I'm not just picking a job

I'm not just picking a job. I'm defining myself-to some degree. I can't recall the last time I agonized so much about a single decision. Choosing residency was easier than this. The decisions for university and medical school didn't have much competition.

 

May 28th, 2008 I took a hike. It was a Wednesday. I had been on night float the night before. Had gotten off of work. Been to the dentist. I must have taken a nap at some time. And it was a gorgeous day, so I made a break for a trail. Just a chance to get out and get some fresh air, and maybe a fresh perspective. I stopped into a bagel shop, grabbed a bagel sandwich, popped into a liquor store and grabbed a cold beer, and hit the trail. I ended up sitting down on a rock in the middle of a small river, and watch as the water crashed over a waterfall hitting a pool below. And I just sat, enjoying the solitude contemplating.

Contemplating bigger issues.

 

Why did I go into medicine.

What did I want to do.

 

I made a list of the things I wanted to do:

-work with MSF

-work on Everest Base Camp for a season

-work in a rural hospital

-work in an inner city hospital

-complete a tropical medicine course

-volunteer with UNICEF

-have a faculty appointment somewhere

-work in Alaska over the summer

 

And there are a lot of things that aren't on that list, that have crept into my thoughts since then. I'm trying to juggle income, finding the job which will allow me to take care of kids and adults, the patient population I want to take care of, the ability to have time off to get back to Southern Africa/Central America/South America.

 

[Courtesy of White Snake]:

 

Here I Go Again
I don't know where I'm going
But, I sure know where I've been
Hanging on the promises
In songs of yesterday
An' I've made up my mind
I ain't wasting no more time
But, here I go again
Here I go again
Tho' I keep searching for an answer
I never seem to find what I'm looking for
Oh Lord, I pray
You give me strength to carry on
Cos I know what it means
To walk along the lonely street of dreams
An' here I go again on my own
Goin' down the only road I've ever known
Like a drifter I was born to walk alone
An' I've made up my mind
I ain't wasting no more time
I'm just another heart in need of rescue
Waiting on love's sweet charity
An' I'm gonna hold on
For the rest of my days
Cos I know what it means
To walk along the lonely street of dreams
An' here I go again on my own
Going down the only road I've ever known
Like a drifter I was born to walk alone
An' I've made up my mind
I ain't wasting no more time
But here I go again
Here I go again
Here I go again
Here I go again
Cos I know what it means
To walk along the lonely street of dreams
An' here I go again on my own
Going down the only road I've ever known
Like a drifter I was born to walk alone
An' I've made up my mind
I ain't wasting no more time
An' here I go again on my own
Going down the only road I've ever known
Like a drifter I was born to walk alone
Cos I know what it means
To walk along the lonely street of dreams

 

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Running, Again? Running, Away?

I don't think it was a whim, but I don't know why I stopped out of the blue to buy new running shoes. I hardy run these days. But I did, and I shelled out the bucks for the new shoes (the current version of the shoes I've been running in since August 2004), as well as some fancy socks and a shirt. And then I came home, chatted with my flatmate, had a glass of wine, and pondered going to bed. Realizing that I should put those new shoes to use (if anything to justify the ridiculous price of 75 US$, I mean that'd do a long way for some friends back in SA), I abruptly stood up from the table, finished a generous gulp of wine, and went and changed to go running.

I put on my ipod to my running mix, the same mix of 164 songs that I've had for years, and set off. I turned the corner and headed down Route 5. I don't know what it was that took me back in an instant to that first night I ran in Dublin. Maybe it was running along a busy road (there, it had been South Circular Road), maybe it was the cool, misty night air. Maybe it was knowing that my legs were going to be sore in the morning, as I was biting off more than I should by hitting the pavement, but I felt like I'd gone back in time. And for a few blocks, maybe a mile (I wish I could say a few miles), I kept having flashbacks to my running progress in Dublin. After that first run, I couldn't run for a week. And then I ran around a park for a while, a meager few blocks, and then I was running more. Running along the River Liffey. Running through Dublin-no longer embarrassed to be out running. As I changed my running route, I discovered new areas to run in Dublin. New Parks I had never explored. New pubs which I made a mental note to check out, though usually forgot about once I got home. When a certain song plays when running, I can recall exactly where I was in Dublin during certain runs...

I turned the block, and ran past an Indian restaurant. And that triggered a flashback to a night when I went running during my intern year. A cold night. I'd run from my flat, down to the hospital, and around a neighborhood. I'd run past Gabby's house- and saw she wasn't home, and I wasn't sure why she and I had not talked in a few days-both busy I'd suspected. The Indian restaurant I was passing is where she took me for my birthday, and the conversation that night is permanently etched in my memory. We were going to make the world a better place. She wouldn't let me sell out, and as I ran, I thought what advice she'd be giving me now. "Fuck those job offers, are you kidding me, there are people out there who really need our help." She didn't hold back. And I miss that. She gave me coffee and a tie for my birthday. I don't wear that tie nearly enough. Maybe I'll wear it tomorrow.

I was lost in thought. Am I running to somewhere? Or am I running from something? For months I've agonized where my paths is going. I've solicited (both bluntly and circuitously) the insight from friends, sometimes hoping that one or two of them would pin me down and spell it out for me. Because I cannot see the path anymore. When my world crashed in July and August, all I could think of was Denver. On more than one occasion in the past 4 months, I contemplated flying out to Denver the following morning, fuck residency. Having the support from my family when I did see them in July, and the joy of hanging out with nieces and nephews, combined with the awesomeness of Denver made it clear, that Denver is where I thought I needed to go, and the ball was set in motion. On a Saturday in September, after Randall's memorial, I was sitting outside drinking margaritas and chowing down Nachos, surrounded by a great group of people; it was again evident that Denver is where I was headed.

I was lost in thought, until I saw a dodgy person on the sidewalk with a German shepherd. I'm in a residential neighborhood, in a safe part of town. This is not Johannesburg. I am safe here. He nods as I run past. More than once, in Jo'burg, I had crossed the street, or taken a turn and changed my path when I was running and saw a group of people on the street at night. It had taken me months to work up the courage to run there. I miss running in the nature reserve; I miss seeing zebras and wildebeests on runs. I miss Jo'burg, period. And then I heard Gabby again, and I wonder if I am running from the thing I really want to do, to oblige the banks who loaned me the vast sums of money so I could get to this point.

As I reach the driveway, the only Jewel song in this mix, Who Will Save Your Soul starts playing. I smile as I stretch. Maybe the answer is neither. I'm not running to nor from somewhere/something.

I'm just running...


BPB

Running into the Sunset

I debated, hard. Opening my bottle of Meerlust and watching the sunset versus a run. I needed something. I needed to appreciate the dusk. It was a perfect cloudless Jozi evening, and the sunset was going to be superb, and I was not sure which would be the better way to appreciate it, a glass of fine wine, or sweating and pounding the pavement.

I gave my Swiss housemate a ride into town today. He is going to be leaving the house and will be living on part of the Wits campus--the old Johannesburg College of Education Campus. At JCE, I showed the guard my Wits Staff ID card, and we drove into the campus. And I dropped him off outside Gyrton Hall. And unexpectedly, a flood of memories were unleashed. Almost exactly 5 years ago to the date, I was dropped off, outside Gyrton Hall, by a taxi, and a few days later I would be getting ready to start my rotation at Bara, as a medical student.

 

From there, I left and headed over to 44 Stanley, home of my favorite coffee roasters. When I was there a few days ago, the head Barista and I were chatting and he told me I must stop by again before I leave Jozi. So I popped in this morning to enjoy my new favorite coffee drink (a PICCOLO- a strong, sweet latte served in a 90ml glass), do a bit of work, and then chat with the Barista. It was slightly embarrassing a few days ago when we did finally chat. For some reason, when he found out I was leaving, we just ended up having this great spontaneous conversation about being foreigners, and life etc. Turns out, he is a Zim refugee, who was a high school teacher before he was forced to flee Zim. (Does this sound familiar)? Anyway, when I headed to the till to pay, he handed me an SA music CD, as a gift. Needless to say, I was shocked at the kindness of this very humble ex-teacher-now-barista.

 

From there I may my way to Parkhurst, where I had a late breakfast with one of my ID attendings. We chatted and ate for 2 hours, catching up on clinic business, as well as possible future plans for pursuing a Trop Med course (she's pushing for me to consider the program where she went). Suddenly it was approaching 1pm, and I was overdue at the HIV clinic for lunch. We parted and headed to Bara.

