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.

 

Cruise Control

Not a whole lot to report right now.

 

Swazi trip was good. Great weather. Camping under the stars was lovely. The "trail" on Sunday was not lovely, and I have the scratches and cuts to prove it. The company was great. I drove through Mbane, the main city-well one of them- 5 years ago. I didn't remember it being so hilly, and nice-appearing. We made it there in about 4 hours, so that was nice.

 

I am taking care of a patient I admitted at the end of last week. Pretty tough situation. Young woman who has progressive neurological deterioration. She defaulted coming to the clinic in March, and showed up last week emaciated, weak, and with worsening coordination. When I saw her Tuesday, she looked much worse to me than when I had seen her last on Thursday. Yesterday her brother called me, and I asked him his opinion-and the thought she actually was looking better. "Help me, I'm dying" is what she told me today. Sadly I think she is right. I was talking to her main clinic doctor on Tuesday the gist of the conversation being what happens when a patient says they are dying. For on Tuesday-I certainly came to the same conclusion that the patient verbalized today. Our consensus was that, when a patient says they are dying, they're usually right. And the goal is to get her home so that she doesn't die in the hospital. She's booked for an MRI tomorrow. It's quite a tragic story, in this land of endless human tragedies. 

 

Wednesday I saw SM in clinic. He's gained 8 kgs (16+ lbs) since I hospitalized him in Feb. He is back to work. He looks amazing. I've been breaking the news to the patients that I've gotten to know since January, that this is my last month in the clinic. (Though I confess, there is an overwhelming lack of motivation to find the head of ICU to coordinate my starting in the ICU in May). And so I told SM and his wife that this would be the last time I see them in clinic. They were disappointed. "I have my husband because of you." How does one respond to that? Guilt because the work here is endless, and it feels like betrayal to leave patients that I've gotten to know well, in such a short time. And anger-because SM didn't get the care he deserved and that all I did was admit him back to the hospital and literally throw the kitchen sink of antimicrobial treatment at him hoping to kill anything that was living in him, a treatment that should have been done weeks before he ended up in my examination room back in February. Thankfully, one of the consultant/attendings will take over his care when I leave, and they have a great rapport with her as well.

 

I was going to write a bit more, but there have just been some gunshots in the neighborhood, and it's late, so perhaps it's a good time to turn out the lights and go to bed. Oh, and this is the second time, in as many weeks, where there have been gunshots late at night. I'm slightly annoyed, because I staunchly argue to my friends that I live in a very safe area. And since last weeks gunshots, I've decided that running after 8pm isn't such a good idea now that it is getting dark out.

 

 

Happy Easter

It's a 4 day weekend here, and the town will be deserted by this afternoon, me included. Cecile, Myr, Thomas and I are headed to Swaziland in a few hours. We'll stay in a B&B tonight, then hit the trail tomorrow and be back late on Monday. It'll likely be the last big hurrah... And the last backpacking trips (sniff sniff) til I'm back in Massachusetts.

 

The week flew by, and I meant to stop many times and make a post. But obviously the posts stayed in my head, and didn't make it here.

 

In a nutshell... (I'll expand on these next week, ideally).

 

Economics of Poverty: Sat in on a very interesting meeting where AK met with the NGO which largely funds the clinic, and was an observer to the economics of HIV/AIDS, specifically to how US funds are being used for our clinic. Some readers have read the book. I've enjoyed pointing out that I am paying for this clinic through my US tax dollars

 

JC: Popped into my office yesterday, looks great. Have invited me to come to a braii and meet his family.

 

There seemed to be some more things, but I was due to leave the house 15 minutes ago, so better head out.

 

Happy Easter.

 

 

 

This is why...

[Disclaimer: this is more of a personal post, but I'm throwing it into the blogsphere. I don't hide my uneasiness of my upcoming move back to America, but perhaps in recent posts I haven't fully explained why Jo'burg has-so completely-caught me off guard. This may not be the most eloquent post-but I'm going with it.]

