March Blogging Hiatus & Experiment.

Dear faithful blog reader,

 

This is the 118th post to this site. The first post was March 23rd, 2008. Just under a year ago. When I made that post, I had absolutely no idea if I would follow through on what would become this amazing experience. At the time that I made that post, I shared my concerns privately with some. Would I sink or sail when the time came? Was this a wise or unwise decision?

 

On the second post, in April, I was packing up my beloved apartment. I packed up memories of the friends who had stayed there. I packed up my outdoor equipment. I packed up the few worldly possessions which have any value to me-old family photos, completed journals. I packed up journal articles not yet read, and martini glasses which have never been used-a shame, I know.

 

In May, I posted about the meal Lucia and I had in Manhattan. A meal at an Ethiopian restaurant, where we chatted for hours, consuming the injera bread and a sweet honey tasting wine, while talking about our shared experience as medical students at Bara, as well as a mixture of reminiscing memories of Ireland, of excited discussions about future plans...

 

And then it was June. It was a whirlwind. At the hospital I had the amazing pleasure of working with one of my mentors on the wards (this person doesn't know it), of having a farewell dinner with my other mentor (who knows it). I made quick trips to Vermont and New Haven while trying to wrap up finishing details for my impending departure. The next thing I knew, I was at JFK Airport, surrounded by a cadre of friends who saw me board my flight. Little did they know, that as I watched them walk away, I still wasn't convinced I was making the best choice.

 

And since then, via this  blog, I've shared.

 

I've shared my personal experiences at the world's largest hospital, treating a population rocked by economic deprivation, on a background history of racial discrimination, and a population burdened by one of the highest rates of HIV/AIDS in the world.

 

I've shared about kids whom I took care of; some who got better, and some who died. I don't think I'll ever forget the morning I heard KR had died. And I'll never forget S, the Ward 18 mascot when we took him to tea break one day, or when I carried him on my back around the hospital. I've shared what it was like to see so many kids brought into the pediatric HIV clinic by their grandparents. A generation is being raised without parents. I'll never forget how furious I was the night I had to keep checking the heartbeat of a 400g baby, who had been delivered by c-section. And the sense of injustice when I certified his death 3 hours later. I didn't share enough about what was probably the most incredible month of learning as a junior doctor, and that was the pediatric cardiology service at Bara.

 

And I shared about life outside of Bara. I shared about trips I've been fortunate to take-trips to Clarens, The Berg, Zimbabwe/Vic Falls, Lesotho, and other weekends trips. I've shared about how I've made friends here who provide refuge when I need some luxury and an escape. I shared a bit of Nepal, and how incredible it was to look up at the surrounding Himalayans and to be looking down as I knelt before the Buddhist monk as I was blessed.

 

And over the past 2 months I have shared what it has been like to work in the adult HIV clinic, as well as my overall introduction to medicine at Bara. I have shared how I can't believe that what I see today seems to parallel what was seen in the US almost two decades ago. Medically stuck in black hole... Not having "the resources" to treat the country which has the LARGEST NUMBER OF PEOPLE INFECTED WITH HIV IN THE WORLD!

 

And since then, there are things I didn't share... And they aren't going to magically appear now.

 

I go back and read these posts often. Sometimes I can recall being at the gym as I thought about how to write what would eventually end up as a post. Sometimes I remember sitting with a glass of wine or whiskey or coffee and getting lost in a train of thought midsentence, or going back and re-working a post and removing the blame which I had written in the post, which may have been misguided. Often times, I cringe at the typos and grammatical errors.

 

What may not be apparent, is the time that goes into this blog. Not that I mind, at all. But I find myself needing a bit of a break. I take immense gratification knowing that what I write, has been read. That I have been fortunate enough to share a bit, so far, of this amazing year. That, unlike one or two close friends of mine who also keep blogs, I haven't received criticism from anything that I have posted.

 

I find myself with a lot of things on my plate, and a lot of great plans for March, and I find myself needing a bit of a break from keeping up the blog.

 

But, that is where you come in. This is what I'd like to do: For the month of March, I'd like to open up my blog, for you to post. It's quite simple. You merely send an email to BackToBara.guest@blogger.com and that email will instantly appear on this blog. The post will be anonymous (unless you add your name to the email). For example, all of the posts that I have made have been from my hotmail account, using the address. [note: if your work email adds a privacy/security clause to the bottom of the outgoing email, it will automatically appear].

 

I ask that you please, please, please do not post about me. Please post about something which you think is in the spirit of this blog (being outraged at the conditions in Zim, or your own neighborhood, an experience of disparities in care/treatment/service). A joke. A News clip. Your favorite recipe. A new coffee shop. A post about your day at work. A post on your reaction to what I've posted over the past 8 months. There will be a guest moderator who will removed or edit posts as needed. You never know what whackos are out there who stumble across this site (or are reading this site) and will post some kind of advertisement for lengthening of a part of the male anatomy, or pills which will cure problems with that part of the male anatomy, or some guy in a foreign country who needs your bank details so they can put one gigabillion dollars in your account while they sell a kidney and then you wake up in a burned forest with Elvis.