 

I joined the HIV team for lunch, AK and I chatted for a bit, and then we walked to the xray department to consult the radiologists on a patient he was seeing, I ended up in clinic and made a round to say farewell to the other consultants, as well as the counselors, and then I headed to Ward 18, my old ward. My favorite pediatric nurse and I chatted for a bit, took some pics, and while I was there, the Registrars I worked with were there for a pedi infectious diseases round, so it was marvelous running into them and having a bit of closure. And then I departed for home.

 

And driving home, thinking about packing up my room, it just suddenly hit me that this was, or is, my last night in Mondeor. I made a cup of coffee, mulled over things, and then it was obvious-I could time it perfectly so that as I ran away from the house, I'd see the blue-purple haze hit the hills, and when I reached my turn back point, I'd capture the best part of the sunset. And that's what happened. Finally, after many attempts, I capture it perfectly. I went to the nature reserve, stopped to watch the stars, and the brushfire off in the distance..

 

Now it is late. Very late. I'm half packed. The bottle of Meerlust has enough wine for one glass (I took it to my landlord's house as we watched SA lost to Brazil and discussed life and their departure for Kili in the morning).

 

That is it. Off into the sunset. A year at Bara is over.

 

Thanks for reading these posts.

 

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One Last Time.

I want to do it one last time... "It" is a long list.

I want to do for one last sundowner at the Westcliffe.

I want to spend a summer evening at Lulu's after work, sitting outside reading and drinking coffee.

I want to be having breakfast at Espresso, hung over (mildly), laughing about the previous night.

I want to go back to Simply Blue on Pride night.

I want to sit outside at Mandela Square, during the week, in the middle of the day, eating sushi.

I want to take the minibus to work.

I want to see the Apartheid museum one more time.

I want to drive on the M1, amazed at the people walking along the highway, on their way home from work.

I want to be back in Nepal, back in Lesotho, back at Vic Falls, back in Cape Town, back in Clarens.

I want to be back in Ward 18 (especially now that I know so much more than a year ago).

I want to run through the nature reserve, stop, look at the zebras wildebeests and blesbock, and still be shocked that they are down the road from my house.

I want to the miracle of people coming to the HIV clinic weeks later, healthier, not dead.

I want to be in the pediatric cath lab with the peds cardiology team, learning and laughing.

I want to be at the airport, seeing the look on S&S face. Not sure if they are more confused because I've returned with only the clothes I'm wearing, or if they are more amused that I can't figure out how the hell to get to where I parked my car.

I want to spend a Saturday at Bean There studying and reading, and then meet up with friends in the afternoon, and end up back at home Sunday night.

 

What do I still want to do.

-nil-

-nada-

-zip-

-zero-

-zilch-

I've done it all. I'm cleaning and starting preliminary packing, and I just saw the list that I made a year ago. I did every single thing on that list. Life is too damn short to make lists of things to do, places to see and to not scratch items off that list regularly.

 

Back to cleaning..

 

-

 

New Pics

Pics from the Sani Pass and from my farewell braai are now up:

 

http://picasaweb.google.com/BackToBara

 

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Bakers Chocolate

This is what I remember. It was winter, and we were on winter break. I was in third, maybe fourth grade. Our grandmother was visiting, and she was legendary for her cooking. And her baking. Our parents were at work, and she was baking away in the kitchen. I'd been hanging out, hoping for left over brownie batter. It doesn't get much better than having warm freshly grandmotherly-baked brownies on a wintery Colorado day during school break. Well, maybe it would have been better had the brothers not been around and I'd gotten both of the beaters and the brownie batter.

 

But I remember watching her put away the chocolate as she cleaned up the kitchen while perfection was cooking in the oven. And I made a mental note to remember where the chocolate had been stashed. And enjoyed knowing that the brothers didn't know about this secret stash. And at the opportune time, when the house was quiet, I made a break for the goods.

 

It's the anticipation of chocolate that I like. Knowing that I'm going to be enjoying one of the most pleasurable tastes of sweetness. Taking a bite of chocolate and letting the chocolate melt as the butteriness of the flavor comes to life is as blissful as that first sip of a great cup of coffee.

 

That's the level of sweetness that I felt on Friday. I was in my surrogate home, the place which has been my refuge while here in Jozi. S&S and I were setting up for my farewell braai (http://en.wikipedia.org/wiki/Braai), and Scott and I were talking about what I was looking forward to, when I get back to the US. And how sweet it will be to see my family and friends again.

 

As I grabbed the bakers chocolate, I took off a piece, for eating the whole thing would raise suspicion. And with that first bite, the shock of the bitterness of Bakers Chocolate was an unwelcome surprise to the expected sensation of sweetness.

Why the hell would there be such a thing as "bitter sweet." And why wouldn't they make that more clear on the damn package.

 

I came here to Jo'burg this year, and had one simple goal. I wanted to learn about TB, HIV, and pediatric malnutrition. Those were the absolute goals. There were other minor goals, but those only involved travel plans. As we sat around and ate Friday, I realized that this year has been far more rewarding than I could have ever imagined. I remember those first few weeks when I arrived here, having a few contacts from mutual friends, but having not really met people, and thinking that it would be a monk-ish year, filled with days at the hospital, then evenings of going to the gym, then reading about patients in the evening.

 

I would have never imagined that Jo'burg would become home. And that the emotions of preparing to depart are emotions I last felt almost 9 years ago when I left Colorado. The work has been rewarding in ways that are much different from practicing medicine back in the US. But on Friday, I realized that I've been fortunate to amass a beautiful collection of friends. And as I've thought about my impending departure, I though about how much I'm going to miss them. On Friday, my friends were South Africa, Dutch, Swiss, Spanish, Argentinean, American, British, Belgium, (and maybe one or two that aren't coming to me right now). And there I was surrounded by my closest friends as we had a farewell Braai The mixture of friendship, feast, and wine was perfect.

 

Like the bakers chocolate, there was bitterness. Bitter that I'm leaving this behind. The friendships will continue, the work will be here shall I be able to return in the future, but all of a sudden I find that I am not ready to head back to the US, and slightly bitter that my departure is now less than a week away...

 

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Whoa!

Back from the Sani Pass yesterday. Was beautiful. The 4-wheeling was great fun.

 

But now, it's full throttle right now. Like a maniac, I'm trying to sell my car (and wow, what a fun experience this is turning out to be), trying to finish my research project (and wow, I'm even further behind than I thought, after talking to my advisor today), trying to decide what to pack (and wow, I have a lot of crap, a lot of which is outdoor equipment I already have in the US), trying to get the post office to find my stuff (and wow, they may give some reimbursement-too bad I can't really recall what was in there, as well as the fact that the most precious thing has no value).

 

I'm in a bit of a whirlwind right now, and am so aware that these minor hassles are a small "price" to pay for such a great year...

 

I slept under the stars Monday night and tried to reflect. I couldn't really reflect because I had a migraine headache, was sleeping outside because the B&B was too noisy, and it was freezing. I thought watching for shooting stars and reflecting about the past year would bring me to some profound thought that I could summarize, and would help my migraine go away. My migraine didn't go away. And I didn't have profound thoughts. But I did see, perhaps, the most brilliant shooting star of my life. And for some reason, enjoying the moment solo, cold, and in discomfort was perfect.

 

The next few days are occupied with the above tasks. Selling my car. Packing. De-cluttering (just will let you guess what that means). Haggling with the post office. Finishing my research. Enjoying time with my friends. Implied in this, is drinking boat loads of coffee (and likely wine).

 

Departure from Jozi: Saturday June 27

Back to work (in the ICU for a few days, if you can believe that one) July 1.

 

-

Briefly

Last official Bara shift starts in 8 hours.

I need to finish packing for my last adventure in SA.

Back in a few days.

 

 

 

BPB

Deflated.

Mail theft.

 

That was the straw that broke the camel's back today. Long night in the ICU, with a few hairy hours due nursing oversight, 4 calls in one week, getting scammed by the auto-dealership (they tried to replace a part which they replaced last time, which seems to still be working fine). And then finding out that packages that I mailed to CO and MA are gone. Gone. Gone. Gone. That little tracking number means nothing.

 

I have purposely not given out my address so that I wouldn't be disappointed when things got stolen before coming to me, but had falsely assumed that stuff I mailed out should be safe.

