'm here, and to maximize my experiences as well.

 

So I explained to the sisters, that sadly, I won't be working in Ward 18 again. It'll be off to medicine with the start of the new year, and then it'll be back home...

 

ps- "eish" is an expression, kind of sounds like A-ish, or hay-shhh. It's a word I've really taken to, mainly because it's helping me erase the "F word" from my vocabulary. As most would know, it's a word I'm kind of fond of...

 

 

Cath Lab

The last time I was in the cath lab was about a year ago October. The the non-medical folks, the cath lab is the room in which they do procedures that involve using real-time xrays to do dye studies. So a big IV is inserted into the groin, and a catheter is snaked up the main artery or vein, or both into the heart, and dye is injected and you get to see all the plumbing and structures of the hear. As well as doing some nifty procedures such as the infamous angioplasty (roto-rooter of clogged arteries) etc.

 

Of course, the last time I was in the cath lab, I think it was the wee hours of the morning, and I was doing and admission on an adult who has having he big one, and needed to get those blocked arteries unclogged so that the heart muscle wouldn't totally die. Adult caths, for me, seem to be slightly monotonous. Blocked vessel, blow it open, put in stent, admit to the CCU service. And as the admit resident, it's pretty cookie cutter usually, with the important role of gathering data for the admission assessment. There's more to this, but those were my flashbacks.

 

Today was different.

 

We did a combination of diagnostic caths (seeing what's going on in the heart, without any intention of fixing any problems) and an attempted therapeutic cath.

 

It was evident by early morning, that we were possible going to finish hours late tonight.

 

Kiddo #1 was actually a kid that I admitted back in August. Admitted with hypoxia, gastro, and was/is dysmorphic looking. Turns out he has an extra chromosome #9 (clubbed feet, bilateral inguinal hernias-already repaired, PDA, VSD, expected mental retardation are the main things he has). He's been intubated in the ICU for the past almost 2 weeks. And there has been debate about is his cardiac lesions are contributing significantly to his respiratory distress. So he went for cath today. He's about 4 months now. Due to limitations of ICU beds, his fate was partially going to be decided by this cath. If he had lesions which were thought to be contributing to his respiratory statues, and were amenable to some kind of intervention in the cath lab, he would continue to be vented for a few more days. If he had lesions which were not thought to be contributing to his respiratory distress, and/or they were not amenable to repair in the cath lab, he was likely going to have care withdrawn, leaving a grim prognosis.

 

Kiddo #2 had a cath done to follow a PDA-which had closed, and a known VSD. The surprise was finding some pulmonary stenosis. Which is something that can be dealt with by inflating a balloon catheter and dilating up the stenotic lesion. Except that we didn't have the right size available today, as this was an unexpected finding, and the balloon caths were not available. She'll have to come back for the procedure.

 

Kiddo #3 has Down's Syndrome, and the typical heart lesion that goes along with Downs. AVSD/echocardial cushion defect. Which is amenable to surgical repair, but the mother refused the surgery in 2005, and today is a follow up cath to see what the progression of the heart lesion has been like. If there is too much progression, surgery is no longer possible, and then life expectancy drops to 10 years or so.

 

In the cath lab today there were the 4 consultants, as well as the other reg/resident and myself. It's a great crew, the consultants are fantastic teachers, skilled clinicians, and really enjoy doing what they do. Not to mention that there is constant banter back and forth, and regular laughter. While we only finished an hour late, not the 2-3 hours as was predicted at one point, nobody really seemed to mind because it was rather enjoyable. A stark contrast to last month.

 

Cheers

Baboons in the Mist

No, I'm not going to Rwanda. (yet)

I went on a fantastic 12 km (~8mi) hike today. Which is in itself a feat, because I didn't even go to bed til 4am, and got my *ss out of bed at 11am. But, I felt the need to get out and explore some new territory today. I've felt a bit complacent recently, so am going to try and maximize weekend plans to explore a bit.

Since I'd slept in, I didn't feel the raging desire to drive the hour+ to the place that I was going to scope out for possible future hike. Instead, I looked over the atlas for patches of green, while seeing what tips lonely planet offered (aka, the bible) and "discovered" that there was a big nature reserve close by. Do keep in mind that I live 2 minutes drive from a nature reserve w/ zebras, springboks, wildebeests.. But the hillage is minimal. So I set off.