 

May March usher in the start of spring, or fall depending on where you are in the world. I'll be back, full force in April when I will resume posts from the Adult HIV clinic at Bara.

 

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Strike Three & 2 Months

I make my way back to clinic this afternoon. I'd seen a patient earlier in the day when I had a free moment to pop into clinic. I sent him off to get some urgent labs done, wondering if he was having lactic acidosis, an adverse reaction to one of the HIV medications. It would be something that would have to be dealt with this afternoon if the level was high. So I sent him to the lab, and said I'd be back at 2pm.

 

It's 3pm, and I'm walking the drizzling rain. It's about a block between the ID offices where we'd wrapped up a lecture, and the HIV clinic. Though on Monday and Tuesdays, it's not the HIV clinic, it is the hematology/oncology clinic. When I get about 100 meters from the clinic, my phone goes off, it is a text message from the clinic. There are no pagers here, the hospital sends out a text/sms with a call back number, and I recognize the number. I quicken my pace, as I'm sure they're annoyed that I am not back yet.

 

I walk into the room, and wouldn't you know it, there sitting in a chair is Lucky.

 

Without even asking a question I tell him, "I'm admitting you to the hospital." Retrospectively I realize that this wasn't the ideal way to great a patient, who must feel like shit being as ill as he is. I remember one of the Pedi ER docs back home basically saying that if somebody shows up for a third time in too short of a span, at that point you basically need to admit. I would have been happy to admit Lucky on the first visit, and tried to persuade him to get admitted yesterday... We'll see what happens.

 

I admitted 4 of the 10 patients who came to clinic the past 2 days. Remember that these are days that we're not in clinic, except that we'll pop over to see people who are too ill to wait until Wednesday. I groan slightly, as my consult list swells..

 

I'm coming to the completion of 2 months in the HIV clinic. Aside from my 2 months on Ward 18 when I first arrived at Bara, this is only the second time during residency when I've done the same thing for more than a month. We have a one-month rotation block back home. I'm not sure if one month is really ideal. But here, the blocks are generally 4 months, which I don't think is ideal either. But 2 months has been enjoyable. I have learned a lot in these two months. Things that I never knew about before such as MAC (basically a brother of TB)-which I'm comfortable starting treatment even when I can't conclusively prove it's there (which may be rather taboo back in the US), and cryptococcal meningitis, as well as how to go about starting HIV treatment, following the treatment, and making changes. There is so much more to learn. There are frustrations, and all is not perfect. But I don't feel ready to leave. I'm having a hard time thinking about my rotations in the coming months, though I have a tentative schedule for the remainder of my time here, and I reviewed it with the Prof of Peds, who thinks it is a wise plan, part of me really thinks about staying where I am.

 

Recently, after a grueling Wednesday clinic session (286 patients), Dr K and I were chatting about the project I am working on, and then we just chatted for a while about what I may do down the road, post-residency. It is tough to know where I am headed, but as I was walking away from clinic today, I thought that if they were able to offer me a job in the department (after residency-as finishing my last year of residency is the only absolute/definite plan I have in life at this time), I would be hard-pressed to not take it. I could easily see myself working in this capacity (with finding a way to do some pedi work) at Bara for a few years. As I have mentioned to some, I will not be ready to leave in 4 months....

 

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Lucky and Friday

On Friday, 3 of the patients, who I had admitted the previous week/weeks went home. I'm seeing them in clinic this week. Was nice to see them going home, as opposed to the other type of discharge...

 

Today was a bit of a whirlwind. Phew. I had the usual  six suspect who were still in the hospital, and had to round on them by 11. I tried to sneak through the ward and escape new consults, which didn't happen, and I picked up to more consults. Good consults though, so I didn't mind. One was a 28 year old who is newly diagnosed, admitted a week ago with pretty profound respiratory distress, and pretty impressive leg/groin/abdomen swelling. He's been there a week, and still on oxygen. The other was a patient we were asked to see for infective endocarditis, who was on a less than ideal antibiotic regimen. So, they were nice consults.

 

I'm on-call this week to see new consults in the surgical and ICU wards, but also get to cover the clinic on Mondays and Tuesdays, when we're in the wards. The somewhat disappointing thing about this is that, Monday and Tuesday are generally the days we get to sneak away a bit early (which still usually doesn't make up for how late we are there on Wednesdays). I got nailed in clinic, with 8 patients to see. Normal would be 2 or 3.