 

Sadly, boxes of books, a box of gifts, and most of my Nepal mementos are likely on eBay or some similar website. In a lapse of judgment I packed up some of the relics I had purchased from the Tibetan Refugee women, including the prayer wheel that I'd finally found, after days of searching for one that I liked. And it had more meaning than that...

 

I topped off the lackluster, post-call day, with a great run in the freezing drizzle. (BK-my motivation to run). I craved some comfort food. Mom's meatloaf would have been great. Grilled cheese was a decent second place. 

 

4 more official shifts at Bara. And then that is it. A year at Bara is over.

 

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Making the Call

We get back to the call room around 3am. I am aware that if I fall asleep immediately, I can get almost 2 hours of sleep, barring any problems, until I need to do my next round. Of course, I cannot fall asleep. I have been up since 9am, and have been at work since 2pm. And I won't leave work until sometime past 6pm. I guestimate that I am somewhere at the half-way mark of of my shift. Aside from trying to figure out how many hours of work I have left, I am making a mental note of things I need to look into. Why is our 35 year old male who his HIV+, with a low CD4 count, and who has Guillian Barre syndrome having high potassium levels? Why is our 20 year old female who delivered a term baby boy a few days ago having severe pulmonary hypertension.

 

The night has been a doozy. We are short one resident/registrar. I am covering the pediatric ICU patients , and the medical ICU patients, and the other resident is covering the surgical ICU and the step down ICU patients. Needless to say, we are taking a moderate beating.

 

And then the phone rings. My thoughts grind to a halt.

"ICU"
"Eh, Dokotela, um, there is a pediatric admission here."

"What?"

"We didn't know about a pediatric admission."

"Neither did I!"

 

Since we are short-staffed, of doctors, and barely hanging on, we are actually trying to not take admissions tonight. We're evaluating potential admission on a case-by-case basis. I have been on the phone with the trauma surgery resident on-call and have helped them manage a patient who may need ICU in the morning, and I have been on the phone with the obstetrics residents helping them manage a patient a well, but technically we have not accepted any patients for admission. However, there was one sick kiddo in the pediatric admission ward, but he sounded ok earlier on, and we hadn't agreed to accept any kids.

 

"Eh dokotela, can you come quick."

"Sure."

 

I grab my stethoscope and glasses off the desk, and the other resident and I head into the ICU. It takes a minute for the scene to register in my brain. On opening the doors to the ICU, I see across the ICU, one of the pediatric residents that I know, doing CPR on a child--on a child, on a gurney in the middle of the ICU. I am a little perplexed. Well, more than a little. Quite frankly, I can't figure out what the fuck is going on. I quickly look to my three kids in the ICU, who are all asleep in their beds. I get to the gurney, and it is a newborn size baby being resuscitated. My brain goes into resuscitation mode. The details which lead to this point are completely irrelevant. I want to know those details, but I'll get them later.

 

The child is intubated. I relieve the pediatric resident from doing CPR as I slip my two hands around the child, and use my thumbs to and fingers to compress the thorax, hoping to generate enough blood flow to perfuse the vital organs.

"He came in tonight."

I'm compressing, seeing the heart rate on the monitor. The heart rate that is being generated by my hands. "Epi please." She calls out the dose of adrenaline. I'm using North American terminology. She is translating, and giving the doses.

"2 weeks old. Took some muti [traditional medicines]. Very sick on admissions."

He's easy to do CPR on. The nurses and I are synced. He's not trying to give the baby a breath while I am compressing the chest. "Labs."
"Severely hypernatremic [sodium too high] and shocked. We're worried about Congenital Adrenal Hyperplasia."

"He's the right age. How much fluids? Can we give bicarb please. Has he had steroids?" She tells me how much fluids he has had. I'm going to give him more. This is a gorgeous infant. It sucks he is going to die. He has this adorable curly black hair.

"How much?"

"40 per kilo."

 

She and I review. We give calcium to try and correct for high potassium. Sugars were fine. I stop doing my chest compressions There is no longer a rhythm when I stop. 20 minutes ago, when we started, there were some heart beats, but now they are gone. I look at this child. His skin is mottled.

 

And I realize, that I have to make the call.

"Does anybody else have any suggestions?" I look to all of the nurses present. I look to the pediatric resident. I look to my co-resident in the ICU.

 

This is one of the first lessons I ever learned in medicine. And it took me a while to understand this lesson. It was February 1994. I was doing my first Emergency Department clinical as an EMT student. One of my friends and I had signed up for a Sunday night shift. And it was off to a painfully slow start. And then the ambulance phone rang, and the report was a cardiac arrest coming in, due to arrive in a few minutes. This is what you wanted as an EMT student, to see some "action" on the clinical. We stood outside the room as they wheeled the guy into the ER resuscitation room and tried to revive this man. And then the firefighter doing CPR had pointed to me and told me it was my turn to do CPR, I froze. This didn't seem like the time to learn how to do CPR on a real person. The guy was sick, and needed somebody who actually knew how do to CPR.

 

After what felt like an eternity of doing CPR, I remember the ER attending doctor saying she thought we'd done all that we could, and then she asked "does anybody else have any suggestions."

 

And I'm sure my eyes nearly popped out of my socket. For, at the time, I remember thinking that she was the "doctor" and should very well know what the hell to do. And in time, I realized that it was a courtesy measure to see if the entire team was in agreement that an adequate resuscitation attempt had been done.

 

So, I asked the team in the ICU for other suggestions But I balked at the responsibility of actually making the decision to stop the resuscitation efforts. I knew that nothing would bring this child back to life; but only doing resuscitation for 20 minutes seemed pathetically short. A 2 week old child, who was alive shortly ago was now going to be declared medically deceased, and was I willing to decide this after 20 minutes in our ICU. I asked the reg who her consultant was. Turns out she is on my old ward, and I knew the consultant would feel we had done an proper resuscitation given the circumstances, of which she'd been informed earlier when this child first showed up for admission. So the resident called the attending who was updated on the events, and the course of our resuscitation attempts, and she was in agreement that the resuscitation attempts should be stopped.

 

"Can we please stop." And a silence fell over the unit. Alarms beeped in the background, but silence fell as there was a collective sense of loss. I thanked the team for their help in the resuscitation (another lesson I learned that February night). I examined the child from head to toe. "Sorry nana."

 

I would have never thought that, 15 years ago, on that February night, that I would someday find myself in Soweto, resuscitating a 2 week old newborn male, having a flashback to Dr S and the first resuscitation I had ever seen...

 

-

 

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PICU Bedtime

This actually belongs under the heading of "More Things You Can't Make Up."

The child in bed 18 in the pediatric section of the ICU has been in for almost 2 months. He is a 7 year old who has an undiagnosed, but improving neuromuscular condition which has left him with paralysis. He's had a stormy ICU course. But as I said, he's improving. And part of the goal is to start normalizing his routine, to the point where he's getting back to a normal eating schedule, and trying to get him on a normal wake/sleep schedule.

So, last night, when I did my 8pm round, he was asleep. With the lights on. So I searched for the switch to turn off the lights in his room. And I couldn't find the bloody switch.

"Excuse me," I said to the nurse taking care of him, who looked slightly annoyed I'd interrupted him from reading the paper, "where's the light switch?"
"Why."
"Because he's asleep, and I'd like to turn out the lights."
"Sorry doctor, the order is written to turn out the lights at 10pm. I'll do it then."

I can't make this shit up!

After a few days of being utterly annoyed by the nursing staff, I had decided I would take the lead from Fatima, one of my co-residents tonight, and just smile and go about my job. But this was a serious test to my smile capability. It dawned on me that I am, in fact, the doctor taking care of him, and I could be passive-aggressive by cancelling the order that is written for lights out at 10pm, and write a new order for 8pm. But I was so flabbergasted at the lack of normal comprehension by the nurse that "turning the lights out" was a pretty flexible order, that he couldn't see the ridiculousness of his reply. But, again, it confirmed my thoughts that the majority of the nurses here work on a "tick-box" mentality. I have a task to do. I do it. Tick. Done. Back to my newspaper.

So I thought, what would Fatima do?

So I dropped my ego, laughed to myself thinking that I would have to tell this story to the attending in the morning, and just moved on to the next kid. And when I, on rounds, recounted the story, it garnered the humorous response that I hoped it would, and I knew that my colleagues on rounds felt the same way.

"Please change the order, to turn off lights when patient is asleep at night."