Am kind of like being my own navigator and pilot. Except when either lost, or can't find where I'm heading. Which, of course, happened on my way to the Suiderbosrand NR. I didn't get lost. I couldn't find the bloody entrance to the park. I figured that I would then just drive all the roads around the perimeter, and would eventually find a way in, which I did.

We're heading into summer. The days have been hot, with impressive afternoon thunderstorms. These are REAL thunderstorms, much like the ones I remember from Colorado afternoons. Downpours. But also strike lightning. Speaking of strike lightning, I went running with a friend on Wednesday, and we got caught in a bad storm. I'll just say that it was easily in the top 10 of STUPIDEST shit I've ever done. I told S, halfway through, that if either of us died on the way back to the house that I was moving it up to the top 5 STUPIDEST things I've ever done...

Anyway, I'm missing fall. I miss the crisp air. I miss the colors.

Today was a fall day. It was misty and overcast. It was chilly. It was the perfect day for a hike. It was also a great day for wildlife.

Early on in the hike there were some Blesbok (antelope-like animals) and baboons a ways away, they were entertaining to watch. Could make out the baby baboons running around. I continued on, and was walking through a bushy area, listening to the rustling in the bushes, and then a few baboons ran by, and a louder one was making very loud baboon sounds. And he didn't sound all that happy. The path was literally leading into an area in which you were in thicket which was about 10 feet tall, and I debated getting a stick to try and fend off this unhappy baboon. I continued on, knowing that there were two guys coming down the trail behind me by about 20 minutes, hoping that they would find me if unhappy baboon had decided to take out his aggression on me. As it would be, we didn't cross paths.

The trail crossed into two meadows, and both had more game. At the second meadow there must have been about 50+ animals, a mixture of zebras, wildebeests, blesbok, and what I learned later, were Elands. Having encountered wildebeests earlier, I knew they were harmless, but the Eland, my god, was HUGE. It looked nice and docile, but I was more afraid it would be spooked and if it ran haphazardly and came towards me, I'd be hosed. Twice in one week (Wednesday) I wondered if this would be my outcome. Dead in SA from an ungulate (I think it is an ungulate?). Oh, here is where I should also mention that the mist was changing into a very mild drizzle. Oh, and I should also mention that since I got such a late start, and stopped to eat lunch while overlooking meadow #1, and had taken so many pics, I was running behind schedule.

I hear to true hikers scoff at the schedule bit.. But here parks close. The gates are locked. You don't want to get locked in... I waited, patiently, for the Eland to move. But he seemed to be enjoying the grass he was munching on. So like a madman, I tried to explain my situation to him, which also failed. Finally, I had to just wave my arms, and make scary crazy person sounds and gestures to get him to move far enough off the trail that I felt comfortable passing..

Anyway, was a perfect hike.

PICTURES: click on the link off to your right to see some pics.

The rest of the weekend has been enjoyable. We went to a comedy/drag/play/show thing Saturday evening to Celebrate David's birthday, then S&S hosted his bday dinner., That wrapped up around 2am.

As for work: We're in the cath lab tomorrow! They do pedi diagnostic/therapeutic caths twice a week. Looking forward to that. But for now, off to bed.

Cheers

Work

This is how work as a junior doctor should be.

 

Not intimidating.

Occasional laughter.

Busy.

Full of learning.

 

That's how the day was. We had a morning conference, which occurs every Friday am, and ends with breakfast. Then we rounded in the NICU, seeing the kids who needed echocardiograms. There was a bit of a funny conversation... One of the other registrars came up to me to tell me that the other day they were all sitting around, and my name came up, and that somebody was commenting on how much I had enjoyed the month. HA! That was funny.

 

Then we went on our Grand Round. Went to see all of the kids that are on the cardiology consult service. It was enjoyable to round with the 4 pedi cardiologists, and have great discussions and bedside teaching. Then it was back to the echo room to repeat echos on selected kids from our round, plus the 2 kids that we did consults on yesterday afternoon.

 

The day ended nicely at 3pm. Was able to pop into the gym, and have rented movies for a quiet night at home. There's been a small break in the rain, but the storms are threatening, so it's going to be a great night to just hang out at home.

 

Cheers.

