Tuesday, July 29, 2008

Wrecked & Breakthrough

Don't mess with the Universe. We were destined for a long night.
The let me come in an hour late from my afternoon break. As I have mentioned before the entire team works most of the day, and then at night there are 2 juniors and the senior on-call. One of the juniors gets 4 or 5 hours off during the day and then is awake all night, the other junior is there all day with the expectation to be able to sleep for 4 or 5 hours at night. And the senior on overnight gets a bit of a break during the day as well.
So, the day was slow yesterday. Not many admissions. They called me and told me to come in an hour later than normal, and when I get there things were still very, very slow. Slow enough, in fact that we let one of the other junior residents go home (technically, we still have one extra junior because I am there, making 5 of us instead of the usual 4).
I swear, that person had been gone no more than 20 minutes, and then there were 5 kids waiting for admission. The night quickly decompensated.
I'm wrecked, having run errands post-call this afternoon, I've been up since yesterday morning. (I did lay down for 30 minutes at 5am).
My Admissions:
#1) A 3 year old with symptomatic anemia, with a hemoglobin of 3. (Should be well above 12 or so). Reason unknown. His color was so pale that when I walked past him at about 3 am I almost freaked out thinking he was dead! I actually shook awake.

#2) 2 year old who was being observed in the observation unit, but had recurrent seizures, so wasn't simple febrile seizure, and then proceeded to go into status seizure.
#3) A 13 year old boy with pretty impressive blood in the urine
#4) a 4 week old with a cold (yes, even in mighty Bara there are some bogus admissions)
#5) A 3 year old boy with meningococcal meningitis. Our 3rd of the month!
We had 22 admissions. But we also had to intubate 2 other kids. It was a little bit crazy.

The breakthrough, though, was more personal for 2 reasons.

First, I've expressed some frustration privately to some about the dynamics of my being back to a junior status. Well, last night was finally the night were I was treated as a peer by the senior, and in fact when one of the nurses said something about the interns working last night, the senior quickly corrected her and told her I was a senior. But more importantly, with the sick kids, when I made suggestion about management of some of the kids, those suggestions were done. And also, things were so hectic that the senior last night didn't write notes on any of the patients I saw.
I had asked to change teams for next month, and found out that this wasn't going to happen. I think had I pressed, I would have been able to change teams, but there has been a shift the past few days and I think it'll be ok to stay in Ward 18.
Second breakthrough. The Grand Slam!
At some ungodly hour (about 3am), I obtained the pediatric grand slam. With only the assistance of a nurse, I got urine, blood, spinal fluid specimens and an IV in the 4 week old child (yes, the one I admitted for a cold). We won't even discuss why this kid got a sepsis work up. It was a proud moment. A proud moment with a lot of fortunate luck (for the child).
Anyway, keeping this on the brief side, I need to sleep.


Sunday, July 27, 2008


More pics to come


Falling #1:
I was destined to fall in love this weekend. I was given the Honeymoon Suite for Pete's sake!
I left the house at 5:30 am on Saturday. I started to get concerned when I figured I was about an hour and a half from my destination, and didn't see the mountains that I was headed to see. I kept thinking of drives from Chicago to Denver, and how you can see the Rockies for hours before you stumble into them. Where were the mountains surrounding Clarens??
I also realized, that maybe I had set expectations too high, and that I should just go with the flow, certainly the mountains here would be vastly better than the Berkshire mountains back in Massachusetts.
And then they appeared. Gracias a dios! I wanted some elevation and trails, and I was going to get it.
As I pulled into Clarens, I actually forgot I was in South Africa. There was a town square, with shops, galleries, and restaurants surrounding the common grassy area. My secret goal had been to find an B&B within stumbling distance (literally) of a nice pub, and enjoy a night of music and then stumble to my bed. That's been my MO in Telluride, Aspen, Breckenridge, PTown. . .
My trusty lonely planet made some suggestions about budget options. I went to the accommodation center, and quickly realized that my price range was already looking unlikely. I had hoped for a room for US$20 a night, but quickly was looking at prices of US$ 40-50 a night. (Here's where I'd like to remind readers that I have no income this year, I'm using a philosophy of splurge/save spending. Living cheaply on a full time basis! Cheap groceries, cheap wine, not eating out, but am also going to live up my time here and small sacrifices will benefit the overall travel fund).
I had my trump card! So I asked about the budget place recommended by Lonely Planet, and ended up going there and scoring a room. A self-catering, Honeymoon suite for US$30! Score. Kitchen and fireplace included. Spouse not necessary. I explained to the very cool woman running the place that the honeymoon suite was perfect! Let me also mention that there were hiking trails right out my front door. And also, coffee shops. And And And.. just very cool.
I was falling in love with Clarens.

I had a nice light lunch of Greek Salad (which of course made me think of my favorite Greek back in Massachusetts, and wondering about my friends who finished residency last month, and have, or are, joining the real world).
Part of the attraction in this area, is that these mountains are on the backside of the Drakensberg, and the National Park is called: Golden Gate National Park, or Golden Gate Highlands National Park-depending which source/map/sign you read. So, that was my next destination. Initially I had meant to pack my hiking stuff and make use of the day to do some real hiking, but didn't get organized, and with such little time, figured I'd scope out the area, and if I felt the need, would let me Adidas shoes suffice as hiking boots.

The time was going to be perfect. 4 hours of hiking, and then an hour and a half to finish driving the park and find a place to watch the sunset.
So, I was hiking along, happily enjoying myself, lost in a train of thoughts.
Falling #2:
Literally, falling on the trail. I've taken some falls while backpacking the past 2 summers. One in the White Mountains, New Hampshire, when I kind of slid down a wet rock face, the other last summer (early-may) in the Catskills. In fact, it took almost a year for my knee to get back to normal, and it's been great since then. Great enough that running isn't even bothering me. So, I've learned that often when hiking, I get distracted, and don't really pay as much attention to the trail as I should...
And of course....
I came across somebody who had fallen. Priscilla, a lovely 60 year old lady hiking with her family had taken a fall, and he ankle was pointing at an unnatural angle (they felt obligated to show me the ankle). I hate to admit, but there was a serious dilemma going on in my head when I saw her lying on the ground. Her daughter and son-in-law and a few grandchildren where there; 2 other grandkids had already run down to summon help. (They had passed me running down, and I assumed they were racing).

Evil Brian: Hey, she's fine, it's just an ankle injury. Going to take surgery to fix it. Not much you can do, and look at the time, you have another trail to hike!
Doctor Brian: Hmmm. Evil Brian does have a point. But isn't there some oath or moral obligation to think about? 
It was going to be a while before help arrived, so I said I'd be around and just holler when they arrived and I'd help carry her down. Oh, did I mention I was hiking to Echo Point? Literally, all they would have to do is holler. So, I compromised, and kept walking. Of course, I only got about 10 yards when guilt set in, and I went back.
Me (the Doctor): "Has she had anything for pain?"
Family: "No."
Me: "I have some ibuprofen, I think it's called brufen here."
Family: "How much can she have?"
Me: "800 milligrams." The looked skeptical. So yes, I said it. "Trust me, I'm a doctor."
Ahhh! Yes, I did say it. "Trust Me, I'm a Doctor." God I wish it could have been recorded, I could feel people mocking me when I mentioned this story!
So, I cleared my conscious with 800 mg of ibuprofen, actually assessed the ankle to make sure there was circulation, and kept going... Knowing full well I'd be back to them before the rescue help came along... I went to the end of Echo Point, or Echo crevasse, or Echo place and took lots of pictures. I felt to self conscious to try out the echo.
To sum up the rescue: The paramedic and 2 EMTs and 2 park rangers arrived. The Paramedic gave morphine. We splinted her ankle. And they placed her on the scoop.-stretcher and strapped her in for the upcoming ride. My work was done. There was one little problem. Well, two actually. Ok, maybe three. Firstly, my down vest, which has sentimental value because it kept me from freezing my ass off on the Inca Trail, and which I had given to the woman to use, was still covering her, and now she was strapped to the scoop stretcher. I couldn't tactfully figure out how to ask for it back, because, dammit, I was hiking for a few more hours! Argh. Could they leave it by my car. It would get stolen. Could they mail it to me? Shit. Problem two: The protocol was 2 people in front, two in back (sometimes needed 6 of us to pass her down the rocky unsteady sections of trail), with a plan to swap out all 4 people regularly; so my quick calculation made me realize that I'd need to help carry. And Three.. I felt obligated to make sure she got into the back of the ambulance in the same condition in which I had found her, what if, heaven forbid, something bad happened on the way down.
So, 4 hours later (after stumbling across them), they were off to the hospital. They were lovely folks. I think they have great pics of "The Rescue." The son-in-law is a photographer and has a developing studio in Durban. We swapped details, and I'll go visit granny when she's up walking later. We stood around talking for ages waiting for the rescue squad. Got to know them. Talked about travels to the US. They had been a couple of times, to New York City, somewhere in Ohio, and were planning a trip San Antonio next year for a conference. When talking about travels, I hadn't known that he was a photographer/owner of developing studio (though he had a huge camera). And so, trying to keep conversation going, I asked what kind of conference. (Maybe they were in the medical field as well).
AA. Yes, the international Alcoholics Anonymous conference is in the US, regularly. Two thoughts came to mind. One, I like international flights, free drinks. Two, thank god I hadn't mentioned going for a drink after all of this.