 

One of those patients was Lucky. I wrote about him a few days ago. He's the one who looked very ill, and had a CD4 count of two. I was actually glad to see him today, mainly because that meant he was still alive, and that resisting my gut feeling of admitting him 3 days ago was ok. He is still quite unwell, and this time I gave into my gut feeling and decided that I was going to admit him. The HIV medicines were making him vomit, and he looked even more dehydrated that a few days ago. But, he didn't really want to be admitted, and so I relented. Gave him a bunch of scripts and will see him (hopefully) again in a few days.

 

The evening finally ended when, I admitted one of the other patients who I'd sent to have labs and an xray done. Again, we teetered on admission versus sending the guy home and seeing him in clinic in the coming days, but it was 5pm, the pharmacy at the hospital is long closed by then, and there is no way for this guy to get antibiotics (aside from paying for them himself). So we admitted him, that and the one crucial lab result that we were waiting for, had seemed to go missing in the lab. Go figure.

That's about it.

Cheers

 

ps-I'm avoiding the obvious irony with the name Lucky. On a similar note, I was reviewing a chart for a study I am working on, and the name of this patient was Happy. He's dead.

 

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"If I'm still alive"

"I was just about to call you:" is how JC answers the phone. The plan, as it stood this morning, was that he was going to be discharged, and that he would walk to clinic and I'd give him a ride home, as he's definitely too weak to deal with walking to the minibus-taxi rank and taking a taxi home. "Well, I beat you to it. What's up?"
"Doc, I'm going to go home tomorrow eh?
"Oh-ok," I'm not sure why the plan has changed, but I can only surmise, that for the second time in as many days, the lymph notes that are swollen in his neck, and those in his abdomen, haven't been pierced by a needle, which is what we're waiting for.
"Can you do me a favor?"
"Yeah, sure."
"Doc," there is a pause on the other end, "can you go get me a loaf of bread?"
"No problem. I'll head to the bridge and grab you some bread. I'll see you in a while."

I need to head to the bridge that crosses over the busy street, and joins Bara to the outside world. It is the only real pedestrian entrance into Bara. I've never seen another white person on the bridge, when I've had to take taxi's to work and come in with those who don't drive to Bara-being most of the nursing staff, patients, visitors, construction men, radiographers, and just about everybody else who works at Bara I have patient files in my bag, and wonder if I'll get checked by security as I walk past them. I have my stethoscope right on top, which often serves as my immunity card to bypass security hassles in the hospital (and so far once for being pulled over as well).

I see some scones and buns for sale, but not any bread loaves. So I go all the way over to the other side, to where some stores line the street by the taxi rank. There is a tour group of white haired older folks. I try to hear their accents, not sure by their dress if they are European, or American, Or Australia. They are all homogenized. I feel slightly righteous. I may not venture into Soweto to hang out with the locals, but after 8 months I feel at home and at ease walking through the crowd. I cringe as I see one of the group take a photo of a woman selling corn.

I enter the mini supermarket.
"Eh, bubba, your bag." The security guard wants me to leave my bag at the door, where other bags are set into cubby holes, much like those found in kindergarten classes. No way, I think to myself. Not with the patient files in there, and also the sentimental value my stethoscope has...
"Eish, I just need a loaf of bread, where are they?" He points, and conveniently they are right by where the queue for the checkout stand starts. "Fine, I'll just walk there, grab one and get in the queue. I'll keep my bag with me." He nods in approval.

I get the bread, and head back out. The white tourist group has moved a bit further down the way, they are still all in a large bunch. Clinic finished on time, and so I'm taking advantage of what I feel is an extra hour to go see some of the patient that I'm following on the wards. I stop on the bridge, over the road, and just stare. To my left is Bara. To my right is part of the heart of Soweto. Actually, Bara is probably THE heart of Soweto I recognize faces walking past me, those of the nursing staff from various wards. Some of the HIV counselors are leaving as well, and they stop to say hi.

I chat with one of the counselors briefly about a patient I started on HIV treatment today. One of the consultants had see this guy last week and had scheduled him to come back and start medicines today, and as I was having a slowish day, he asked if I would see this patient. Dr T called the patient from the waiting room, and a cachetic (wasted appearance), guy stood up, and walked toward us. He was unsteady on his feet, and stood before us with labored breathing. He looked like somebody I would have admitted just based on how he looked. How ill and distressed he looked. Dr T shook his hand and explained that he was behind schedule and was it ok that I saw him and started his hopefully life-saving) medications.

"He's ready to start 1a." 1a is the starting HIV regimen for adults in SA. d4T, 3TC, and Efavirenz. I knew to start him on 1a. Dr T doesn't say this as if I don't know which medication to start him on, but rather to gently let me know that he is aware of how dire this patient looks, and that I just need to start treatment, and not admit him, nor go fishing for more problems-and in fact the patient is already on prophylactic TB treatment.

We walk to the end of the hallway, and I lead him into my room. I review his chart, and examine him. He's failed, twice now, to go register at the TB clinic. I get slightly irritated that this hasn't happened. But realizing that the TB clinic is equidistant in the opposite direction from the Bridge, and where the taxi stand is, it's no wonder the guy hasn't gone to register. It's likely he doesn't have the physical, and maybe even emotional strength to walk that far.