ICU madness

Wow, I have strayed from the pleasantries of the HIV clinic.

 

"I've had it up to here," I said, with my hand above my head. I was standing in the middle of the ICU talking to Linda, one of the pediatric ICU consultants who was looking at xrays. She's been one of the few persons who seems to be keen to improve standards, and when she hears about events which need to be addressed, she addresses them. (I'm keeping this vague for professional/legal reasons, but ask me in person and I'll gladly tell you stories).

"What do you need"

"Well, 2 milligrams of midazolam IV, now would be helpful." [midazolam, a sibling drug of valium]
"For who?"
"Me!"

 

It was just that kind of day--today and yesterday. Half the residents are new. We're short staffed on the resident end. We have some really, really sick patients. (I know that sounds slightly ridiculous, I mean it is called the Intensive Care Unit so one would expect that the patients would be sick, but on the spectrum of sick, we're at the extreme level). Our ICU team today got the major shaft of covering all the 5 admissions that I did yesterday, plus the 5 sickest patients in the ICU... And in the midst of this morning, I decided I no longer was concerned about making friends with the ICU staff. My competence has been proven to my colleagues, and especially to the consultants/attendings, and I no longer give a fuck if the "nurses" and I do not strike up a friendly relationship. Enough said in the blogosphere on this issue. Argh!

 

It doesn't help that I made a schedule trade because I had a call next week which conflicted with other plans, and so to fix the schedule, did a trade which means that I now have 4 calls this week, and one of those calls will be this Friday night, and we'll be short one resident...

 

But I see the light at the end of the tunnel. My ICU time in limited. I've been in the ICU for over a month now, and feel fairly comfortable operating in this environment. And, at least when I'm on call the next few nights, I get to cover kids. And Linda is the attending on all week.

 

So, I'm hunkering down for a long week.... and to boot, am on for 2 weeks in a row.

 

Thank you, the whining is over.

Kruger Pics

Check out: http://picasaweb.google.com/BackToBara for pics from Kruger

 

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Kruger Day 3

Here kitty kitty kitty..

I know I skipped day 2. Woke too tired to get out of bed. The goal had been to leave at 6am. Who the hell gets up at 6am on vacation, from a warm bed??? Ug. Drove around for a few hours once I did get up. Saw hippos, elephants, giraffes, and other things. No damn lions. Came back to my hut (I'm not kidding) did a bit of reading and a bit of work stuff, took a glorious nap, and then went on a night drive safari. Just like the TV show, had bright spot lights to look for the reflection of eyes in the dark. Saw a white Rhino and some other non-cat animals. Had to listen to the constant moronic babble from the people behind me. And wondered why I didn't bring whiskey along. Oh, and during the morning, as I came back from the communal kitchen with hot water for *gasp* instant coffee, a little twerp monkey ran away from my kitchen area (it's in front of the hut) with my yogurts!! And then a few hours later, as I was stopped at a picnic area, admiring the view of a river, a little twerp monkey jumped up from my feet (I didn't even know he was there, I was lost in thought-but people looking on witnessed the entire event) and grabbed my apple out of my hand and ran up a tree and ate in in front of me. Bastards. I am thinking that shooting monkeys may be permissible

I compromised with myself today, and decided a 7am start time was realistic. And low and behold, was rewarded with a few lions and cubs this morning. Well, not infant cubs, they looked older. Got some pics, and then felt let off the hook. I've seen 4 of the Big 5 Animals, just needed a leopard or cheetah (honestly, what's the difference) and was setting my expectations low. 4 of 5 is 80%. I can live with that.

Drove around a bit this afternoon. Stopped at a lunch spot and started reading "Left for Dead" which is Beck Weather's account of the failed 1996 Everest climbing expedition. And then I drove to a hide. I turned off the car, manually locked the door as I didn't want the beeping of the car alarm being activated to put me on bad terms with those in the hide. These folks are serious! Got to see some animals from the hide. There were some overzealous photographers there who were too serious... They got all pissed off when a car alarm beeped twice as the hit the button before getting in the car so that the alarm didn't go off. To which the serious photographer remarked to his wife "asshole using his hooter."

[note: hooter is South Africa for horn. Not like the American Hooters. Either form of the American Hooters]

Anyway. My laptop was in the back of my Bakkie. I have kleptophobia (the fear of having things stolen-ever since my car was broken into a few years ago), and so, I tried to remotely lock my car while I was in the hide. I figured the serious photographers wouldn't know it was me. I kept hitting the button, but did not hear the "beep beep" of the alarm turning on. C'est la view. When my kleptophobia got the best of me, I decided I would leave the hide. As I started to sit down in my bakkie, I wondered why the alarm light was blinking out of sync. Sadly, I couldn't stop the downward pull of gravity, and as I rocked the car, my car alarm went off.

Yes, thank you very much. I again, fucked up at the hide. Bye bye animals. I could almost hear the serious photographer mutter "asshole." Apparently, when I had hit the button to engage the car alarm, it had worked, I just didn't hear the beep beep.

When in Africa... I'm glad I've done the safari thing. It's been a successful trip. I've seen lots of game. Have finished one book, and am starting another. Have even gotten a bit of work done. But at the end of the day, give me my backpack, and mountain solitude, where not encountering animals is often ok (bears for instance).

You can take the boy out of Colorado, but you can't take the Colorado out of the boy...

-

Kruger Day One

Wow. I'm in a fog. I got up just past 3am this morning to drive a few hours east to the Kruger Park. I wanted to maximize my time here in the park, and so wanted to arrive in the early morning in hopes of seeing some animals before the day-time sun drove the animals to seek shelter from the heat. I managed to get just over 4 hours of sleep last night, but of course, was post-call and hadn't slept all day. It had been a great day. Left the ICU, went to the gym, then went grocery shopping (for my trip) and then home to pack a bit, and then back to work to plug along on my research project.

 

Then, Celine (an ID fellow from Hopkins who is also here for a year), her husband, and few peeps doing Epi from Hopkins came by for a tour of Bara. It was great as we were able to make a general run through NICU, Ward 36, Ward 18 (where sister Nicah-one of my all-time favorites was on-duty), and then ICU and medical admissions.

 

About ward 18-the other day I was walking outside along the corridor, and as I looked into ward 18, this kiddo waved at me. He had the open-close hand wave. He's tiny! So I stolled in to ward 18, and picked him up and looked at his chart. Turns out he is 2 years old. Though physically looks more like a 14 month old, but developmentally is closer to a 2 year old (though with possible language delay) and has some hormonal issues that is affecting his growth (I didn't read his chart far enough to get the specifics). But he is such a ham! I enquired if he needed a home-in America. And when I saw sister Nicah-she said that Thando does haven parents, and that he has been in the ward for many weeks...

 

Anyway, back to Kruger Park. The Prof of the ICU has already told me, explicitly that she will not give me an ICU bed if I get attacked by animals. This was her response when I asked exactly what people did here at Kruger. I assumed it would be like most parks. Some hiking trails, walking around etc. God I need a good hike about now, and was also looking forward to doing some running this weekend. And I was quickly told that in the park, you stay IN THE CAR! What?? What the hell kind of park is this where you have to stay in your car. Apparently, it's a park with lions and other cats that could/wold eat people??

 

Culture clash. I was driving along the dirt road about mid-day. I'd seen a bit of game. Elephants. Giraffes Buffalos. Birds. Plenty of miscellaneous antelope-things. And figured, as everybody has told me, that the cats are not really out during the day. So I was driving along, enjoying being on a dirt road, pretending I was driving my JEEP, ipod blaring, leaning out the window kind saying "here kitty kitty kitty," I was thoroughly entertaining myself, when I rounded a corned and came upon a "hide" and some disapproving stares of folks who had probably been sitting there for hours in the peace and quiet hoping to see animals. Well, they did. Doctorus americanus cum africanis, exhibiting the combined behaviour of being post-call from the ICU, sleep deprived, and enjoying being in nature. Oops.

 

I'll be on good behaviour tomorrow.

 

 

-blog

Blurred Vision

It's 3am. I am wide awake. I did my 2am round on the trauma ICU patients. They were all were still alive, bleeding controlled, vent numbers appropriate. Here was my chance for 2 hours of sleep, barring any unforeseen emergencies. I laid on the bare bed of the call room. No sheets. No pillows. And I stared at the ceiling. In my mind, I couldn't put down the book I had been reading, but I wasn't going to give into my inner-child's curiosity and piss away a chance for 2 hours of precious sleep to continue reading. This book is giving me some clarity into future job prospects, and now, at 3am in the ICU, I can't stop thinking about what I want to do with my life; at least my life for the next year, or maybe even two.