They are of Indian heritage, so I'll join then for food Indian food in Durban.
So, we finish the rescue. The Park manager and I are chatting, and I'm still bound and determined to get one more hike in. But the park manager convinces me to come back another time, and instead tells me the spot to go and see the sunset.
So, I drive around for a while, end up by the "Vulture Restaurant" (see pics which will hopefully be up in a few days). And proceed to watch one of the most beautiful sunsets that I have seen in years. Part way through some wild coyote-thing (I don't know what the South African term for this wild dog-thing is) comes up very close and I'm thinking maybe it really isn't a coyote thing, but more of a wolf thing, and that maybe it's not a scavenger, but more vicious, and that it's getting close enough that I need to stop trying to take a picture and make sure it realizes I'm not sharing my dinner, or my flesh! (Insert saying here: "The dingo ate my baby"). And off it scampers with some madman hand gestures.
I look around. I envision real South Africans watching this unfurl.
"Look at that mad American scared of a pathetic ishyeant!" (I've made up ishyeant, by the way).
There is nobody around.
I'm there until the very last bit of orange-red hue is gone, just watching and thinking. I get lost in a sea of thoughts, thinking in amazement that a month is already gone! Thinking that Dean, who sold me his car which I took possession of on Friday, kept mentioning that he couldn't believe that his year in SA was over. And even though it has only been a month for me, it feels like I've been here longer. And there is so much more to do, to see, and to learn.
I get up to leave. And then I get rewarded with stars. And the Milky Way.
The combination of fatigue, sunburn, dehydration, and coffee-deficiency have hit, and I actually feel a bit physically ill. I head back to town, make my way to "Friends," a local pub where I'm told the owner of the Inn is playing music. I promptly order coffee and beer and a hamburger. Living up to it's name, the bartenders, Andre and Vic and I enjoy friendly conversation, and for the second time today, I forget where in the world I am....

Friday, July 25, 2008

Surprises: Thoughts on Coffee and Patients

Last week, while in the grocery store, I stopped in the coffee section, and analyzed a few products. I know, I know, I have issues with coffee.
Let me also take a minute to say, that I have been spending way too much time in grocery stores. I could write volumes about my fascination with grocery stores abroad. I like finding things that I didn't think were consumed (chicken hearts), in the meat section, as well as all other sort of new things (digestives: a type of biscuits). I actually, still remember when I was visiting Ireland, and walked into the grocery store there and walked around (thinking to myself, I can live here, at least they have food). I have to add my absolute delight of finding an Irish section in the grocery store in Massachusetts. For god's sake they have Aero Bars, Golden Pouring Syrup, Kerry Gold butter, and digestives (among other things)
Anyway, grocery shopping, hasn't been the targeted run in and out shopping trips that they usually are back home. I have a list, but then wander the aisles looking at assorted spices, snack foods etc.

So last week I literally got stuck in the coffee section. Not the coffee bean section, which happens  to be very paltry at this store. I tend to do most of my shopping in the non-affluent mall. It's closer. However, I will add that the other day I stumbled upon another grocery store, in predominantly white suburb, and the coffee selection there was exciting!
So, there I was. Looking at coffee makers and travel mugs. You know you're a connoisseur or addict when you predict which travel mug will spill, and which coffee maker is the best value. Also, having learned once before, just because a place (or country) sells coffee makers, doesn't mean they have coffee filters.. And so once again, I held a mental debate about sticking with instant, or buying a coffee maker. There's a financial aspect (coffee maker, or half a tank of gas, or a night in a B&B, or crayons for the kids on the wards.. that money can be spent better ways), the addict aspect (why do I need so much coffee), and the reality of that fact that I'm here a year, and I'm tired of accumulating material possessions So, I decided to fight on, and not give in to the addict raging inside of me.
Surprise #1: A care package showed up with, among other goodies, 5 or 6 pounds of Starbucks coffee. Hello heaven. Decision made. Ironically, when picking up the care package at the post office, I stumbled on what may be a coffee shop of the hang out and ready/study type. So this evening, I made my way back to the aisle where I spent an excess amount of time last week and bought myself a coffee maker, and a travel mug.
Tomorrow morning, when I head out for my overnight trip, I'm going to have Starbucks coffee in the car with me! Now that is a pleasant surprise..
I admitted 5 kids on call yesterday. 
One was a kid with panhypopit who was coming in with headaches, and was for rule out meningitis/sepsis. Of course, I neglected to think outside of my USA box, and when we admitted the kid didn't really consider TB as a cause, as in TB meningitis. (Though really, the kid looks too good and his pain is sooo minor wouldn't be mentionable except that this kids is not physiologically normal and at risk for infections).
I admitted a 9 y/o boy who has juvenile dematomyositis, but also has TB of the right knee, and has had oesteomyelitis (MRSA-our friend back in MA who is hardly seen here) numerous times. He came in with worsening pain/swelling to the same knee (is still on TB treatment). And was admitted with a differential of osteomyelitis (again), septic arthritis, abscess, DVT. He actually went to surgery last night where they drained the knee. Organisms not yet identified.
I admitted a cute cute cute 3 month old who was in pretty moderate respiratory distress. Her sats were 82% on room air (again, should be >90-92.). Her chest xray was hyperinflated, some patchiness, maybe a soft call of right upper lobe PNA, but really more viral bronchiolitic looking. Until we rounded with the attending this am, who thought she's likely TB. Again, diagnosis of TB based on clinical suspicion.
I admitted an almost 6 year old male who is somewhat psychotic... I'm just going to leave it at that.
And then, just before leaving, I admitted a 9 day old infant. The presenting complaint was irritability. If that's enough for admission, I'd have been admitted by then as well. Seriously, though, this child was sleeping in mom's arms. That being said, the doc at the local health clinic and the docs in the pedi ER (equivalent) had thought the kid was irritable. And really, at 9 days old, that's enough to justify looking for infection. She was marginally irritable during the exam, but consolable with a bottle.
Infection presents weird in this age. Irritability is a common sign. But also, this mom had the "my baby is just not herself today" complaint, which I think has a very high predictive value for a problem with the baby.
So, this child was going to get the full septic work up. Blood. Urine. Spinal Tap. Chest Xray.
For 9 days, she could squirm! But I felt the needle pop it, and looked for the spinal fluid to drain out.