I examine him. The thrush is still growing in his mouth, at the base of his tongue. I look up at his palate and see a Kaposi Sarcoma lesion. I glance and see that it hasn't been noted before, and I feel oddly proud that I have found it. This is a worry, though, because with the HIV treatment, if there are lesions in his lungs, they could swell when the medications are started and worsen his already fragile respiratory system. There are other scattered KS lesions on his body. I listen to his heart beating away at 140 times a minute, double the rate of what a normal adult heart rate should be, and beating at the rate of a newborns heart. It's beating regularly, and I'm fairly certain that the significant dehydration, plus the lung disease is what is making his heart work at twice a normal rate.

I look over the labs. His kidneys work. His liver studies are normal. He has 2 CD4 cells. 2 lonely CD4 cells to fight infection. I imagine his CD4 cells hanging out, circulating in the body.
"Hey Bob! look, down there," as he points down the blood vessel.
"Oh shit, is that a colony of bacteria growing?"
"Yeppers. We're not going to be able to take out all of them."
"Lets just surrender."

I take out the sheet that we use to give information to all of those who start 1a. It has the medicines, a diagram of how to take them, as well as the side effects. It actually almost feels pointless to talk about the risks and benefits of starting the medicines. For without them... I go through the sheet. I make an appointment for him to come back in 2 weeks, and stress stress stress that he must come back if he feels worse.

I'm turn to head down the ramp of the bridge, and run into another counselor She served as the interpreter today. After we'd finished tying to figure out whether a young woman was really taking her pills or not, I asked if she would help me interpret over the phone. When I arrived to work this morning, I pulled out DM's file to get a phone number. I needed to give him a stern warning/lecture to get his ass back to the hospital immediately. Mourning was over. I was sorry his brother had died, but he had been let out for a weekend pass only. And the weekend pass had now gone on for 10 days. I was annoyed to see that the only phone number was for his sister-in-law. That could make it tricky to get a message to him, without letting it be known what was really going on. I had talked to the sister-in-law for all of 30 seconds this morning when she said, "Sesotho."
"Ok, I will call back.:

I explained the situation to the counselor. She grabbed my phone and made the call. They exchanged polite introductions. And then I head all I needed to hear.
"Dead. On Sunday. Ohhhhhhh, so sooorry," and then the phone was abruptly handed to me, as if I needed to hear for myself.
"HI again..." I expressed my condolences and then said goodbye. There was really nothing else to say. "Shit!" I said out loud. DM had to make one of the toughest decisions, and he made the one he thought he needed to make, as much as we were opposed to his choice.

As I headed off the bridge, and started walking toward the wards, I ran into AW. AW is a patient who we were asked to evaluate on Monday. He is a man, in his 30s, who has Non-Hodgkin's lymphoma, which is what the found when they biopsied the mass that had been growing for months under his jaw. And at the same time, tested him for HIV, and found him to be HIV positive (which wasn't a surprise). He is escorting a woman to the bridge.
"Are you his doctor" she asks.
"No. Well yes, I am one of the doctors taking care of him."
"Well, tell me what's going on with him."
"What do you mean?" I ask this to buy time, and to see what she knows. I've been here long enough now to know that HIV is a secret, often times. People don't mention it. It's like RD's wife finding out he was HIV positive. She found out a few hours before he died, when he asked her to pass him his HIV medicines.
"I mean, when is he leaving the hospital?"
"I'm not sure, they need to finish evaluating his cancer. Why?"
"We have a funeral to go to on Saturday."
"Well, I bet he can probably get a weekend pass, as he's just waiting for CT scans and other tests for next week." AW, himself, has kept quiet the whole time. I look at him, "I'll come see you in the ward and we'll chat. I have one other patient to see before you."
"OK doc, I'll be there in 5 minutes."
"Take your time, it'll take me longer."

VM was suppose to get her abdominal ultrasound today. She's been in the hospital 6 days now. And she was actually looking better this morning. The swelling in her legs and abdomen had gone done, the pains in her stomach were better, and she was eating. I told her to make sure she went for her ultrasound today, and that I'd see her in the late afternoon. He bed is at the end of the corridor, and as I walk down, she has a grin on her face.
"I walked to the ultrasound department" she informs me.
I grab the chart and look at the report. Normal liver. Normal kidneys. Normal gallbladder. Minimal amount of ascites (fluid in the abdominal cavity). But the sleen is enlarged, has microabscesses (small collections of what is likely infectious material) as well as enlarged lymph nodes in her abdomen. All suggesting TB. She did, in fact, have an abdominal TB IRIS. And she's improving. We chat, and she's doing her best to convince me as to why she should be able to leave the hospital, and go home. Little does she know that I am already in complete agreement, but it's nice to see her have some energy in her, so I let her go on. Last week, when she came into the office, swollen from the abdomen downwards, looking miserable and in pain, and having gained 8.6 kilograms, (the equivalent of 8 litres of water, or 2 gallons) and looking depressed, I wondered if I would be wrong. First time I met her, I wasn't sure she'd make it. Then starting TB treatment she looked great. Then crappy again. And now great again.
"Ok, I think you can go tomorrow, you have an appointment to come back and see me on the 27th anyways." She smiles, looking thrilled to be able to leave. "You're going to do great, ok. You are going to get well, and stay well." I say this, perhaps, to also convince myself.