 

 

Obama Part 2, Heart Part 2

Yesterday, I had lunch in Nelson Mandela square. Eating sushi, overlooking the 2 story tall statue of Mandela, thinking about the election, it was a damn near perfect afternoon. There was a bit of a weird feeling walking around the mall yesterday. I'm curious if other expats had similar feelings, but for the first time in quite a while, I was proud when people make some mention of me being American. I didn't wear an American flag t-shirt, nor an Obama button (I don't own either), but after months of adopting the Jozi greeting of "howzit" I reverted back to my best American accent of "howwer you?" and was sure to include the uber-american "thank you very much, and have a nice day."

 

Strangers had the liberty yesterday to congratulate me, be if for specifically electing Obama, or electing the first AA president. It didn't matter. Yesterday, I walked around thinking that for the first time since the decline of America's global reputation (decline isn't the right word, that implies something slowly heading downhill...) I wasn't going to be automatically placed on the the defensive, trying to defend America's actions.

 

Electing Obama has almost been interpreted here as acknowledgement of error, or many errors in decisions made in the past many years.

 

Oops, we fucked up. We're sorry. We're electing new leadership.

 

It was a great day to be walking around in Jo'burg.

 

As for work....

 

The pediatric consultants were back today. We did echos on the kids that the other reg and I've seen all week long. It was a bit of a proud moment, when the echocardiograms (ultrasound of the heart) confirmed most of our clinical diagnoses.

 

We're following one kid who has a single atria and a single ventricle, in addition to a slew of other valve and stenotic lesions. He basically needs a new heart. And he won't get one. After spending a few days on the vent, he's acquired a nice pneumonia, and now a palliative procedure will be deferred until the pneumonia clears a bit. He's off the vent, and I'm pretty sure he is no longer being considered for re-ventilation. Mentally, I pointed out, to myself, all day how unfortunate that down in the neonate area, there are likely kids there who would be donors, but there doesn't seem to be the set up for such transplantation..

 

Anyway, have a bit of reading to hammer out.

 

 

 

Obama, $0.02 Part One

Part two tomorrow.

 

I've gotten home, very late tonight. Part two will show up, hopefully tomorrow.

 

Suffice to say, this is such a tremendous victory.

 

The Vote

All day long, it's been politics. And hearts.

 

If I worked really hard at it, I'm sure I could write a better post linking something philosophical about the election and my pediatric cardiology rotation. But I need to get to bed ASAP so that I can get up at 3am or so and start watching the news.

 

All day long, Obama is the talk. People here are waiting for results. People here are excited about the election. Somebody asked about having an election party, and when I pointed out the time difference, that thought quickly vanished.

 

Work has been fantastic the past 2 days. Seeing very interesting kids w/ complex heart lesions. The consultants/attendings are away at a meeting and return Thursday. So a private cardiologist has come daily to do any emergent echos, see and emergent kids. The other resident and I saw about 10 kids in clinic today. I'm actually off tomorrow, kind of nice.

I'm taking the bakkie in tomorrow for it's 120,000 kilometer check-up. Sadly will have to leave the house very early, and will then walk to the mall near the car shop, and plan on spending the day having coffee, seeing movies.

 

More soon, just a brief post the purpose of which was really to try to convey how SA is abuzz with US election anticipation.

 

B

Therapy

Leaving work at 2:30 early on the last day, heading to wine-expo, meeting up with a dozen friends to sample wines (it's all good to me), more interested in all the eye-candy than the wines, much to the dismay of the wine snobs in the group, eating dinner at almost midnight, getting up early this morning to go get an hour plus massage, coming home and booking a trip to Vic Falls, then going for a nice hike/walk I the nature reserve, coming home and talking to friends back in the US, it's been a little bit of self-indulgent pleasures to congratulate myself for getting through what was a long, miserable month, mostly miserable from work. Looking forward to getting back on track, engaging dormant parts of my brain, getting caught up on neglected projects.

Happy November.

Which really is my favorite month.

Ethics

"But in America if you don't have money, you can't get on a ventilator."

 

I feel my shoulders stiffen, the hairs stand up on my spine, and I'm ready to fight. Not debate. I'm quite tired of this constant bullshit view of American healthcare, which includes among other things: Money=care. No money=no care.