Surprise #2: Turbid! Mom was right. Don't even need to see this under the microscope, this baby has meningitis. And given that we're in South Africa where mom's aren't tested for Group B Strep before delivery, this is likely Group B strep meningitis..
So, I arrive at work this am and start my day. I decided to just start in cubicle one, and work my way through each cubicle. The patient shuffle (see previous post) has been done to accommodate the 21 new admissions and there is no tracking system. So I just walk into a room, look for familiar faces. I know that back in MA, I tend to prioritize the list of seeing patients (sickest first, most pain the ass last-really, that's how it happens, unless the family is the pain in the ass, then see them first before the family is there). But here, I just take one of the many leaps of faith and assume that if a baby is sick, the universe will inform me.
I'm on kiddo numero 3 or 4 to see when one of the other Docs (who was on overnight call) comes into the cubicle where I'm seeing a kid.
S: "Hey, your baby died last night."
Surprise #3: My synapses don't seem to really be connecting that information. But I make a mental note to buy a coffee maker today so I can take coffee with me to work which will allow me to think more clearly at work.
I'm not really sure how the fuck that baby could have died. "Meningitis???," I think to myself. Baby looked ok. Exam not too impressive. Vitals were ok. Jesus, was there something else as well that was totally overlooked.
Me: "What?!"
S: "Your baby died last night."
I say "what", because to me it's obvious that there is something terribly wrong here, and "what" means clarify who, when, why, where, or more to the point: WHAT THE FUCK HAPPENED?!?!  But, I see this is a lingo barrier, and I need to be more specific.
Me: "Meningitis baby?"-I hate using a disease term to identify a person, but honestly the names are still pretty foreign to me, and often I mispronounce them.
S: "No," she looks at me like I have 3 heads. "KR"
Surprise #4:
I can't really describe what happens inside my brain next. There are about 5 simultaneous thoughts.
#1-he was 4 and a half, and wasn't a baby.
#2-that explains how I got to cubicle 5 and hadn't seen him yet.
#3-why didn't I look for him first thing this morning.
#4-and I told his family he would get better.
#5-What the fuck!?!?
I hate writing about/thinking about/acknowledging feelings. It's easier to be cold and cynical and numb. But I was really disappointed to hear this. Look at his picture again from my post a few days ago. If this kid needed a home, I would have adopted him. This kid is #7. More to the the point, this is the second kid I've had die in a week. I'm not use to that. At all. Unlike KP who looked so bad and wasn't likely to make it, (I rooted for KP because he was such an underdog!) I thought KR would make it. His level of malfunction, if you will, was treatable. And curable?
I make a mental note to think about this more (which I have done throughout the day). It's a busy morning, and there are 4 more kids to see before we round.
During rounds, I see KR's family walk into the ward. It dawns on me that I have no clue what happens in these circumstances, and with poor phone lines, using cell phones as primary contact numbers, I get concerned that they may not even know he is dead. I quickly ask, and am told that they "should know." As his family (Dad, Aunt, 2 grandma's and a few others) walk back into the hallway, I can't make eye contact with them. I don't feel responsible for his death, but I do absolutely regret telling them he would get better.
We move into the next cubicle on rounds. I was presenting while his family was walking in and out, and know that I need to do the right thing and go see them myself and talk to them. I fear, most, that they will be upset and angry. Which would be normal, but I fear they will be upset that I told them he would be ok, and now he is dead.
As I walk out of the cubicle, the two grandma's meet me. Both are women who looks to be in the 70s (but are more likely in their 60s-their life experiences have aged them). The are so humble looking. The smile and extend their hands as when they get closer. I feel a sense of warmth from them, there is no indication of anger.
Grandma: "Doctor, thank you so much for taking care of K."
Me: Nodding, "I am very sorry he died, I thought he would get better."
They just nod. There are no tears. The have a level of understanding which I don't have after such a short time here. I wonder if there is acceptance on their part because they hoped he would live, but maybe expected he would die. 
Whereas, I expected he would live.


Wednesday, July 23, 2008

Possibly Quiet for a few days

My internet access at home has been out since yesterday, and right now there are no assurances it will be back up anytime soon... so lack of posts don't reflect lack of on-goings, but rather no internet at home...

Meningitis Follow ups

I think I mentioned of of the kids that we admitted with meningococcal meningitis. We admitted a 4 year old boy, and an 11 year old girl. The girl was miserable, and for days just moaned. Happy to say that both went home today, and appear to have escaped without any sequelae (such as hearing loss etc).
On another note, though, Sunday after I had left, there was a girl who was being seen with meningococcal septicemia (ie, the infection was in the blood) and she died before being admitted.
3 cases of meningococcal disease in 2 weeks..
I had a bit of a headache a few days ago, and got a little paranoid! (We took antibiotics after the exposure, and are covered) Smile emoticon
KR is hanging tough. He's getting a bone biopsy tomorrow morning... more to come on him, but really, really need to read a bit before heading out to the gym.
Am making plans for a weekend escape. Not too sure if I'll drive out Friday night, or defer to Saturday am.

Tuesday, July 22, 2008


This is KR

He's my 4 and a half year old who I wrote about a day or two ago. He's HIV positive. This is him this morning. He spent all of yesterday lying down, not interacting, spending his energy on just breathing. He actually did get an echocardiogram yesterday, which didn't give much new information. But the diuresis has taken quite a bit of fluid off his lungs, and this morning it was good to see him upright, eating some toast. His lungs sounds better too. I found myself treading lightly when the dad and the other grandma showed up this afternoon, as I wasn't aware how much they really knew about his overall condition. I asked some questions like "Tell me about his medical problems, if any." One doesn’t just ask openly about HIV/AIDS status... So he's looking a bit better, but still has a bunch of issues to be sorted out.

I called for another insurance quote today, and it was double the amount from the another place. The annoying this is that I spent 40 minutes on the phone with these people. I had planned for a nice long run in the nearby nature reserve, but sadly that was cut short by dealing with these bastards. I told the guy the quote was outrageous, and then we started to bargain; I already decided that I wasn't going to use these guys, but knew he was being paid commission (he told me so as part of the upfront legal disclaimer) so managed to keep him on the phone and practice my haggling skills.

Anyway, time to stop neglecting some reading...

Monday, July 21, 2008


Here's a secret.
I almost gave up on the idea of coming here when this was all in its infancy-a year ago. This happened early on. It must have been about 3am, I was sitting in my flat in West Springfield (Goan-fine, apartment). And I was trying to sort out all the freaking paperwork hassles. Seriously, I'd give a kidney (assuming I have two, I don't know for sure) to NEVER have to do paperwork again in my life. I had saved over a dozen web pages for SA government, heath councils, the hospital, the med school, Massachusetts sites. I had downloaded numerous forms, some of which were over 20 pages long. I tried to diagram how to get this process going.  And at 3am, I really, really had to think this through. 
I break out in a cold sweat when thinking about paperwork hassles.
"Can't I just show up there and do this?" I whined out loud to the universe and my plants. (Those plants, by the way.... 3 of them committed suicide before I left, they knew I was going to abandon them. The one given to me as a gift by Julia and Jeff in 2005 is flourishing. And the 2 I bought myself to cheer me up one cold winter day were still alive. I gave the 3 remaining plants to a friend in MA to take care of).
My whining wasn't answered.
And somehow, I made it through the mound of paperwork. I don't think people realize that I had to get a letter from the police in Ireland saying that I had lived there without any problems! I mean seriously-pain in the ass.
Why do I mention this?

Because, I will take possession of the car that I am buying on Thursday or Friday. For the record, this is a financial decision. I will lose less money buying a car for a year, and then selling it, than if I had rented a car for a year. But, in all honestly, it would be SOOOOO much easier to throw away a few thousand dollars on a car rental in order to avoid getting my car registered and insured.
Let's talk insurance. A necessary evil. Flashback: I miss having my 81 Honda accord and ford escort, which only had liability coverage! Of course the jeep is fully insured. So, I looked around on-line and got some insurance quotes. I got a call from one place today, and was on the phone for over half an hour.  My favorite question:
"in the past 2 years, how many times has your car been hijacked?"
Like it is an everyday occurrence.. Oh wait..
So I get the quote. Getting insurance, it turns out will be the easy part. And, the more important part, because I hope to drive my new car out of town this weekend and go see some mountains.
Saturday, I asked Scott and Siza about the other hassle, registering the car. 
This is the email from Scott:
Hi Brian,

Here's the information on registering your car and getting coverage.