I make my way to ward 22. Before I get to AW, I see SM. He's walking down the hallway.
"Sorry doc, I was in the shower." He thinks I was looking for him.
"You're looking good, how's the breathing." I guestimate his respiratory rate has settled from the 40s when I saw him in the office, to the low 20s. And he's talking more comfortably.
"Much better."
"Ok, I'll come back and see you tomorrow."
He's still waiting for a test result to see if he has PCP pneumonia...

I find AW sitting on his bead. And I draw the curtains closed, which only gives a false sense of privacy.
"Does she know?"
He shakes his head no.
"Why not?"
"We're not really married anymore, we don't live together."
I assume, or hope, that implies that either they are not sexually active, or that they are using protection.
The hematology team have asked us to start HIV treatment ASAP, while he is in the hospital. Starting the treatment in the hospital isn't really ideal, as there seems to be better compliance when it is started in the clinic. Also, AW lives close to a clinic that can give him HIV treatment, but there may be a delay in him getting an appointment there. So we've been debating what is the best option. The hematology team is impatient, and they wanted the treatment started Monday. Fair enough. AW and I talk about the logistics, and have to plan it around a possible weekend pass out.
"I guess I have to tell them?"
"Well, what do you think?"
"They aren't going to be happy. My mom is going to cry and be sad."
"Why do you say that?"
"My brother died of HIV. But he didn't take his pills right. He missed a lot of doses. In the end he got real sick and died. My family is going to be mad, but I guess I got to tell them. I just got to tell them. If they get mad, they get mad. Nothing I can do about it. I just got to tell them."
The way he keep repeating about telling them, makes me think he is trying to convince himself, more than explain to me.
"It is probably best if you tell them, but I can have the counselors talk to you about telling them." I just stand there for a minute. It's the stigma of HIV that will continue to make HIV/AIDS such an insurmountable disease in South Africa "It's not easy to tell people these things, but it will be best to be honest." I empathize I can think of many times, year ago when I was coming out, how I kept repeating the same mantra to myself: I just need to tell them. Just need to get it over with. We finalize our plan. He'll be away this weekend on a weekend pass, then will collect his medications on Monday. We've decided to postpone starting until Tuesday. That way he doesn't have to take his pills bottles home, which may release his secret before he wants to. Unlike RD, AW wants to be frank about his disease.

I finally make my way to JC, to drop off the loaf of bread.
He laughs. "What am I doing to do with a whole load of bread?"
"That's what you asked for, a loaf. Share it with the others?
I flip through his chart. He's basically wasted this week in hospital. The lymph node excision that the surgeons were to do on Tuesday never happened. The ultrasound-guided lymph node biopsy/aspiration (in his abdomen) that was suppose to be done today never happened. He stated TB treatment this morning. I think it should have been started a week ago. I've watched him lose weight this week. And get weaker.
"How's the ensure?"
"It's sweet."
"Well, you can dilute it, just use 3 scoops, not the full 6."
"Dr T was surprised to see a can of it here. She didn't think the dieticians had any for the patients."
"What did you tell her?"
"I just let her believe it came from them, not from you."
"Thanks."
We talk a bit. He's worried that if he has to do DOTs (directly observed therapy-where he will have to go to clinic each morning and swallow his TB pills in front of a nurse) that it will be very exhausting, as he doesn't think he has the strength to make the daily pilgrimage. I think that the extra calories he'll burn each day walking to the clinic would be better saved... He'll be discharged tomorrow, and will come back in early March for the biopsy, and for review in the ID/HIV clinic.
"I'll see you then?" he asks.
"Nah, you'll see Dr T. I'll be out of the clinic for a bit," he seems disappointed. "but don't worry, I'll be in the clinic again in April. I'll give you a shout in a few weeks to check up on you, and make sure you're doing well. We'll meet up in April."

His reply: "If I'm still alive."

And it is the first time, in the almost 2 months of taking care of the sickest overall population I have ever encountered, with such high mortality, that somebody has actually verbalized insight into their own mortality...

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New Pics Up

Check out: http://picasaweb.google.com/BackToBara for updated pics from the last 2 weekends away.