It's 10am. I have half a dozen eggs in one hand, and sweet chili sauce in the other. I'm sweaty and smelly. I got home from work at 9am, debated going to bed and sleeping away the morning, seeing as how I wasn't able to sleep when I had the chance during call. I had a cup of coffee before leaving work, a red-bull when getting home, and then another coffee, and still lacked the motivation/energy to go running. But the thought of going to the grocery store, buying fresh strawberries and making home-made strawberry pancakes was enough motivation to get me to take off my scrub top, change into running shorts, grab my ipod and head out the door. My legs are sore. I ran along a greenbelt that I would normally avoind in late afternoons, and at all costs in evenings, for fear of safety. But, I really enjoyed running along the greenbelt this morning. I live by the mantra that serious crime doesn't happen on Saturday and Sunday mornings. After a pathetic start, I hit my stride and settled into an enjoyable pace, lost to the beat of itunes, and lost in a kaleidoscope of thoughts. And right before I headed into the grocery store, I decided to make a brie omelet with sweet chili sauce-which is what I ordered for breakfast yesterday. I took a R100 bill note with me, and shoved the R79 into my pocket as I headed out the door and started salivating at the thought of a scrumptious omelet for breakfast. I walked past the guys selling sock, who seem to only be out selling socks on weekends. And then I passed a guy, who I guessed was blind, and an amputee sitting on a piece of cardboard, staring off into space. I didn't hesitate to reach into my pocked and fish out the spare change. He startled when I stepped on a piece of the cardboard (confirming my suspicion that he was blind), and stuck out his hand when I said, "here ya go." And I walked on. And immediately, I wondered two things. Why hadn't I just given him all of the R79? And why do I readily give handouts here in SA (and Nepal and Ethiopia), but not back in America? The reason, I've concluded-as I've been thinking about this for a while now, is that here, as in Nepal, Ethiopia, etc there is no real provisions for the destitute. No real welfare-to speak of...

It's 1pm. I'm in Maponya Mall, in the heart of Soweto. I'm fulfilling a promise, to join JC and meet his wife. When his family was here at Easter, including his father who was in town from Zimbabwe, he'd invited me over to meet his whole family, and have a braii. Painfully, I had to decline, as that was the weekend I was headed to Swaziland. And so we made plans to meet today. I'm on American time, he and his wife are on African time. We meet half an hour later. I'm blurring the accepted "doctor-patient" boundaries that North America has taught me. He already has my mobile phone number-as do a dozen or so patients, as well as my email-as do a handful of patients. But meeting outside the confines of work seems to be outside the "norm" of doctor patient relationships. I note, to myself, that I am no longer his doctor which makes it seem fine to meet him.

He arrives with his wife, their daughter is off playing with a friend, but I'm told we'll pick her up later. We walk the few short blocks to their place. It's a single bedroom. It is smaller than my bedroom here in SA. And has one bed, a fridge and a stove, and a TV. There is no running water in the room, and the toilet is outside as well. It's what I anticipated, well except that it has electricity. I immediately make myself at home, sitting on the bed and we catch up since we haven't chatted in a while. Coincidently, I'd talked to his Infectious Disease Doc a few days ago, who gave me updates on a few patients that I had been taking care of, so it's easy to shy away from asking about his meds and his CD4, viral load, and TB cultures. Instead, we quickly delve into politics. SA has elected a new president since we last spoke, and The Mugabi-Tsvangirai Coalition have pleaded Zimbabwe's case for international donations. We have lots to chat about, especially because news coverage of Zim has fallen off the radar and I've lost track of some of the current events. As we're talking, Rumi makes sandwiches for all of us. The awkwardness that I was worried about, doesn't seem to be materializing. It's as if we're friends who just haven't seen each other in a few months.

As we finished eating and as the political discussion mellows, Rumi brings our old photos. I stare at a photo of a younger man, in a graduation ceremony.
"Can you pick him out of the crowd?" she asks.
No. No I can't. None of the three of these men look like JC. Except for his distinctive smile. Which I can pick out in the photo.
"That's him."
"Can you believe it? Look at that photo. Look how different he looks today. Look how much weight he lost."
I look at JC. He's gained 10 kg (22 lbs) since I admitted him to the hospital in February. But his physical stature is completely changed from the person in the picture.
"Every day I thank god that you saved him."
I swallow, unsure how to respond. "I'm thankful he's doing so well."

We finish looking at the photos, and then we take a drive, going through neighborhoods of Soweto that I'd be uncomfortable to drive through on my own. We pick up their 5 year old daughter. I make a fuss over her new braided hair, which has happened since I last saw her, and she giggles and grabs my hand an pulls me toward the bakkie. We head back to Maponya mall, where the activities include taking an anchored hot-air balloon ride for an aerial view of Soweto. It goes 120 meters high, and you get to be up there for 15 minutes. We hop aboard, and JC points out places in the area. I'd been to Soweto last weekend to see some of the historical sights, so it's great to be getting a better overview now, with the history of Soweto fresh in my minds. We snap photos from the top, and photos of us.

After the balloon lands, we head into the mall to print pics, and then we get KFC. Friends of theirs are coming over to join for dinner, so we're getting some KFC to compliment some fish that JC is going to bake for dinner. We walk through the mall, their daughter is practically attached to me, grabbing my hand, or my shirt. In the line at KFC, their daughter is trying to teach me a few words of Shona. She doesn't understand why I don't speak any Shona, or even Zulu. JC and Rumi enjoy the show as I slaughter the pronunciations. We collect the photos out as we walk out of the mall and head back to their place.

"Have you noticed it" asks Rumi.
"What?"
"You're a celebrity today. The reaction of the people seeing a white person walking around here. Especially with T grabbing on to you."
My vision is blurred. I didn't see it. I no longer see this. Being the sole white person in the gym, or the mall no longer registers in my mind. And today, there seemed nothing unusual about going to the mall with friends and their daughter.

We get back to their place, and LJ, his pregnant wife, and their 6 year old daughter join us. We tear into the KFC as JC prepares the Tilapia for the second course. LJ went to university with JC. We're all the same age. It's small chatter for a while, talking about the balloon ride and the events of the day. I tell LJ that I want to know what JC was like in university, I want stories. I try to break the ice a bit...

"I've known this man for a long time. I could barely come to visit a few months ago..." This isn't really the ice-breaking story that I was hoping for. LJ continues and tells me how depressing it was to come to visit, watching JC getting worse and worse. LJ had lost hope, thinking JC wasn't going to make it. His eye-contact drops off as he talks, but his eyes meet mine when he thanks me for taking care of JC. Again, I swallow hoping I can keep myself composed.

The next thing I know, the Tilapia is gone. The KFC is gone. And 2 hours have passed. In that time we've discussed South African, Zimbabwean, and American politics. As well as the failing healthcare system here in South Africa, especially as it pertains to Bara, as as it pertains to a friend of LJ's who died this week. We debate affirmative action. I try to just memorize this moment. I don't want this moment to be blurry. I want to remember it in absolute clarity, for the rest of my life. Sitting here, invited into the home of a patient/friend, a friend who, up until recently was an illegal Zimbabwean immigrant, sharing dinner with his family, and his friends, on a cold Johannesburg night, has been one of the most meaningful experience of this year, if not the past many years.

LJ and JC walk me out to my car. I make plans to see JC and his family soon, and pass along my number to LJ, so that he and his wife can call me if they have any problems when she goes into labor in a few weeks time. I drive home, still listening to Mrs. Potter's Lullaby... My blurry vision seems to have cleared up.

-

Hey Mrs. Potter

I'm driving home last night. Post call. Well, post-call hours before. It had been a hectic night. Kids crumping. Adult admissions. A full ICU. I went home. Slept for an hour. Met up with a friend for lunch. Met up with another friend for dinner. And I'm stuck on this song which I listen to on repeat the entire way home. I don't know why I mention this trivial detail, but I've included song relevant songs during the past many months, and this one gets added to the list.