The license plates ("number plates") stay with the car when you purchase it.  You need to get a roadworthy certificate and then register a 'change of ownership' on the car, as explained below.


When you purchase a new or used vehicle, the new owner is required to register it under his/her name.

Documents required:
  • ID Documentation (Passport is fine.  You will need a "certified copy", see below.)
  • Clear Copy of your ID (Picture must be very clear)
  • Original vehicle registration certificate
  • Valid Roadworthy Certificate
  • Notice of Change of Ownership Form (copy attached)
  • Possibly, a registration form (copy also attached)
  • Proof of physical address  (bank statement, rent bill, lease agreement, utilities bill .... something official showing your physical address)


Any vehicle used on South African roads must be roadworthy.  A vehicle has to undergo a roadworthy test when you purchase a used vehicle.  The vehicle must be taken to a "Roadworthy Testing Station".  These are private approved garages
Documents required:
  • Clear copy of owner's ID (picture must be very clear)
  • Copy of vehicle registration document or license disc.
The AA (083-843-22) provides Roadworthy Testing service at their "Test & Drive Centres".  The nearest branch to you is probably Roodeport or Westgate Shopping Mall, but there are also branches in Edenvale, Randburg and Sandton (Wynberg).  It's website is:  http://www.aatestanddrive.co.za/

The two services listed below will do both or either of the Roadworthy Certificate and car registration for you for a fee.   It might be easier, if you have the time, to take the car yourself to for the Roadworthy corticated and to then let one of these services do the registration.  If you have a full day, you probably can just do both things yourself.  I'm not sure of the cost of these services, but I imagine they charge R500 for each of the two services.
The email neglects to mention the hassle of finding these places, standing in lines etc...
Is it too late to rent for a year?

Sunday, July 20, 2008

24 hours

24 hours ago I was at a dinner party.
S&S invited me out for dinner 2 weeks ago, and then I had dinner w/ them again last week, and they decided then to have a dinner party last night. I walked into their home. They have one of those homes that I think I had probably dreamed about owning at some point in life. There's a small courtyard, a small pool, a fireplace, a gorgeous dining room, and a very chic kitchen. At some point in life, I think I wanted a home like this. Or like the home B&B have in CT, or the home H&R have in Boston (and the cape). A sort of elegant sanctuary. Now, I'm just happy to have friends who have these gorgeous retreat-like homes, and would rather just show up and enjoy their homes from time-to-time, rather than the thought of ownership. The thought of owning a home gives me a choking sensation. The thought of having friends who own nice homes, makes me smile.
It was such a stimulating night, I didn't want to leave. And when it was 2am, and I knew I had to be up in 4 hours, I decided that I really had to leave!
People I met last night:
V: Who was at the dinner 2 week ago. A lovely Belgium pediatrician who has been working in SA for the past 3 years or so. I've made a mental note to ask him how he became licensed in SA. Nice guy. Very humorous.
D: Fascinating! UK Doc, who works more in the microbiology aspect of the STD world. SMALL WORLD HERE! My boss from Denver Public Health was here a few months ago working with D!!! WHOA! And, D is good pals with all the head honcho Docs of DPH! Everybody I worked with back in 1998-He knows, and works with some on international committees, etc. This is just exciting. I'll at some point mention my other small story world.
T: Is a college prof, who works with Human Rights Watch, and has done most of his work in Rwanda. Stayed in a certain hotel before it became famous. Lives part time in Cambridge, MA with his partner. Use to live next to a certain famous sex columnist-who actually wrote a great book about 8 years ago, which I have read. Fascinating guy!
D: From western Pennsylvania, who has lived in London, Sydney, and now Jo'burg, works in business, and had some of the funniest stories!
T: Cute, but not really worth mentioning. Mostly smiled the whole night, a little too young to be at the adult's table.
S&S: Elegant Hosts, who have been so generous the past few weeks.
Fast Forward to 6am. I'm wrecked.
I'm on the road to Bara, and for the second morning in less than a week I see the cops pulling people over. I notice a car pulls away from the road check. Cops are indicating for random cars to stop, and then it happens, they point AT ME!! I'm scared, but also really excited. I have my R 100 bill in the ashtray, and am FINALLY going to get to bribe a cop. Unless something goes wrong, and then I may end up with a fine, but who cares.
Cop: Drive's license please.
Me: (There is a slight pounding in my temples-my issues with authority trigger massive epinephrine releases from my adrenal glands).  I fish around for my wallet and grab my MA license, the cop is looking into the car as I open my wallet. Of note: there is about R300 sticking out of my wallet, and now it is going to be sooooo obvious when I go for my R100 bribe from the ashtray and try to tell the cop that I don't have any more cash--- he's just seen my loot.
Cop: Doctor? Are you on your way to work. (He saw the stethoscope on the passenger seat).
Me (aka Doctor-thinking it not wise to be a smart ass): Yes, I am (and there are sick babies that I need to perform emergency life-saving surgery on in the next 5 minutes, and I'm late, tired, and maybe have a slight titch of hang over).
Cop: Ah, sorry Doctor, you may go.
Me: (Membership, again, has its privileges). Thanks.
I arrive on the ward. We had a day off..
The night nurses like to play this game called patient shuffle. There may be rules, but I haven't figure them out yet. There are roughly 10 cubicles that have the beds/cribs in them. Generally the first two cubicles are freed up for the new admissions, which in part, lends shuffling of kids, but oddly enough, kids have been moved into these cubicles. There's also really no list to where the kids are, you just have to wander around and look for familiar faces.
I'm sitting at the computer checking labs. And I glance over to cubicle 3 to where two of my kids were, when I left on Friday.
My cutie jaundiced biliary atresia baby is there. But in the other bed, where of one my kids use to be is a now-unfamiliar face. So I get up and walk and peek into the other cubicles.

Death #5.
I owe Indian food to my coworkers.
Sister (aka nurse), when did KM die? (Because it is obvious, to me, that he died, I don't see his face anywhere, and there is no other possibility of where he would be).
Oh Doctor, early in the morning yesterday morning.
I'm fairly sad. Then it dawns on me, that I didn't see my 3 month old who had a congenital heart defect, who was getting a sepsis work up on Friday, and had a horrible looking chest xray. (Though, who knows what her baseline CXR is).
Death #6.
Well, that's the only thing that made sense to me. And I'm taking this a bit personally.
Sister, what happened to KP?
Oh Doctor, that baby was discharged home yesterday.
Interesting for a variety of reasons.
Sister, there is no way he was discharged.
Oh Doctor, he was, I am sure.
Sister, was he discharged home, Alive? (Now I'm thinking that discharge may, in fact, include expired).
KP is dependent on supplemental oxygen (which appears to take about a month to get home oxygen sorted), can't bottle so gets fed through a feeding tube, was looking septic so was going to get at least 48 If not 72 hours of antibiotics, and we didn't work yesterday, so there is NO WAY he was discharged.
I let it go. He will show up somewhere, or I'll hear the story later. And it turns out he got intubated, and is being a bit of a pain in the posterior! Well, just refuses to be oxygenated.
He is not, #6.
I admitted 2 kids before I left this evening.
One is a 4 and a half year old who is heart failure, HIV positive, started anti-retrovirals earlier this month. Lives with grandma who is raising him and his 14 year old sister. Mom died of HIV when the baby was 2 months old. Grandma is a champion. She knows his antiretrovirals, give a great history of his illnesses recently. Is basically the one who took this kid from Dad because he isn't such a great parental unit, took the kid to get tested, and has been the motivating force, and the stability needed, for the kids to get meds!
Anyway, this kid is a cutie. He's in a little too much heart failure right now to smile and be interested in anything other than breathing and staying alive, but I bet when this kids feels better, he's going to be running all over the ward giggling and bringing joy to others. You can tell this kid brings joy to grandma. And hopefully in a few days, to Ward 18.
Good night.
I'm tired.