 

The neonatologist who is giving us a tutorial on Ethics, is apparently, quite respected around here for her ethical views. We'd be discussing the Shiavo case (painful, didn't we hash this out at the time) and I must say I'm quite aghast at some of the views being expressed in the room.  We move past Shiavo and she is talking about different access to health care goods in different countries, when she makes the gross statement above; which almost made me fall off my seat.

 

I raise my hand. In protest. And I voice my protest at this statement. And I'm quite pissed actually. I've seen so many babies and children denied the right to be ventilated here in SA because there are no vents available, that to make such a statement pisses me off. I've never seen somebody denied being placed on a ventilator for reasons of no vent available in the US, or because the person couldn't pay. And mind you, I've been in health care for a while now.

 

And so I say that, this simply isn't true. Somebody wouldn't be denied the right to be placed on a vent because they couldn't pay. To which, she replies, "I've been to America, and I've seen this happen."

 

Yes, I'm sure. That's what we like to show foreigners when they come to America.  Walking down 5th Avenue on a bright sunny day there is some homeless person gasping outside what ever hospital is on 5th avenue with a sign that reads "I can't breathe, and they won't vent me because I don't have money."

 

And now I kind of look like an ass. Because my tone isn't chill and calm, and I state my authority on the issue (being an American, having WORKED in AMERICA in healthcare for years, and knowing lots of doctors in other hospitals who have never mentioned this happening). I try to bring it back to an adult conversation, and explain that the way hospitals are reimbursed by medicare/medicaid means they can't really refuse care like this. But I get no where.

 

"Let's move on, I will recognize your objection." Oh yeah, I bet you wish you could have seen the look on my face then... As if I should just bow down, kiss her ass, and leave it at that. I'm not making an objection. I'm making a point.  

 

A poor child who has AIDS will not get vented, here.

An poor adult who is a sub-optimal ICU candidate will not get vented, here.

 

I refuse to back down. Health care in America is far from perfect. I readily acknowledge this. But heaven forbid I am every really sick, please, please, please let me be in America. Where there are resources to help make me well. And if I don't have money... sure, I'll go bankrupt and be even more poor, but let me be somewhere where there are resources which I can get access to.

 

I'm thinking to the care we give back home. And I think, that in the hospital where I train back in the US, that we give excellent medical care to every patient, regardless of their socio-economic status. I won't bow down in this argument, and won't take a pacifying bullshit statement and let her continue her lecture.

 

"Excuse me," I say as she moved on to the next slide, "instead, let us agree to disagree." (A saying my college advisor taught us).

 

I keep quiet the rest of the lecture/debate, and observe the thoughts of my colleagues.  I observe in slight horror.

 

Reality Check (or Cheque)

The motion detector in my room makes a very slight clicking sound when it detects movement. It bothered me for a while when I first moved in, but like most annoying house sounds, eventually you tune them out.

 

Except for when it happened at 1am this morning. And of course, it had to happen at 1am this morning, because I went to bed early, with the plan of getting a SOLID 8 hours of uninterrupted sleep. So, at 1am, I heard the damn thing make its slight clicking sound, and jumped to the conclusion that something had set off the motion detector. For some reason, I wondered if the motion detector had been set off by something in the house. So, I did the logical thing of getting up out of bed and looking down the hallway and walking into the kitchen and living room. Of course, all was well.

 

All was well, but I still left of the hallway light to scare away boogeyman as I looked under my bed and crawled back into bed, hiding under the covers. Ah, flashbacks to being 5 years old again.

 

And then, just before work, the alarm on the landlord's house went off. It was like 7:15 in the morning. Who the hell would break in to a house at that ungodly hour? So, I waited. And waited. Figuring that they had set it off accidently on their way out of the house, and that they would reset it immediately. One minute went by. Two minutes went by. I debated calling them to ask them if they were thinking about turning it off... What I was really afraid of was that I would leave the house, and as I left the armed response company would show up. And since I drive a sort of ghetto robber-ish car, I'd be worried that they would shoot me. Sadly, this happened recently to a couple returning home from vacation as robbers were breaking in to their home. After about 5 minutes, I decided to look out the window and see if there was anything interesting going on, especially if the alarm company had shown up.

 

One of the other tenants from a small house on the property was standing outside talking on the phone, and so I chatted with him, and found out that all was safe, that the alarm had been accidently tripped by him, and that there was actually nobody home to reset it. See, I knew it would be silly to rob a house at this hour.