 

As I was driving home Sunday evening, I couldn't help but obsess that I am under the 3 month mark. It had been a non-stop 3 days. An almost maniacal pace to making sure to enjoy my weekend. Work. Friends. Fun. Not wasting the present moment, aside from the drive down the M1 toward home, wondering how I make sure to squeeze every drop out of my last months here.

 

JT (clinic doc I work with) "What's Holy Cow?" she asks me as we both walk down the hall. I'm caught slightly off guard.

Me: "A cow in India?" I assume there must be a joke here. Then I realize I'm being culturally insensitive. "Actually, any Hindu cow."

JT: Smiling. "No really, I've never heard this expression before."

Me: "Huh?"

JT: "You just said 'Holy Cow' a minute ago in the hallway."

Me: "Did I? Oh. Well, it's a more polite way of saying 'Holy Shit' if you really want to know."

 

I'd just come out of my examination room, and ran into SM. He's the guy I admitted back in February, who came into the clinic having been sent out of the hospital in January with a whammy diagnosis of AIDS and PCP pneumonia. He had to wait a month to be seen in our clinic. And when I saw him that day for his initial visit I admitted him back to the hospital, thinking that his PCP wasn't getting better, that he likely had some TB as well. What the hell, I figured, he looked so bad that I decided we'd just treat him for everything but asthma.. When I left for vacation, I'd just seen him in the clinic, and he was breathing better, but still looked like crap. And so there he was in the hallway, he'd put on weight, he was able to talk without having to stop and catch his breath. I don't know if the "Holy Cow" was when I saw him, or when he asked for a letter saying he was ready to go back to work. That was Thursday.

 

Then on Friday morning, as usual, there were folks milling about outside the entrance the the clinic. The packed waiting room was to be expected. There were already charts pulled, people were ready to be seen by the doctors. It was going to be a hectic day. But hectic is the norm for this clinic anyway. Friday was hectic to a new level, given that we were short four doctors. But really, that didn't induce stress or concern because all that we could do was just plug away and know that at some point we'd get through seeing all 185 patients. I managed to see just over 30 patients during the day. Most were fairly routine. A few were complicated: failing treatment regimens, sick visits, questionable TB diagnoses. In addition to HIV, I meddled in routine management of high blood pressure, diabetes, and epilepsy. But I enjoyed the day. And as I packed up my stuff, I thought back to some of the patients I had seen, and that's when it dawned on me, that I hadn't discussed any of the patients with an attending. Which isn't unusual, per se, but almost invariably I look for guidance on managing an issue, or turn to my attending for help when I'm stuck. But, things had just clicked during the day. There were times when I didn't know for certain exactly what my attending would do in such an instance, but I was confident that I was making good decisions.

 

We, miraculously, finished clinic at 4 pm. And I walked out with AK,  and Dr. T (the other clinic consultant), reflecting on the day in general, but also on how busy the clinic continues to be, with no end in sight, and likely escalation of services. (There are some 500,000 people who still need to get on HIV treatment in SA!). And then there was talk of other clinic business, a conversation which maybe wouldn't involve junior staff in many places. The whole event of Friday's clinic made me feel like I'm an employed doc there. This is why I'm dragging my feet on setting up a new rotation for May and June. I could easily stay in the clinic for two more months. Though, after chatting with AK and Dr T, I went to the wards to try and find a patient that I had admitted, and ran into the Chairman/Professor of Medicine. I hadn't seen Prof in a while, so we chatted about the clinic, and also about my schedule for the rest of the year. We also had a great chat about Kili, and Machu Picchu, and travels in general. And I almost died when he suggested I take a few days off to go travel to the Okavango Delta, in Botswana. [Jean-I hear you].