 

"Mrs. Potter's Lullaby" by the Counting Crows:

well I woke up in mid afternoon cuz that's when it all hurts the most
dream I never know anyone at the party and I'm always the host
if dreams are like movies then memories are films about ghosts
you can never escape you can only move south down the coast

I am an idiot walking a tightrope of fortune and fame
I am an acrobat swinging trapezes through circles of flame
if you've never stared off into the distance then your life is a shame
and though I'll never forget your face, sometimes I can't remember my name

hey Mrs.. potter don't cry
hey Mrs.. potter I know why
hey Mrs.. potter won't you talk to me?

well there's a piece of Maria in every song that I sing
and the price of a memory is the memory of the sorrow it brings
there is always one last light to turn out and one last bell to ring
and the last one out of the circus has to lock up everything

or the elephants will get out and forget to remember what you said
oh and the ghost of the tilt-a-whirl will linger inside of your head
and the ferris wheel junkies will spin there forever instead
when I see you, a blanket of stars covers me in my bed

hey Mrs.. potter don't go
hey Mrs.. potter I don't know
but hey Mrs.. potter won't you talk to me?

all the blue light reflections color my mind when I sleep
and the lovesick rejections that accompany the company I keep
all the razor perceptions that cut just a little too deep
hey I can bleed as well as anyone but I need someone to help me sleep

so I throw my hand to the air and it swims in the bees
it's just a brief interruption of the swirling dust sparkle jet stream
well I know I don't know you and you're probably not what you seem
oh but I'd sure like to find out so why don't you climb down off that movie screen

hey Mrs.. potter don't turn
hey Mrs.. potter I burn for you
hey Mrs.. potter won't you talk to me?

when the last king of Hollywood shatters his glass on the floor
and orders another well I wonder what he did that for
that's when I know that I have to get out cuz I've been there before
so I gave up my seat at the bar and I head for the door

we drove out to the desert just to lie down beneath this moat of stars
we stand up in the palace like it's the last of the great pioneer town bars
we shout out these songs against the clang of electric guitars
you can see a million miles tonight but you can't get very far (x2)

hey Mrs.. potter I won't touch
hey Mrs.. potter it's not much
hey Mrs.. potter won't you talk to me? 

 

As for the ICU...

 

Status quo. The ICU dramas which I see unfolding are, in some cases, no different than ICU dramas anywhere in the world. And then there are dramas which shouldn't be unfolding. Such as the kid who had a perforation in his bowel, and was delayed getting to a referral hospital for an excessively long time. He's not doing so well.

 

We do a hand-over round in the late afternoon. The night team has arrived, and then we tell them about the patients and things to do and follow-up. This is one of my new favorite acronyms. KATH

Keep

Alive

Til
Handover.

 

Which, don't get me wrong, is implied for each patient.

 

This coming Saturday will mark the final 5 weeks here in South Africa. The theme for the last 5 weeks is Work Hard, Play Hard. Though right now it's been a bit lopsided...

 

B

 

More from ICU

I'm not really sure what day it is. But that doesn't bother me. I know I left work this morning, and that I go back tomorrow morning. I'm not sure why I am up still. My plan is to head back to the hospital in an hour or two and go back to the clinic where I was the last few months and plug away at the research. There is a new sense of urgency to this project, which is lingering more than I would like, as I must collect all the data before I leave South Africa. I can start the analysis while stranded in Abu Dhabi on my layover back to the US.

 

In typical post-call disorganized thinking patterns, I pulled into the driveway thinking that maybe I should consider doing an ICU fellowship. Maybe a pediatric ICU fellowship. It's been a steep learning curve the past few days... and this ICU business isn't so tough. Ok, that's a bit of a lie, but I'm going with it.

 

What has been enjoyable, is that when I'm there during the day, I'm taking care of adult patients. Half medical, half surgical. During the day, the 2 pedi residents who are in the ICU are usually taking care of the pedi patients. Makes sense. But at night, my co-residents have absolutely no interest in covering the kiddos. So, I get to cover the kids at night. For me, it's a win-win.

 

But last night was slightly shaky. Lots of kids, most on vents. A few sick trauma kids, a few sick medical kids. Problems with the blood gas machine (basically not working)- which made it more challenging to manage vents. A problem with nursing (oh come off it, I hardly every speak bad about nurses back in America, but I'll have enough stories from the nurses here to write a separate blog. Which I don't mention in the blogosphere because that would be slanderous-which isn't really appropriate. Buy me a drink, and I'll tell you stories that will FREAK YOU OUT). Where was I... Oh yeah, I couldn't sleep last night, because a few of the kiddos were fragile enough that I didn't have the confidence to let the nurses oversee the care and so I basically hovered like a hawk.

 

Anyway, aside from the lack of running water for a few hours-which made it impossible to make coffee, the night was par for any night in an ICU.

 

We did our hand-over round this morning, the consultant agreed with my management during the night, and all the kiddos were still alive.

And in my hypo-caffeinated, post-call victory, sleep deprived state the idea of a PICU/ICU fellowship made sense.

Enough rambling for now.

More soon, I'm sure.

See One....

See one.

Do one.

Teach one.

 

The old mantra of teaching in hospitals. See a procedure done. Do the next one. And then teach others how to do one. It has kind of fallen out of favor back in the US. More like. See one or two done. Be observed while doing a few. And then teach to the interns/junior residents next year.

 

"When was the last time you did one?"

"Oh, when I was here at Bara in 2003."

"Great, you scrub, I'll walk you through it."

 

I think medicine has become less invasive in the US. At least where I train. We aren't as aggressive about placing central lines (an IV into the neck or some other big-ie, not arm- vein), or other invasive procedures (like arterial lines) unless really needed. But here, entrance into the ICU almost guarantees a central line and an arterial line. You're likely already intubated.

 

I went to see what the recent blood gas showed on my patients. He'd been rather ok at 8am, but we were making strides to get him off the ventilator. When I dropped by earlier he was somewhat agitated after being suctioned. But when I went by again later, he was in respiratory distress. 6 days ago, he was hit by a car. He has lung contusions bruises, bilateral hemothoraces (blood accumulating between the lungs and chest wall) and still has in one chest drain (to get the blood out, the other drain was removed the day before), a clavicle fracture, and a head injury. Oh, and now he's in respiratory distress. Shit.

 

I assess him. And he sounds full of fluid in the lungs, and it is spurting out his breathing tube as well. I try to dry him out a bit, and to sedate him a bit, but I don't make much progress. I had ordered his daily chest xray hours before. But it has not been done. I call them again. I get one of the other residents to come assess him well. We escalate our treatment and give some ketamine while we wait to switch vents so we can also give some nebulizer treatments as well. We call the attending to ask to sedate and paralyze the patient; which he vetoes.

 

The xray folks kindly show up, almost and hour and a half from when I called the first time.

 

And shit, he now has a new pneumothorax (air trapped between the lung and chest wall) on the side which we'd heard the worse crackles. While it is nice to have an explanation for what's causing him to (quickly) decompensate, it would have been nice to know that an hour ago.

 

And there I am, cutting his skin like the internist that I am. Gingerly. I'm thankful that the brash trauma surgery resident who is also working in the unit is post-call and gone, for if she were guiding me through this, I could imagine her level of irritation at this point. And I dissect down, splitting the layers of muscle and poking between the ribs to release a gush of air and old blood.

 

Well, isn't this what I signed up for? Yesterday I placed a central line without the comforts of ultrasounds. I learned the anatomy of where to stick the needle in the neck to hit the jugular vein. And on the same patient I placed an arterial line as well. And today I inserted a chest tube. Next time I do these, I should, by historical training guidelines, not only do them alone, but teach somebody how to do them. I don't feel like the expert who could teach somebody how to do one.

 

I swung by Ward 36 after work to say hello to a friend who is on-call for pediatrics tonight. It was a zoo, and I had fond memories. She was in the treatment room. I headed in there and tried to sooth an infant as she tried to jab in an IV. Jab isn't a nice way to say it, she was being the skilled doc that she is. I saw the thrush. I saw the lack of tears and very dry mucous membranes. I saw the increased work of breathing and fast breathing rate. I felt the enlarged liver. The kid looked appropriately nourished.

 

"Let me guess. HIV exposed, not tested yet, gastro and pneumonia?"

She smiles.

"Want to stay and admit kids tonight?

 

She didn't get the IV. "What's wrong with this one" I ask as I hold the infants hand which has an IV in it.

"It's not working."

 

I try to flush it. She laughs in an I-told-you-so manner. I remove the tape at the IV site. Pull off the tubing connected to the IV catheter, and I try to flush it. The saline goes in nice and smoothly.

"Dr Brian!"