 

I still drove out of the house cautiously.

 

Fast forward to the gym... There I am, lifting weights, lost in thoughts and music blaring via my ipod. Totally in my own world. And blind. When I need a serious session at the gym, I prefer to go without contacts/glasses, that way I don't get distracted by... well, you know by what, and can just chill out and be in my own zone. But, flashing red lights can get into my zone, as I found out tonight.

 

I was doing some arm machines, when I looked outside and saw flashing red lights. So I got up and looked outside. Of course, I had to squint hard, and I could make out a van or something with flashing red lights. I couldn't really see more. I made a mental note to think about laser eye surgery, and decided that it was a AA (the SA equivalent of AAA, not AA as in problems with the bottle) probably jumping a car battery or changing a tire. I made this deduction based on the fact that there were red lights only.

 

I returned to my gym area, where a few thoughts suddenly dawned on my simultaneously.

One, when I heard that slight clicking thing go off in the bedroom in the wee hours of the morning, it was likely set off by me rolling over in bed. I don't think it goes off if the other motion sensors are set off. And now I was going to have to figure out a way to test this hypothesis. Why didn't I pay more attention last week when the bird flew in through the kitchen security door (the one with bars, the real door was open to allow fresh air, and birds, in). Now I'm going to have to get either a friend to come over and walk around, or maybe I can lure a stray cat or dog into the house and try out this hypothesis.

 

Two, as I left work, and got stuck in the queue to get out of the hospital drive, an ambulance was coming down the road, and it, in fact, had only red flashing lights. Would I be a bad person if there was some guy having medical problems in the parking lot, and I didn't help because I thought it was a dead battery?

 

So, I walked back to to the window, where thankfully there was one gawker left.

 

Me: What's going on out there?

V: Oh, I guess some guy's just been shot in the arm.

 

I slowly run this sentence through my mind, much as I suspect Microsoft Word does when it checks grammar. Some-guys-just-been-shot-in-the-arm.

 

Me: Oh.

V: Hmmm.

 

Now obviously, the first thing that came to mind was semantics. Does he mean that this guy has "just" been shot. Like he was freshly shot out there in the parking lot OUTSIDE OUR GYM? I mean, it would seem silly that he was shot say a few hours ago, had a nice work out (maybe decided to not work out his arms today, just did legs), and then realized that he was woozy post work out and called for an ambulance? So, just may mean that it just happened.

 

Or, does he mean, he's "just" been shot in the arm, meaning, no big deal, it's "Just" the arm. We do have two of them? I'm hearing the voice in my head quote Monty Python "It's just a flesh wound, I'm not dead yet." So, really, being shot in the arm isn't a big deal.  At least the guy will still be able to walk around ok, right?

 

V: Do I detect an accent?

Me: Yep, I'm from the states.

V: cool, what do you do?

Me: I work at Bara.

V: Oh, are you a doctor?

Me: Um, yes.

 

OH SHIT! THAT'S RIGHT, I AM A D-O-C-T-O-R. And now because I have a big mouth, V knows this fact. I try to recall the oath we took when we graduated, it doesn't technically say anything about rendering medical aid to people who have "just" been shot in the arm, and I mean the ambulance is out there...

 

Me: So, what do you do? (hoping he'll forget about Bara)

V: I work on a farm

Me: Wow, that sounds cool

V: So, you must see a lot of bad stuff at Bara

Me: (damn, back on the doctor thing), Um, yeah.

 

I'm debating two things as this conversation unfolds. I already feel guilty because I haven't been to the gym since Thursday, and god knows after what I did to my body this weekend, I need this session. Sadly, the gym is closing in 15 minutes, which doesn't really give enough time to render medical aid, and complete my work out. Two, I mean, it's "just" an arm. Of course, I'm assuming the trajectory is from the front or back, meaning that the bullet would have continued onwards. But then I realize that if the shot was from the side, it is possible it could have entered the chest. Oh, that would be "just" bad. V is saying something, and I'm nodding, realizing that I should head out there and see if I can help, and that's when I see the ambulance pulling away. Phew, decision made for me.

 

We chat a bit, and I head off to finish my routine. And I'm slightly anxious. I mean, somebody was just shot out there in the parking lot.

 

Reality check.

Reality check.

Reality check.