 

 

Weekend Warrior

When I threw on my pack this morning, the pain in my shoulders and hips reminded me of the 14 miles we had hiked the day before, and the 4,500 foot elevation gain we had made in the 8 hours that we hiked yesterday. With the pain, I also had an immediate flashback to being in Nepal, and the second day of my trek. I tried to console my sore spots this morning by remembering by the 3rd day or 4th day, my body had gotten use to the pack, and I wasn't sore. But sadly, this was only an overnight trip.

 

Friday night Cecile and I drove down arriving past dark, to find that Thomas had set up a tent and had a fire going. The stars were out in full force, the moon hadn't yet arisen, so as the fire died down, we decided to just thrown the sleeping bags outside and sleep under the stars. The only danger was the possibility of rain (it had been raining all week) and the almost softball size pinecones. But risking head injuries from falling pine cones and rushing into a tent were well worth it, as in the end it turned out to remain cloudless, and only one pine cone came close to hitting one of us, and we were greeted with a sunrise and a perfect day.

 

The goal, was Mount-Aux-Sources. Many months ago, David and I did some hiking in the Berg, and we hiked to the base of a waterfall, which was DRY! Well, this hike that we had planned was a 14 mile hike, gaining 4,500 ft in elevation, which included 2 chain ladders going up a few stories of a mountain face, to the plateau at the top of the Drakensberg Amphitheatre. It was a cloudless day, and a perfect hike. The views were incredible.

 

It was great being away, and having periods on the trail to just think about what's been going on lately.

 

I thought about how I'm still pissed that GT died. I wondered why DM hasn't returned from his weekend pass, which he got the weekend before. I keep thinking I should find his file in the clinic and see if we have a working telephone number for him, and call him and tell him to get back ASAP. I worried about VM-the patient I wrote about recently who looked so great after finally starting TB treatment, who I saw in the clinic and is all of a sudden not doing well, and had been mismanaged a few days ago, and was sent home instead of being admitted. I thought about JC, and how Saturday was his birthday, and was glad that he was home on a weekend pass, to celebrate with his wife and daughter--I am learning JC's story, and it is inspiring. While thinking of these patients, and many others whom I have not written about I vented multiple times to Cecile (who is in medicine as well) about my frustrations.

 

I reflected on what it has been like to be so far removed from the lives of family and friends, and colleagues, and to have missed special occasions etc. And what it will be like to return. I find myself bringing this up more and more with a few friends who are perpetual transplants in this world.

 

I felt guilty for enjoying the weekend. I know my consultant does an incredible amount of work on the weekends, part of it has been on a project I am involved with. And I envision him sitting at the computer doing some work, and there I was watching hawks fly overhead, making false goals to come home on Sunday (tonight) and to complete the 20 chart audits I have brought home for the weekend, as well as the database which I had hope to have revised by tomorrow.

 

I didn't enjoy wondering if we would encounter "Bandits" who are known to roam these parts and "steal hiking boots" and other things at night while people sleep in their tents. But it made me think how dire things must be if people who live in the surrounding areas can only survive by occasionally borrowing from persons who can afford the luxery to have fancy outdoor equipment and come invite themselves into their backyard. I had taken what I had hoped would be plenty of bribery money so that if I was awoken by strangers at night, I could give plenty of money so I could keep my boots. Hiking back today, I was glad to have my hiking boots.

 

As we approached the car, I couldn't help but think about how hectic tomorrow will be. Yet, I didn't find myself dreading work tomorrow, I found that I was actually eager to get to the wards, and see that my patients are doing ok.

 

Time to wrap this up. There'll be no weekend warrior next weekend, as it will be a frantic weekend getting caught up from the two previous weekends spent away.

 

I must add, though, that I was very distressed to learn that ibuprofen (aka wonder drug) is only sold by prescription here. I can consume ibuprofen like tic-tacs at times, and could really use some tonight, seeing as how I depleted by ibuprofen stock months ago. I actually had to ration them in Nepal. And had I know, I would have stocked up there for the return trip.

 

Cheers.

 

PS: photos coming up soon.

-

Mixed Bag

It's kind of been a mixed bag week. Almost feels like I'm on the hematology/oncology service, as most of the consults I'm covering in the hospital seems to have blood or lymphoma problems, too little of one, too much of the other.

I admitted a patient from the clinic yesterday. Who, I felt was quite ill. Wrote his admission orders and left a fairly good laundry list of stuff that needed to be done when he was admitted. Went to see him this evening, and was a bit annoyed to see that they hadn't even bothered to do most of the things that he needed done on admission, and to annoy me even further, they admitting registrar seems to have completely minimized his symptoms and level of illness. I had the luxury of having plenty of time to take his history and examine him in the clinic. I am almost willing to bet that that the admitting resident spoke to him for less than 5 minutes, and probably only listened to his lungs, then copied my admission note. Which would be fine, had the lame-ass bothered to copy what needed to be done for the patient. This guy may not live; this is based on my recent experiences.