Friday, July 18, 2008


It's Friday, and then end of a 12 day stretch!
I can't complain. I actually got out early, and have had a lazy afternoon. I'm sitting outside, just finished a Castle (popular SA lager) and munched some biltong (a SA meat jerky). I'm actually not sure what kind of meat it is-check out: http://en.wikipedia.org/wiki/Biltong. I almost made a break for the Drakensberg mountains this afternoon, but would have gotten down there about dusk, and then would have needed to head back early afternoon. Could have maybe gotten a quick hike in, but I also read about this amazing place to watch the sunset, and figured that I wouldn't be there for the sunset.. so am postponing. Maybe until next weekend. (If I can get my car all registered by then).
My 1 year old is still alive. His sats are better today, he looks a bit worse overall, but seemed more alert. It's really tough to know if he is suffering. In one sense, how can he not be suffering, yet he doesn't raise much protest. Though, he may well not have the energy to protest much. He is still eating, still peeing, which I take as good signs. He finally did get a chest xray at some point yesterday, after we had left. And it looks horrible, but he actually sounded clearer this am. I'm thinking there is a slim possibility that he may make it. I think this kid has got to be a bit of a fighter, he's been neglected for so long to get in this shape. One of the other docs thinks I'm crazy to think this kid will make it. She may be right, she has loads more experience. So, as crass as it may sound, we have a dinner bet on if the kid is still alive when we get back to work on Sunday.
Between yesterday and today, we've started TB treatment on half of my kids!  I'm learning the diagnostic criteria for TB.
1-positive PPD (skin test)
2-TB contact
3-abnormal chest xray and has a cough
4-weight loss and TB contact
5-exposed to somebody w/ TB and _______ (fill in the blank)
6-positive gastric aspirate or sputum for TB
7-Kid's been on antibiotics, isn't getting better, must have TB
Ya kind of hate to label kids with diseases, but the diagnosis of TB is very much a clinical one, and I've been trying to stick to objective criteria, but am learning that TB sometimes just has poor objective tests, or tests whose results take too long (TB cultures take weeks).
Have a good weekend.

Thursday, July 17, 2008

Adios AL

A.L. Reaching for my camera
My pal

Farewell to my buddy. When I left, I discharged AL. I can just look and this kid now, and he'll start to laugh. He's been a tough cookie to crack, but he just needed some constant attention, and lots of tickling to make him perk up. Fingers crossed that he doesn't fall through the holes (they are larger than cracks) of the system.

This morning was a bit hairy. I walked in and noticed that my 1 year old malnourished, neglected, HIV kiddo was on a face mask for oxygen. And looks much worse. (his labs reflect it with a white blood count over 30 now, CRP over 240, platelets down to 27). He lungs sound horrible. His sats, on full supplemental oxygen were 68%. Somebody mentioned get an ABG. Why? What are we going to do different w/ those results. This kid is "Not For." I called the Reg to inform her. I really didn't think he'd make it another hour or two. He has these beautiful brown eyes. It's the only expression of personality that he has. He's too weak to make sounds (though he lets out a tiny, tiny cry when he gets blood drawn). He's basically too weak to reach out as well. An hour later he stopped making eye contact, he would barely crack his eyelids when touched. Somehow, though, this kid was still clinging to life when we left this afternoon. I want to be optimistic that, but...

I went for a great run this afternoon. As mentioned before, there is a nature area close by, and I hit out and instead of running the path that cuts through two big hills/slopes, I took the path that went up one of them. My plan was to see the surrounding area, and wait to the last minute possible to see the start of the sunset, then high-tail it out so I made it out of the park on time. I have a nice wipe out headed up hill, added a nice right next to where I gashed my leg while running a trail a 2 months ago. Of course, in my self-conscious nature I looked around to see if anybody had witnessed this, and sure enough, there were a few people down in the valley who must have seen, cause they were staring at me. I waved and kept going.

I'm looking forward to my day off on Saturday!

Wednesday, July 16, 2008


While at dinner on Sunday, I asked Scott-another expat on what happens on getting pulled over. The only ID I keep on my is my MA drivers license. I ask because I barely missed a road block a few days back (I decided to go home rather than head into Jo'burg and run an errand).
I guess a 100 Rand (15 USD or so) is the going rate for a bribe to get out of a ticket, whether there is a legitimate reason or not.
I'm keeping a ZAR 100 bill in my car...

Strike Three

AL didn't have surgery today. Strike Three. The herculean task of getting an ICU bed for his post-op day wasn't the issue. The anesthesiologists refused to do the case, on some whim, but basically saying they didn't think he was optimal (note: if her were optimal, would he need surgery?), and want to wait a month. The excuse they used was concern that he had been admitted for pneumonia (or rather what we learned was heart FAILURE). What-ever. The thing is, this kid is looking fantastic, and it sucks, but he's laughing, happy, he looks like a normal kid. I would take this kid home in a heart-beat. So, we're going to discharge him tomorrow, to follow up at the ENT clinic in a month (when the gassers have decided-albeit arbitrarily). This kid looks sooooo much better than we I met him on July 1, that I really have a tough time sending him out with a prescription for lasix, potassium, and a prescription for good luck in not getting lost in the system.
My jaundiced kiddo.. turns out to have... Biliary Atresia. I've gone 3 years without seeing a kid w/ biliary atresia, and now we have 2 on our ward?? Whoa! She's adorable, and smiles. And is likely off to the OR on Monday.
Pleasant surprise of the day: My extremely malnourished 1 year old is.. HIV negative. By PCR. It's official. He's not doing too well. His CRP (measure of inflammation) is now over 200 (normal < 10), and still going up. He's at least feeding. He's so sad looking. He makes eye contact, but that's about it. Ug.
We admitted to kids with meningitis tonight. One has meningococcal meningitis---another turbid tap. The other is strep pneumoniae. I have my stat dose of antibiotics to take since we were exposed to the meningococcal kid. But, I'm having a beer right now, so wasn't sure alcohol and the antibiotic were wise. Decided to leave the med for the morning, thinking the beer was more beneficial right now.
I think I've previously mentioned organophosphate poisonings.. Wiki it, but it's a nasty chemical which is used as a fertilized. I found out today that it is readily available. Sold in clear plastic bags. They are small black bead looking pellets, and are used as poison for rats etc. Which help in realizing how kids accidentally ingest them. Hell, if I saw a bag of them on the desk I'd likely pop a few of them in my mouth. Candy?
Except that my patient who I admitted w/ organophosphate poisoning this evening is a 13 year old who intentionally took the OD after she had a fight with her Aunt.

Monday, July 14, 2008

Just Another (Not?) Normal Day

This morning before I left the house, the lights flickered.

I don't even know where to begin. So, I will just go chronologically.

I arrive at 7:30, and first assess my three month old with jaundice who is going to have a liver biopsy at 8 am. I run the blood form to the blood bank so that the fresh frozen plasma is ready for her biopsy (it'll keep her from bleeding out after the biopsy-her liver dysfunction is keeping her blood from coagulating normally). Also, at 8 am, AL is suppose to go be seen by the ENT doctors, so I make sure to have seen both of them by 8 a.m. It is 745, and in my neurotic need to make sure that everything goes smoothly this morning I plan to remind the nurses that AL needs to be headed out the door to be at outpatient clinic. Unfortunately, the nurses have just begun singing, and their shift report will happen afterwards, so now I feel screwed knowing that nothing will be ready until 845.

Moving on... I go back to the blood bank after seeing KP. KP is my two month old who had heart surgery shortly after birth due to a congenital heart defect. Goal number five for today is to find a small size nasal cannula so that he can get weaned down on his oxygen, and hopefully get transferred back to the referral hospital. Much to my delight, a nasal cannula has magically appeared since I left yesterday. But, unfortunately it is not pointing into his nose but rather is pointing at his chest. [As an aside, I have been using adult size cannulas and trying to snip them shorter to fit children.] Now, KP is quite dependent on supplemental oxygen and he tends to get a bit fussy, and a bit blue without his supplemental oxygen. I checked his pulse ox while putting his nasal cannula into his nose, and let's just for the record note that it was way less than 70; his goal is to be greater than 70. In fact, it was very far from 70. Let's just say we set a new level for LOW pulse ox-and the reading was real/legitimate, it correlated with the heart rate I calculated. But, he quickly perked up into the 70s range with the oxygen. I taped to the cannula in place to prevent oxygenation attempts via osmosis through his chest. [Another aside, I'm getting really use to seeing sats in the low 80s, and in fact, I actually haven't been alarmed recently. I may have to have some re-entry training to get alarmed by low sats when I return back to the US].