They never flush IVs, they clot off all the time, and you just have to replace the tubing which allows you to keep the IV site and then you don't have to poke the kids again. I just smile. They are getting nailed. She has brand new interns on tonight. It's going to be a long night.

 

I head to the car. I had been in such a comfort zone the past few months, that I forget what it was like to be somewhere where almost everything is foreign to me. I know the physiology. I know the diseases. I am marginal at managing the vents. I don't know the technical procedures. I don't know which medicines they use. I don't know how to prescribe the drugs as milliliters of drug, and not milligram of drug. But I'm learning And I'll learn fast. When I stepped into Ward 36 ten months ago, I didn't know how to place an IV in a kid. I didn't know about HIV....

 

Sometimes I just forget that I'm here to learn.

 

 

BPB

Brain-Ache

My brain is actually sore. Good to be back in acute medicine, but very rusty. And having to learn new trade names of drugs (Trade Name= Tylenol, Generic=paracetamol) etc. Different treatment protocols. And different vent terminology.

 

Off to take some ibuprofen and read!

 

 

Changing...

Wow, seasons are changing here. It's cold, and overcast today. It is really fall now. I have this urge to go by some pumpkins, to have chai tea latte. Instead, I brewed some of the tea that I bought in Nepal (thanks D). It's a spiced tea. I think drinking tea/coffee was the only way to get warm some of the time. So it seemed fitting to brew a pot of this cherished tea, and just enjoy a Sunday doing nothing much other than reading the paper, finding new music on itunes, and getting caught up on a few emails.

As mentioned, I'm changing to the ICU, and will start in the morning. Though, thankfully am not on-call for a few days. I've had time to review some medicine/pediatric topics, going over ventilator management, ABGs, EKGs, septic shock.

I'm being bumped out of that comfort zone. Headed to a unit where I'll, once-again, be the outlier. Having to explain- -again-why I am here at Bara. And even more tiresome, explaining that I am both a pediatrician and an internist. That yes, it is possible to do both. That's part of what I am looking forward to tomorrow. I have no idea if I will be taking care of pediatric ICU patients, or adult patients tomorrow. The unit is a combined pedi-adult, medicine-surgery unit. I'm really looking forward to the mix. It's basically what I'm training for--the ability to manage and understand the disease spectrum and the differences in physiology etc between kids and adults.

Here are some random pics. I noticed that I really haven't posted pics in AGES. (But astute followers will know that the picasa site with my travel pics has been updated regularly, the link is over there to the side).

This is a photo taken out of today's paper. This is TRUE. We've seen it in our clinic. People are so poor that they'll stop taking their HIV treatment, in hopes that their CD4 count will drop, and they will quality for a disability grant. It's a largely held misconception that a CD4 count under 200 will quality people fro disability. Desperate times call for....

Full Circle. This makes me feel like I've been here the almost year that I have been here. The return of brush fires. And they've been great recently. It's dry again, the summer rains brought lush green grasses which have now died and turned into ripe tinderboxes. This is a shot taken on Thursday night as I drove out of town.

I'm off for an dusk run. I love when it gets dark early in fall, it's great running weather. For the umpteeth time since moving away from Dublin, I'm trying to run regularly again.

Hope you had a great weekend.

200,000 and 7-1-10 (or 1-7-10 for those outside the US)

200,000

 

"When are you going to move back?" JPP looks at me. We're standing in the kitchen, beers in hand.

 

"July 1, 2010," I respond, automatically. There isn't even a hesitation in my reply. This is what makes sense. Maybe it's a combination of my rose-tinted glasses, with a bit of influence of beer goggles, but I don't think so. I knew it before we met up that night, that I'd be moving back. JPP and I have a friendship that goes way back, and we haven't seen each other in a long, long time. But out paths have crossed again, and when he asks me this question, I know that if I give a less-than honest, open answer, he'll call my bluff. But I'm not bluffing when I say this. This is home. And 7-1-10 will be my first day of ultimate freedom. I will not be a resident physician I get to choose where I want to live, and what I want to do, starting 7-1-10.

 

He grabs his iphone, "Ok, I'm putting it on my calendar. Brian moves back." I feel like I've given him my word.

 

It's Wednesday. CN is in clinic. She's lying on the examination table. In a week, she's lost more weight. There was no point in weighing her. In fact, she looked to weak to even get on the damn scale. I know her examination. I examined her twice last week in the hospital, and the week before that, and back in February. It's literally back to square one. She is actively dying, and there is no explanation. Rather, there is an explanation, but it's not one that I, nor our attendings can figure out. So I'm wiping the slate clean, trying to rid preconceived notions that I hold about what is wrong, or may be wrong, and examine CN, again, hoping to pick up something that escaped me before. She is wasting away. Her neurological status is deteriorating as well. She's not eating. She's bordering failing her HIV medications. What the fuck is going on? We're making no progress. I'm irritated. She was discharged from the hospital and hasn't had the follow-up care that we asked for. She hasn't seen the nutritionist to get her supplements. She hasn't see the physiotherapists (PT) to get mobility exercises, let alone a damn wheelchair. She didn't have a neurology appointment made. She hasn't fallen through the cracks, she's plummeted through the cracks.

 

I ask AK to come and see her. He hasn't seen her since a week before she was discharged. We review her care in the hospital. I feel like we're backed against a wall, and without doing something drastic, she's not going to live another week. I'm almost willing to treat for TB, MAC, and to change her HIV medications. It would mean starting her on 9 new medications at the same time. It is slightly illogical in that she's barely taking anything by mouth as it is. But shit, come on. Something has to be done.

 

"Doctor, careful." I put one arm under her knees, and the other one behind her shoulders, and I lift her off the bed. I'm surprised that her frail frame weighs this much. Of course I'm going to be careful. I sit her into the wheelchair, and her heads slumps down to one side almost resting on her shoulder; her eyes are barely open. I feel complete, and utter hopelessness, and helplessness. I'm so disappointed by what I feel, and see. The intensity of these feelings is something that I've only felt twice before

 

The tone went off in the fire station, and the ambulance was being dispatched to a Village Inn, for an unknown medical emergency. I was 18. I was in the fire station for my second ambulance clinical (the first clinical had been a complete bust). I was barely competent to take a blood pressure, let alone know my left hand from my right hand. And we showed up to the Village Inn, for our unknown medical emergency. It was a woman in her 60's. She was slumped over, barely conscious. We were close to a local hospital, so we basically packaged her and took her to the hospital. Maybe she was having a stoke? I remember it as this horrible event. She was conscious, but not really alert. Was she in pain? What was going on? Why couldn't we make her better? We watched as the ED doctors intubated her. We left the hospital, and wondered what was going on with her. And I wondered if I was really cut out for medicine. I was a college freshman, and had other possible career choices, and was maybe thinking that medicine wasn't what I was meant to do. I didn't feel tough enough, and I couldn't stand this feeling of being completely helpless. As it would turn out, we went back to the same hospital a few hours later, with another elderly lady who had broken her hip (while bowling!), and found the first woman. She was sitting up in bed, unsure why we were talking to her, as we were obviously interrupting her while she (get this) ate. Yep, she was a diabetic who had profoundly low blow sugars, and all she needed was a little glucose to perk up. Which, sadly, she got after being intubated. And then all of a sudden, I snapped out of it and figured maybe I could handle this medicine stuff, and I made a mental note to always check a blood sugar.

 

The second time was the worst. On entering the ED for a night shift, I'd popped my head into the resuscitation room, and saw a young guy on the trolley, and lots of commotion in the room. But something didn't seem right, and I couldn't figure out what was wrong, until I recognized the face-a face I knew from the club scene. He'd overdosed. And all night long I was on eggshells, waiting for the code to be called in the ICU.

 

We looked at CN, and talked with the family. Dr AK and I debated the pros and cons of my desperate plan. He's gently vetoing it. He has more than 20 years of experience, and I trust him. I know that he would jump on the TB/MAC/failing-HIV-treatment bandwagon had there been more evidence. But as it stands, there is something else going on, it is not TB/MAC/treatment failure. I am re-assured, but unlike the two previous times I'd felt this way, CN isn't going to live. And we place her into hospice that afternoon--mainly so that she can get the proper nutrition and physiotherapy, but knowing full well that she is likely terminal. I talk to her primary HIV doc who, again, re-iterates that she had been doing great up until February.