JC's story is unravelling.


That's gotta be it. It is almost 10 pm, must quickly pack for a weekend backpacking trip, have about 10 charts to review, and some other things to get done.

Cheers.

-

JC

My phone rings this morning at 8:30. It's one of the ID attendings, asking if I know where JC is. The radiology department had just called her to try and track down JC, and they couldn't locate him (doubtful they even tried, but I wouldn't want to be the one spending an hour searching wards for a patient, just rather call the person who ordered the test). So she asks me if I have seen him. And wouldn't you know it, I get to be the one to try and track him down...

 

So I head to the most likely place. The ward he was originally admitted to last week. That was ward 38. Though he was never technically in ward 38. He was admitted to ward H1. And then on Thursday he was bumped to ward 22. It took me half an hour to find him on Thursday. So I show up at 38, no sign of him. Perhaps he just hasn't returned from his weekend pass yet. But I'm slightly paranoid about what radiology wants, and I'm a bit worried that they have bumped him from a CT scan which has been arranged for tomorrow, to a study today. And if they want to do it now, and we can't find him, it's possible he will lose his spot, and then god knows when it will happen.

 

I depart ward 38 and decide to head off to ward 22. As I'm stepping into the ward, the attending calls me again to explain that what radiology wants is to confirm, again, the details for tomorrow. The CT scans are so backed up at Bara (do keep in mind there are 2 CT scanners, for 2,000 plus beds) that on Tuesdays they send patients to a nearish by hospital do have scans done there. They depart in the morning, and return in the afternoon. Everything has to be arranged for the trip. A functioning IV has to be working, the consent has to be signed, and food has to be arranged.

 

As I walk into the ward, verifying the details with the attending, I hear my name called out, "Doctor Brian." My surname is too confusing to pronounce, and in fact, I've grown to prefer Dr Brian.

 

JC is back. We chat about the weekend. He had a nice time home with his wife and daughter (who I keep referring to as his son, and only half the time does he correct me, so I am perpetually confused if he has a son or a daughter). I write a brief note in his chart for the ward team, again laying out what needs to happen for him to get his CT scan tomorrow. While this may not give all the answers, it'll hopefully shed some insight into the mass that is easily palpable  in his abdomen. I finish my note, and tell him later I'll see him on rounds.

 

A few hours later the attending and I go visit him. It really is more if a visit than to evaluate him.

"Here, I'm done reading these," he says as he hands me back some magazines I left him.

"Pass them around, I've already read them." It's a bit of a lie. Last week when he was admitted, he forgot to bring something to read, so when I was at the bookstore I picked up some magazines. As an aside, I actually found it quite tough to figure out what he would want to read, and I didn't want to pick something insensitive, like Home and Garden or Men's Health. I figured current affairs are always safe, so I grabbed a Time and some other local current affairs type magazine. I honestly can't recall what was on the cover of time, but on the cover of the other one was an anti-genetically modified article. This cover is showing as he hands it back.

 

"GM foods are evil. More attempts by the US to make profit on the hungry in the developing world."

I love it. Just love it. The comment is from one of the ward docs who passes and sees the magazine.

"Actually, we're just trying to save the world from starvation," I add.

"But don't you think that modifying the genome of foods will possibly have some consequences that we don't know about," asks JC.

I confess to him, "I don't know anything about GM foods, I just like to play devil's advocate when US affairs are mentioned in a negative context."

 

JC goes on to tell me his concerns with GM foods. I will never be able to explain how bizarre this is. I don't have these conversations with patients here at Bara. In fact, as he is talking it dawns on me that he have such little interaction on a personal level here. I have a flashback to talking about Moby with a 50 year old patient when I was on the CCU service as an intern.

 

But there is more to it than just having a conversation, it is the fact that we are having a fairly cerebral conversation. I am not sure how to word this in the most appropriate context, so let me preface by saying that if what I write seems offensive, or insensitive, then it reflect my desire to type this out quickly so I can get back to the hours of work I still have to get done tonight. The population that accesses health care in Bara are not persons who are employed in careers which have required higher education. Which is not to say that the people aren't in-tune with current affairs etc, but to be discussing the science of GM foods is a rare at Bara.

 

"So, you're calling my bluff."

"Eh doc, it's no problem. I studied biochemistry before."

 

Before. Before he ended up as a refugee in South Africa. There is more to his story, but I don't know it, yet.

 

 

 

BPB

Champagne Castle

We orchestrated a weekend retreat this past weekend. 5 of us rented a Chalet in the central Drakensberg. I'll get the pics up in the coming days. We got off to a delayed start, and the initial mood was slightly less than festive as the traffic in Jo'burg was horrendous, and what should have been a 4 hour drive took 6 hours. So we finally arrived at 10:30 to the chalet. And in true form, we unpacked, cooked dinner, and sat outside drinking wine til 3:30 in the morning. Waking up Saturday we just enjoyed the amazing view from the porch and had a lazy brunch, walked a bit, then had an evening horse ride, and returned to the chalet to cook up another storm. Sadly the weekend flew by, but it was a great weekend. We keep talking about "doing this again soon," but I fear that realistically "again soon" is sometime after my departure at the end of June.