I run to the lab and pick up the fresh frozen plasma. Biopsy time. In the room where we draw blood is where we are going to do the conscious sedation for the liver biopsy. The lights flicker-the power is threatening to quit. That wouldn't be good. Biopsy in the dark doesn't sounds like fun to me. I know, I know, where's my sense of adventure?? Regardless, iIt actually went quite smoothly.

I head out and check on my remaining patients. I glance at my watch after the biopsy is over, and get a little anxious realizing that it is creeping up on 9 a.m. AL still has not gone to the ENT clinic. I remind the charge nurse (aka sister) and she tells me that someone will take him shortly. I finish seeing my remaining patients, including my 8 year old friend to was discharged on Friday. It is now about 10 a.m. The senior residents have gone to one of the other wards to see a patient, so I have not rounded with them, yet.

One of the senior residents comes into the Ward and I tell her my plan is to round on my patients with her and then I will take AL to ENT clinic myself. I've been told this isn't necessary, and that I could be there for hours...

So, we finish rounds and I find where I have to go, which happens to be about a 10 minute walk. I debate carrying AL, but decided that wheeling him in a small mobile-crib-like-thing is better. And Jesus, let me tell you that this made such an intense squeaky noise that people down the road looked back in order to see what was so damn loud. Let me describe the noise. Take 500 children with long finger nails, let them scratch their nails on a pristine chalk board at the same time that 300 vultures devour small animals at the same time that 200 kettles start whistling. It was that loud, I don't exaggerate.

For the next 45 minutes, we would generate plenty of stares. Not only did the hideous noise from the crib force people to look, but the fact that this white doctor was carrying a black African child-I felt so Angelina/Brad/Madonna-generated plenty of additional stares. I managed to find my way to the ENT clinic, conveniently located on the 3rd floor. I grab my friend and up the stairs we go. And then I was slightly horrified to see about 30 people in a tiny hallway waiting to be seen. Not that I really care about waiting at this point, but lunch time is approaching, and I'm hungry. Oh, and one more minor detail. AL is on LASIX, a great diuretic. And it kicked in. For a minute, I wondered if I peed myself, but no, it was AL's soaking diaper. And I didn't think to bring a new one.

We got our number, number 80, and I decided what the hell, I had nothing better to do than to hang out with AL and 30 of my closest friends waiting for the ENT docs.

But, thankfully membership has its privileges, and we were taken by the next available doctor after about 20 minutes. And to my non-surprise, the ENT doctor quite quickly decided that AL needed his adenoids out. And to my pleasant surprise, he scheduled the operation for Wednesday-in TWO days. I hate to admit, but after two weeks of a frustrating lack of progress, I felt a bit giddy that AL was finally on the path to some useful treatment. Of course, then I freak out realizing that I haven't seen family at AL's bedside for a week now, and who's going to consent for the surgery? Maybe AL and I will go drive around Soweto looking for them! (Not).

We take the long way back to the Ward, and we had a nice stroll. I actually contemplated going via the cafeteria and sitting out in the warm sun having a play lunch with my pal, but decided that if the prof walked by, this may not be well received.

Then things go slightly downhill from here...

A patient was transferred to our Ward this morning as a TURF. Meaning that this kid has previously been taking care of on our Ward. And therefore the way the system works is that any child who is readmitted, goes back to the ward were they have been admitted previously. It lends a new meaning to the term turf wars. Anyway, this new kiddo, KM, was assigned to me. So I go in and read through his chart... After the past two weeks, I felt like I was beginning to develop a bit of a thickened skin and that not much would really surprise me at this point. I was wrong for two reasons.

Reason one: one of the ward sisters behind me says "doctor, do you know this baby? I think this baby is dehydrated." She was not talking about the Turf Kid I was seeing. To which I replied, after barely glancing at the baby, "no, I don't know him but I can look at him in a minute, or you can ask one of the other doctors." Now, the definition of dehydration can be interpreted in different ways. That baby was de-hydrated, in the eternal sense. He was one of our severe malnutrition kids. Who at some point in the past hour or two had actually died. And that was it. No calling a code, no resuscitation, no getting excited. This is life, plain and simple.

Death #4.

Reason two: Now, back to KM. KM is 1 year old. He has been admitted twice before, once for failure to thrive, and once for pneumonia. He weighs four kilograms. He weighs a kilo more than his BIRTH WEIGHT. He should weigh at least 10 kilograms by now.

He is not in good shape. I made a list of his problems, they include:
2--tuberculosis exposure
3--failure to thrive/marasmic-kwashiorkor
4--social neglect
9--sepsis/leukocytosis/elevated CRP
10--immunization delay
12-deformed ears (which is important because there could be renal deformities)
13-hypotonia (likely because of NO muscle mass)
Any, by report he is HIV negative.

He is a train wreck. And honestly, I am not sure I have ever used the term TRAIN WRECK for a pediatric patient before. For an adult, sure, all the time. That is normal for adult medicine admissions, and normal medicine admissions usually have more than 5 problems. Train Wreck.

Problem 14 would be the profound sense of helplessness I feel when thinking about this kid.


Sunday, July 13, 2008

Turbid Taps

So, it ended up being a relatively quiet on call. There were only seven admissions yesterday. Apparently, up until about a month ago, this had been the usual number of admissions for a month or so. There have been lots of guesses as to why admissions have fluctuated and have gone from numbers around five or 10 to well over 20. (Last night was likely low because it was so miserably cold). The nursing staff believe that there had been a drop in the number of admissions because people had fled during the xenophobic attacks a few months back, and now that admissions are back up to usual numbers, they believe that it reflects people moving back to the area from the refugee shelters that had been set up. One of the profs believes that we had seen a natural lull with a mild RSV season. Who knows?
We had 7 year old who came in yesterday afternoon looking quite ill. Her spinal fluid, which should be crystal clear, was actually fairly turbid looking. And sure enough, she has meningococcal meningitis. She has the classic definition of board like rigidity, meaning that if you put your hands behind her head and pull upwards, her neck doesn't flex. I'm not sure how long she had been unwell, but hopefully we are seeing her early enough that she may make it through this, and remained neurologically intact.
I arrived on the pediatric ward at about 5:45. Every morning that I get to work, the lights are on. And, a 6 a.m. round of porridge or bottles have already been handed out. Part of me has wondered two things recently. One, are the lights on all night long? Two, do they really really wake kids at 6 a.m. to feed them? And the answer to those questions are yes, and yes. While not all the lights were on the early in the morning, most were. And, I watched as A.L (my two year old who needs his tonsils out) was woken up and give and porridge at 6 a.m. I thought about this while I was at the gym this afternoon, and it does seem a bit cruel to wake of the kids for a 6 a.m. feed... but, part of the reason I am sure it is because there are very few parents on the ward, and the nurses are responsible for feeding the children. So by default, feeds occur on a scheduled basis and everyone eats at the same time. I suspect that give the level of malnutrition these kids live in, they must be hungry more often than not...  
My eight-year-old to has pulmonary tuberculosis for the second time is still here. I technically discharged her on Friday. I was slightly annoyed to see here here yesterday, and quite frankly expected that she would be here this morning. Apparently, they cannot reach her mother to come and pick her up. The one functioning number on her admission facesheet, doesn't appear to be the correct number. Her mom hasn't actually been in the hospital to visit at all since she has been admitted. I suspect, like many of the parents, and that the cost of a taxi, or bus, has been too expensive to come for regular visits. I'm not sure know, when she'll head home.