 

200,000

 

It's Thursday. There are patients everywhere. Everywhere. The waiting room is packed. The corridor down the hallway is packed. People are sitting outside. Friday is a holiday, so people have come on this day to be seen (which is great, because it shows ownership of their treatment), and also, the load was light on Thursday because the papers had erroneously written that we'd been on strike. Part of me really doesn't mind. It's my last day in this clinic. I kind of like the madness. I started here almost four months ago, and remember, how on that January day, I walked in knowing so little about HIV treatment, and the whole disease spectrum of HIV-related illnesses. In clinic, on Friday, I saw patient after patient, knowing what to do for the routine patients, what to do for those who are showing resistance to their HIV medicines, started TB treatments, and battled with a patient to convince him to get admitted to the hospital for his low potassium. This clinic is home.

 

"Dr Brian, why are you leaving?" It's sister Gerty. I would take her with me to America if I could. She is a Bara legend. She has been working here for more than 20 years, maybe even 30. Her grandfather is a retired school  teacher, who taught, among others Desmond Tutu. She is the one who was able to get the placement for CN yesterday. Sister Gerty was a palliative care nurse before going into HIV, so when she calls for favors, they happen. So I explain how I decided I should rotate through the ICU here at Bara, and that I've had a great time in clinic, and that I'll be back to see them regularly.  I also add, that I'll be back in the US in 2 months anyway, so I was bound to leave at some point.

 

We have our regularly Thursday group lunch. The waiting room is still packed, but we sit to eat anyway. I snap a few photos. I joke that I'll consult ID every chance possible, that I'll demand they come to the ICU to start HIV treatment for every person who has HIV. It's a joke, because HIV treatment is rarely indicated acutely/emergently, but we get regular consults from the ICU for this exact reason. I see my last patient in the HIV clinic. I recognize the face, immediately, but can't recall the story. We walk back to my examination room, and I'm flipping through his chat. Oh yeah, now I remember. This is the guy who I saw last Friday late in the afternoon. He had an abscess just below his left pec. I'd been a bit hesitant to stick a needle there to see what came out (one of the other docs had seen him earlier in the day, done a chest xray, and he showed up to follow up with me as the other doctor was out of the clinic). One of the consultants did the aspiration, and then we literally had him run to the pharmacy to get some antibiotics before they closed (they would be closed until Tuesday since Monday was also a holiday). I'd kept his name on my follow up list, just so I could see what his culture results showed, and see what was growing in that abscess. And it has been bland, nothing on the culture as of that morning. But, low-and-behold, at 3:35 when I checked again, the smear for TB had just been changed to positive! And it was a mad dash to do the TB paperwork, and have him run, again, to the TB center to get treatment before heading into this 3 day weekend.

 

200,000

 

Clinic was done. We'd cleared the book. The waiting rooms were empty. The only people hanging around outside were waiting for rides. I found myself talking with the 3 attendings/consultants talking about my experience in the clinic over the past many months, and being invited (jokingly, but not) to stop by on my post-call days and come see patients in the clinic. Dr AK and I hung out to discuss a bit of the project I'm working on, and then we just chatted a bit. A month ago, I would have asked how I could pursue coming here to work after residency, and as we were chatting, I debate bringing it up. And I almost start to when I force myself to stop.

 

200,000 is the salary of a job posting that showed up in my email this week. The sign on bonus is 20,000 US dollars. And there is a 10,000 moving allowance. 20,000 is just about what I'd make if I came back here to Bara to work in this clinic. Maybe a bit more, like 25-30,000 if I really pushed. But no more than that. If I were able to get an NGO job, which would be a back-door way to get into the clinic, the salary would jump a bit, but not enough that I'd be able to make student loan payments.

 

200,000 is the salary for a med-peds hospitalist position. One week on, one week off. The location isn't where I'd plan to live. When JPP asked me, "when are you going to move back," I was standing in his kitchen, in a Denver suburb. And at that time, there was no doubt in my mind, that I would be back in Denver on July 1, 2010. At lunch on Thursday, one of the consultants asked me, "what are you going to do when you finish next year." And I couldn't answer. Fighting HIV in Africa for no money. Taking care of hospitalized kids and adults in the US for a shitload of money. Living, where I feel at home-Denver, Jo'burg. Or on to the next home. I just don't know these days....

 

-

Final Clinic

Tomorrow is my last day in the ID/HIV/AIDS clinic. Was tough to make the decision to move on to the ICU.

 

More soon... have been really trying to buckle down and read recently to get ready for the ICU. Have enjoyed mostly reclusive weekends for the past 2 weekends as well.

Fighting

The politicians are fighting in SA. Well, fighting for votes. Zuma is likely to win this fight. Having escaped corruption charges to be able to officially enter the ring. It's a scary thing. It's great to be in a foreign country for elections. A chance to witness the culture of voting. I've been in Mexico during a national election-where alcohol sales are banned for 24 hours before, the day of, and 24 hours after the election. Of course, I was in Ireland during elections. And now to be here. The ANC is going to win this election. This is the party of Mandela. A party which has brought good changes: lots of housing, and basic essential to those most marginalized by Apartheid. But it also is the party of Mbeki, the present of SA who is directly responsible for killing (murdering, genocide...) some 300,000 men, women, and children. (http://news.bbc.co.uk/2/hi/africa/7716128.stm) Way to go ANC! In SA, the president is not elected by the people. The president is basically appointed by the party which has the largest majority in government. South Africa faces lots of issues presently, and even more serious issues in the near future, and it is electing a future president who has been tried for rape (and then "showered" afterwards so he didn't get HIV), and who just barely escaped corruption charges. Oh, and a president whose formal education stopped at Grade 6. (Not to point fingers, as one must wonder when GWB's education really stopped). Anyway, its been appalling to me that the ANC is going to win such a victory. But my perspective changed a bit last weekend when Andrew and I visited Lillieslief farm. Seeing the room that the then-leaders of the ANC used to coordinate efforts to rid SA of Apartheid, the room where Mandela slept as he lived under the guise of a hired hand on the farm-even making and serving lunches, the videos of how horrible people were treated during Apartheid, and it made me realize why so many of the people will vote for the ANC...

 

The Doctors are fighting in SA. I attended a meeting yesterday about the possible upcoming strike. Doctors have been in negotiations regarding, mainly, salaries, but also general conditions in hospitals. And they are on the brink of strike because of the lack or progress in negotiations. And in fact, north of Jo'burg, some doctors in hospitals went on strike today. I struggle with this, as I think it's almost deplorable for doctors to strike. To abandon patient care, to me, is against the moral fiber of the duty we have to our jobs, our patients. Patients suffer. The impending strike is complex. The public sector is very understaffed, there is little motivation to work in the public sector. The work load is heavier. The patients-I think-are sicker. The services that can be provided are restricted. The conditions in public hospitals are shitty compared to the private hospitals. And, of course, the pay is less. Much less. I will earn more money next year when I return to my residency salary, than does AK-the head of infectious disease here at Bara. A man who is a silent hero in Soweto. A man who started the ID/HIV clinic 20 years ago. The man who I am sure spent this national holiday today working most the day at home researching topics, writing papers. Taken in context, thought, student debt is very low, cost of living is low, and doctors do well, financially. But there is a drain from the public sector to the private sector due to the low pay. So it's tough. There needs to be a way to provide a larger incentive for doctors to want to keep working in the public sector.. I am hard pressed to think that a strike is the best way to force changes in this area.

 

We had our ID grand round, where we go to the bedside of a patient who is being seen by the ID service. And we examine and discuss the medical condition of a 26 year old woman from "Mozambique" who is hospitalized for an enlarged spleen. The spleen is a small organ, under your left rib cage which is involved in blood and infection processes. Sometimes it gets large, and you can then feel the spleen as it creeps past the rib cage. But with this woman, her spleen went down to her waist level. It is absolutely MASSIVE. But she's a total mystery. The enlarged spleen isn't the main mystery, the patient herself is. She showed up to the hospital with a note from a doctor in Mozambique asking for her to be assessed and treated for her enlarged spleen. But nobody has been able to communicate with this woman. No English. No Zulu. No Portuguese. No Xhosa. No Sesotho. No Tsonga or Tswana. No French. No Spanish (I tried). No Amharic. No Swahili. But what amazes me, is that this woman, on her own, made it from Mozambique to SOWETO, to see a doctor. Who knows where she is really from... She's basically fighting for access to medical care.

 

And I'm fighting fatigue.

Goodnight.