 

 

 

Dead Wrong

Ok, I was dead wrong.

 

GT is dead. Made an afternoon round after clinic wrapped up, headed into one of the wards, and the curtain was closed around his bed, and when I peeked in saw the defib machine. That's the surprise. He's the one I thought would live, at least for a longer while (talking years).

 

So I walked to find JC and see how he was getting on. I calcuated that 60% of the patients I have admitted from the HIV clinic had died. So I was worried about JC. Finally tracked him down to another ward. He is status quo. He'll head out this weekend on a weekend pass, and has lots of investigations lined up for next week.

 

I left him, and then as I was walking I saw PM, who is the guy who had infective endocarditis, from previous injection use. He was in clinic to follow up and to start HIV treatment, but has a fever, and so is being re-admitted. He was, in fact, discharged by the ward team earlier than we thought may be best. (Reasons-bed space?). I walk up to him as he is standing outside of Ward 20, the admission ward. He starts to talk, as his tears start to form, and he is explaining how frustrated he is, has been there all day, and hasn't gone to a ward yet, he isn't feeling well (and he's in mild respiratory distress as I watch him talk). He tells me how painful it was as the medical student kept stabbing and stabbing to get the IV and take bloods. And they want to poke him again. I'm afraid he'll just leave, he looks like he is at breaking point. But I am fearful that if he leaves, he won't be back, and he'll go home to die. I try to convince him to stay. He says he will, and I head off, wondering if he really will. 

 

Bara is a place like no other...

 

 

Vitality in your 30s

I'm tired. It's late. I have a good bit of work to finish before bed. But as I was driving home from my new late night bookstore (a SA B&N equivalent), I was thinking about today, and the guys who I am rounding on in the hospital.

 

They are all in their 30s. In fact, I am older than all of them. I though one of them was in his 40s, based on how aged he looked, but yesterday I realized he is 32.  Right now I'm not really sure what their individual prognoses are. Only one of them seems to really have a diagnosis, and that's Doctor. He definitely has non-Hodgkin's lymphoma. The other one GT remains a bit of a mystery. I think I'm starting to favor a diagnosis of lymphoma in his brain. He's waiting for an MRI. And JC, is likely to be lymphoma or some other nasty cancer in this abdomen.

 

None of them look well. None of them could walk to the end of the corridor without having to stop and rest. IN fact, GT can't walk period. There is no sense of vitality, at all.

 

But, back to JC. I'm at the bedside, with two of the consultants. One is Dr JT, who saw JC on Jan 22nd, and did the initial work up. She's a little miffed that an ultrasound was done to, among other things, evaluate the mass that you can feel, and about which there is NO comment on the ultrasound report, and the other is the head of our unit, Dr AK. We review the notes, and the likely diagnoses, and what needs to happen, and happen fast. Dr AK takes some ownership, and decides that we'll go ahead and arrange for some of the work up, we'll book the CT scan that needs to get done, and we'll add one some labs. There isn't time to waste anymore, the clinic already wasted 6 months of this guys life, and the team who has admitted him are post-call and swamped today, so we'll help them in getting the ball rolling.

 

While the 2 consultants get into a discussion about something else, JC and I talk a bit. I'm slowly piecing his story together. He lives with his wife and 5 y/o child. He is from Zim, and is quick to point out that he has refugee status. I tell him what he plan is. He'll have a CT scan. A bone marrow biopsy. An scope down this esophagus into the stomach, as likely have one of those large lymph nodes taken out. It's going to be busy, and unpleasant. He wasn't to know what he'll get for pain control for the bone marrow. I hope they give him something, but I am unsure. He remarks how he is glad he ended up at Bara, and that something is finally being done to help him. He explains to me how after a while he thought maybe there wasn't anything wrong with him like the clinic doctors were telling him, and that maybe it was all "in his mind" like they said. And that he would get better with the HIV treatment. My attending catches a bit of this conversation and shakes his head.

 

We talk about it as we're walking to CT scan, to plead our case and hopefully get an urgent CT for JC. Dr AK re-iterates the reason why he doesn't like to down-refer patients to the outlying clinics. (Down referral-basically transferring care to the community clinics which can manage HIV treatment). Even though there are more than 4,000 patients on treatment in our clinic, and even though there are 3 vacant doctor posts at our clinic, and even though sometimes the clinic doesn't finish until 5 or even 6, and even though sometimes the clinic sees well in excess of 200 patients a day, it's still better to keep the patients where we can make sure they are getting the correct care. It's not about work load, it's about good patient care...

 

 

BPB