Saturday, July 12, 2008

Cold Winter's Night

Yikes, it is freezing out.
It's actually felt like a cold Dublin day today. Had that grey hanging cloud cover that never left, a bone-chilling cold, and some mist in the air. It was really, really slow so I actually left at about 5pm. (We're on-call tonight). There were 4 SHOs on, now that one of the others is back from vacation. So not much to do. We'd only had 4 admission by the time I left..
Anyway, we're rounding at 6:30 AM on the old patients (SIX THIRTY AM) and then 7:30 on the admissions from call. This seems a bit cruel, but it means we'll get out earlier tomorrow.
I'm going to pour another glass of wine and read a bit more of Eat, Pray, Love. Which, I must add, is turning out to be a fantastic book. Let me add one last thing. Today it dawned on my that I paid 148 ZAR for the paperback version of this book. At about 7 Rand to the dollar, it works out to be a bit ridiculous for the price of a paperback. I'll add, that the reason to read more was to find something to occupy me so I wouldn't be wasting so much money elsewhere.. Hmmm. I may have to search for a used book store, or one of those places where you go and get books and then give them back.. What're they called again? Libraries?

Friday, July 11, 2008

EBM is bullshit, part 2

I've called this EBM is bullshit part 2, because I've lamented both personally and via email to many about how much I have come to hate EBM. Evidence-Based Medicine.
I find it tedious when rounding back home to discuss which drug, if used in 1.5 billion people is likely to save an additional 3 lives, and was the study well designed, blah blah blah. Let me puke. This doesn't mean I don't practice EBM. I want to be a good doc, so I'll look up the most recent study to see which drug/treatment/witch-doctor potion is best for "X" condition. But I'll also adapt a herd mentality, and do what my colleagues do, and more importantly, what the insurance will pay for... (No use prescribing a novel drug is it cost too much for people to afford).
There is nothing sexy about the mental masturbation of EBM... There isn't really much sex in medicine, contrary to what the TV shows portray. What is sexy though, is when on rounds, the pathophysiology of a condition is explained, when parallels are drawn to other diseases, then the lab results etc are correlated with what's happening at a cellular/tissue level. We're talking medicine in a bikini or thong sexy here. (Aside: Medicine seems to have a lower population of people who would look great in a bikini or thong. There's some irony to that).
I have visions of rounding back in the US were we all pull out our tools (palm pilots!), somebody gets on-line and we debate if 1 or 2 mg/kilogram of prednisone is best for the treatment of a pedi asthma exacerbation (who fucking cares cause the kid will likely spit out part of it, part of it will spill when the jar is opened, and it'll be forgotten on 2 days)...
Rounding here, there's no debate on this crap, there's discussion of why thy kid with nephrotic syndrome has an elevated ESR... (GROAN-what's the evidence behind the usefulness of ESR in the diagnosis of Nephrotic Syndrome-I can HEAR that question being asked by EBM Fans)... There's a 20 minute discussion of using the history to help figure out if an infant with jaundice has a pre-hepatic, intra-hepatic, or post-hepatic problem, and a conversation of what on the clinical exam will rule-in, or rule-out which congenital infection!
Don't get me totally wrong, I am fully aware of the utility of EBM in advancing medicine, but sometimes I just have to think that it's at the expense of the sexy part of medicine...

3 Deaths.

This morning as I made a run for coffee, I saw the Cuban surgeon who evaluated the child who I thought may have had intussusception. And I asked him about how's the child was doing.


Sadly, he did prove to have an intussusception, and in to the operating room, they found dead bowel. The child made it to the ICU, but they were unable to maintain a blood pressure for long. This is the third child to die, or we seem to be averaging about one a call.

I also realized that the child who was in liver failure from suspected Reye's syndrome, had also died.

A couple of days ago, I overheard they few of the pediatric residents talking about the number of deaths from last month, and I don't recall the exact number, but I do recall one of the residents saying "well, you're under 10%." As if 10% were of the upper limits of acceptability. And I hope to point out that this reflects not only to the limitations of services, but also the severity of illness that is seen at the hospital. I highly doubt that the child with intussusception would have survived back home, and he came to the hospital so late.

On Fridays, the head Professor of the pediatric department rounds with the team that is on call on Saturday. Which means that the prof rounded with us today. We made a run through the ward and reviewed some of the unique admissions. It was phenomenal teaching. I was slightly apprehensive that this was going to be another pimping session, and was afraid of coming up with blank answers, but instead it was more of a guided tutorial at the bedside. This is how teaching should be. So we rounded on about six or seven patients with the prof, and there was much to discuss. The depth of knowledge of the prof was fairly impressive.

I diuresed my patient list today.... both Baby S and baby T. were discharged. Fingers crossed, and that we continue to get some adequate nutrition and gain weight. Baby T. is moving out of the area, and I am actually a little afraid that his mom won't follow through on getting him care for his HIV status.

As for follow up, our boy to was admitted with bilharzia continues to have bloody urine, and has failed his first treatment course of which apparently is not usual.

A, my 2 1/2 year old who has right-sided heart failure from an obstructed airway... I spoke to the ENT doctor today and explained the story, and apparently they will see the child in clinic on Monday. He was at least interested in seeing the kid, and his initial thought was that he will have to schedule the child to have his tonsils and adenoids removed.

And the and shocker this morning was going through results and finding out that baby M is actually HIV negative. He is the child who is six months old and has failed to meet most of his developmental milestones, and came in with failure to thrive. It was assumed that his neurological status was due to his HIV disease. His mom was tested on admission, and she tested positive so he preliminarily was considered positive as well based on his clinical picture. (He had other stigmata of HIV disease). Ironically, when I admitted him, his hypertonia and overall condition let me to think that he probably had cerebral palsy. And now that he has ruled out for HIV with a negative PCR, he probably does have cerebral palsy. Thankfully, the occupational and physical and speech therapists have had time to work with the mom and have made a little bit of progress, as well as to get him set up for outpatient care.


Thursday, July 10, 2008


After uncounted unanswered emails and phone calls, lost and then found and then lost and then found and then lost and found again money, I am registered to practice medicine here in SA.
Now I feel like I legitimately belong here. Tomorrow I can start enhancing my skills at IVs and blood draws. I spent 4 hours in Pretoria today getting this finally settled, so was only in the hospital for a few hours this am...

Wednesday, July 9, 2008

In Another World

It started off as one of those days... We're post-intake (call) and so I got to work early so I could round on my old patients, before we did the post-call round and saw all of the new patients.

There were 25 admissions yesterday.
Kiddo A: my 2 and a half year old who has cor pulmonale (heart failure from a non-cardiac cause) has gotten better w/ diuresis, but it is now PAINFULLY obvious that the problem is that the kid needs his tonsils and adenoids out. The cardiologists signed off after they did their echo. Apparently the kid needs a neck xray before the ENT docs will see him. And I fucked up and wrote his name on the wrong list so it didn't get done yesterday!! Argh, wasn't too thrilled to figure that one out this am. Hospital day # 10 for this kid. So, he finally got the xray this am, and I asked about getting the ENT docs consulted. To which I hear I need to get the radiologist to read the xray. Well, at 3pm when all the other urgent stuff has been done, I enquire about getting the xray read, to find out that it has to be read earlier in the day, that they are gone by this time. And, then my coworker guestimates that it could be months before he goes to surgery...
Kiddo K: Day of life #70, born with transposition of the great vessels, with NO shunt who was admitted with sats in the 30s (who knew that was compatible with life), and eventually had an atrial septostomy, and I've been caring for him for almost a week now. We're waiting to make sure the kid gains some weight and to get the cardiologists final blessings before sending him back to his home hospital. Yesterday, we tried a trial off oxygen. He failed. Back to a sat of 30. (his goal is >70). So back on oxygen he went. This am, the oxygen mask is (no nasal prongs his size) hanging close to his air passages, and sats are 60...  
Kiddo K: a cool 3.5 y/o who has some congenital renal/bladder issues (history of posterior urethral valves) who has been in the hospital for a week. Reasons not worth going into. Who I couldn't FIND this am. Don't get me wrong, this happens back home often w/ medicine patients, but not w/ kids. He'd been in isolation on another ward, but we were taking care of him, and he was due to be transferred back to our ward... So, after walking between the wards twice, and looking for the familiar face (and he's a cutie!), I gave up and decided to ask the nursing staff... but, and this is a great part of the day: It was the time of the day where the nurses start their shift with singing. There is no interrupting the am ritual of morning song, and no interrupting morning report (which lasts for an hour). I figure that at some point, the kid will appear (I don't even think the kid should be in the hospital, and I make a mental note to see him before I leave).
So, needless to say, it was a bit frustrating this morning.
But,  there were some really good things about this morning as well. Some of the kids that I have been taking care of for the past week are starting to look much better. Baby S and baby T are both starting to put on a little bit of weight, and are even starting to show a bit of personality. They look much different than when they were admitted a week ago. Instead of examining them from head to toe each morning and a looking for new problems, instead I enjoy picking them up and examining them while I carry them around. In some ways, it feels like a leap of faith to let them leave the ward, which will hopefully happen in a few days.
We eventually got around to starting our post-intake ward around, and again, we hit almost every chapter of a peds  textbook (there was no cardiology stuff today). Some notes I made during rounds.
1-We're taking care of an infant who is in acute liver failure. The reason is not entirely clear. The best working etiology is that we are seeing another possible case of Reye's Syndrome. There was debate on the ward round as to whether this kid was a candidate for intubation and for the intensive care unit. After some lengthy debate, the child was intubated after discussing w/ the ICU if there would be room for him.
2-We admitted two children with diabetic ketoacidosis, both are new onset. It was oddly refreshing to see a medical condition which I feel fairly comfortable with. However, I realized that my usual management was a bit different. Whereas, one of the new onset kids was in mild DKA, and could have been managed with subcutaneous insulin, both were managed with IV insulin coverage. I was also curious to see what kind of insulin regimen these children would to go out on. It looks like we will be covered on three times daily regular insulin and then intermediate insulin at 10 p.m.
3-We had another organic phosphate poisoning. We seem to be averaging about one on each call.
4-I admitted a three-month old who has been jaundiced since birth. This is the first admission for this condition for this child. I can't quite piece together all the details, but apparently when the child went for immunizations yesterday, the general practitioner noticed the jaundiced and referred the child to us. I am not sure how the jaundice was not noticed during the previous immunization visits. The working diagnosis is some form of biliary atresia. However, just before leaving, the CMV came back w/ positive IgG and IgM... perhaps this is fallout from congenital CMV?? I need to read up on that tonight.
5-Mumps: We admitted a child with mumps as well last night. However this is not just simple mumps. This child also has bilateral ear infections, is malnourished, and likely has HIV +/- TB.
6-Congenital Myopathy?? We rounded on a new three-month old who is admitted for hypotonia. We're talking flaccid like a rag doll. And she's been this way since birth.
7-Pneumococcal pneumonia...
8-Hep A: were seeing a three-year-old who was diagnosed with hepatitis A a few weeks ago. However she is having worsening jaundiced and appears to be going into liver failure.
So, it is quite a busy service....
I kept a list of things to read up on tonight, but it is too extensive to hit all the topics.

Sunday, July 6, 2008


We were on intake (aka call) Friday night. Basically 24 hour admissions, and it was a light call with only 16 admission or so. The process goes something like this: Kids with medical problems are seen in POPD (Pedi Outpatient Department-AKA pedi ER) unless they are a trauma, in which case they are seen in the trauma unit (flashbacks to 2003). They docs in POPD do their stuff, and it seems like kids can be there for a while.. initial hydration attempts, maybe x-rays (not usually labs). If it looks like they are going to need admission, they are shipped over to the Admission Ward (Ward 36). This to me is brilliant!
Once we'd finished most of the days chores, the team essentially splits up. Some in our ward, and then the others headed to the admission ward. The ward is half admission, and half "High Care" Like a step down Pedi ICU. Though, that being said kids in high care may be vented, and waiting to get in the combined adult-pedi ICU. Admissions are split up, histories taken, x-rays done, labs done, etc etc etc. 
[reflections back home: I've often thought this is how our medicine service should be run. If they obviously looks sick, and are stable, the IM residents should do the bulk of the work up and initial management. ED decisions seem to often function at the brain stem level, not the cortical level. Sick lefts just pick 2 random antibiotics and give them, who cares about cultures before abx etc.. I digress]
Random pts from intake (not mine, but since admissions are a team sport you basically see all the kids).
An 8 month old sent in for question of gastro. The strikingly obvious thing was that his belly was HUGELY distended. You could almost make out the loops of bowel pressing on the skin. Shit, this is not gastro... Someone asks-Ileus? Maybe. We're doing IVs and blood on the kid, and he doesn't even flinch. The red flags are literally dropping from the ceiling that there is something really, really wrong here. I'm having a slight bit of anxiety at this stage cause I'm banking that this kid has intussusception! (Some know my intussusception stories from back home, so I always hesitate to bring up the I-word). This kid is not an ileus, he's gotta be full on obstruction. We get the abd x-ray, sure enough huge fluid levels, totally obstructed. Incidentally, the kid did have a CXR in POPD, which we saw after the abd x-ray, and even on the CXR you could see fluid levels. Pedi Surgeon (super guy from Cuba) comes over, he's pretty sure it's intussusception, and likely bowel necrosis by this point, and is going to get an  ultrasound. Now, even during normal business hours, getting an urgent ultrasound is a bit of a challenge... All I know is the kid went to surgery for likely intussusception. No idea how he did.
4 month old comes in with a sat in the 70s.... Blue. Supplemental oxygen and admit to the ward.
11 y/o boy admitted with Bilharzia. (Google or wiki it). Bilharzia! Looked at his urine under the microscope and boom-diagnosis made. That's good stuff.
I like the team sport feel to admissions. Nice to have everybody there, a procedure room-do bloods, lumbar puncture (spinal tap), and IV in one swoop.
When the kids are transferred to the ward. The sisters (nurses) wait until there are 3 or 4 who are ready to go, and regardless of the age they are placed on one of the famous red gurneys and covered with a blanket. A strap is placed across them to keep them from rolling off. I saw 3 infants and an 8 yr old on the same gurney.

Saturday, July 5, 2008


Two babies. Infants really, but they are so tiny I think of them am newborns. I've been taking care of them all week.
Baby S. Is 8 months old. He weighs 5 kilograms (11 Lbs). Pathetic is the word that best describes him.  He came in with vomiting, diarrhea, having been given some muti (spelling?)- or traditional meds. He is the definition of a marasmic kwash. He is wasted in size, and also edematous. He has strep viridians growing in his blood culture, and e coli in his urine culture. His lips are cracked and peeling, his perineum (the part that sits in a bike seat) is also excoriated, and raw. It's painful to look at. He usually stares off into space. He makes an attempts at a cry when examined. Again, he is 8 months old. He doesn't sit up. He doesn't roll over.  His mom is HIV +.
Baby T is 4 months old. He weighs 5 kilograms (11 Lbs). He came in with one week of gastro (vomiting, diarrhea). He was acidotic and ill appearing on admission, required aggressive fluids. He doesn't have anything growing in his cultures. He isn't marasmic, or kwashiorkor. His mom is HIV +
Baby S should weight 8 kg/17 lbs
Baby T should weight 6.5 kg/15 lbs
Both have gotten better as the week has gone on, both are off of IV fluids, taking in formula, and even have gained some weights. Both have been tested for HIV. It's been tough to think of HIV status as another label for all of these kids. I sometimes just think that all of the kids are HIV positive, they look so small and sick, it's hard for me to grasp that this can be the sole result of not getting enough nutrition.
Enough nutrition. This hasn't really been a problem in my training thus far. And, in fact, we deal with TOO much nutrition. We have a "chunky" baby who looks like a normal baby to me. But this kid looks chunky here. The other day as we were doing bloods and IVs, I tried to explain how we have to counsel parents on LIMITING junk food, eating veggies etc.
So there are all these new factors to deal with. HIV status. Nutrition status. I've been trying to link HIV status with overall appearance. Like, if an infant has TB, then that kid must have HIV as well??
And this week I learned that you can't tell.
Baby S is HIV negative.
Baby T is HIV positive.
The only way to tell is to test.