 

I was home for about an hour on Friday, chatting to my new house-mate (a Kenyan anesthesiologist) and then was out the door to go visit AC. AC was holed up in his house, having had some kind of "face surgery" on Wednesday. I'd been lying to friends all week, saying that AC really had Botox and that it had gone bad and he was too embarrassed to see the world. So I headed up to his neck of the woods, and we had a great evening eating take away, catching up, and watching episodes of Little Britain and other mindless crap on the TV. But it was nice to just have a night in.

 

And then Saturday... I went to the gym in the morning, which I NEVER do. But I knew it was going to be a gastronomic day, so decided to do a little damage control before the damage was had.. And then CB and TB and I (CB, TB, BB-whoa) went for High Tea at the Saxon hotel. Talk about chic. Talk about lavish. Talk about fun. Sitting outside, on a beautiful fall day, sipping champagne, eating scones, cucumber sandwiches, and other heavenly desserts while planning next weekends upcoming backpacking trip in Swaziland was pure bliss. The bill was 630 Rand. That's roughly 63 dollars. For all three of us. Twenty bucks per person for high tea at one of the classiest hotels in Jo'burg. This is why...

 

And then there was a bit of excitement. We were all in separate cars, driving to the outdoor gear shop at the mall, when we came up on a car wreck. A truck had overturned. Thankfully, CB is also a doc. We walked over to Moses and took care of him for the HALF AN HOUR that it took for an ambulance to arrive. Moses had pretty nasty head wounds, which were bleeding pretty profusely. He wasn't really all that bad, aside from blood everywhere, which included on my khaki pants by the time we were done.  And we proceeded to shop, all the while I was hoping people wouldn't notice the blood on my pants. This being Jo'burg, who knows what people would think.

 

Thankfully, I had packed a change of clothes. One never knows when they'll have to render first aid and get all bloody in the process. So I headed over to S&S house to change. Actually, the plan had been to have dinner with S&S, and just before leaving home earlier I'd grabbed some extra clothes, kind of thinking that we were long overdue for a late night in which I usually just crash at their place. So I headed over to their house to just relax on the porch and have a chance to catch up with them. While we were hanging out, David called. He's this lovely guy from Argentina, married to great South Africa guy who had left that morning to start his new job in Abdu Dhabi. So of course we quickly told him he was joining us for dinner.

 

Dinner ended up being 6 of us, with S&S, myself, Clifton (whose boyfriend-the Belgium pediatrician-was out of town, skiing in Europe), Argentina David, as well as British David. The food was decent, the wine was superb--and flowed freely, and the conversation was fun/hysterical-and flowed freely. We must have finally left the restaurant sometime after midnight, and then headed out to go clubbing for a few hours. A few of us ended up back at the house, and we crashed for the night. Well, Siza and I decided it was necessary to continue drinking wine til just past 5am. The morning after usually consists of breakfast, and then we all depart on our way. But after breakfast, we went back to the house, lounged around, and then headed to an Art Show. Not that I have any appreciation for art, but it was fun people watching. As that wrapped up, we bumped into more friends there, so then we all went for coffee, and then ended up back at the house for a bit, and then headed out to dinner. Finally, well past dark, it was time to head home.

 

This is why... I'm having my cake, and eating it too. I know this cake is going to be gone. And I have a hard time thinking that the next cake is going to be this delicious.

 

On Thursday, I got to see SM, in person. To see that he really is better. That he feels better. That he is actually going BACK to work. It's powerful to see folks, who are close to the brink of death from HIV, make these recoveries. And sure, it sucks to see those who don't make it. I find this immensely gratifying. I contrast this to the work I do back home, which I do find gratifying as well, but to me the outcomes back in Massachusetts/USA are more certain. I feel like there is more of a guarantee that folks will get better, but that here, that guarantee is gone, and so there is a level of pleasant surprise when people get better. There is also more of a challenge practicing medicine here. Labs may not come back quickly, x-rays are slower. CT scans are days away, and MRIs are almost nonexistent. You have to make a clinical diagnosis, and plan your treatments, and weather the storm while waiting to see if you're on the right track or not. And it's gratifying to have to use more cerebral power to take care of patients, than to use technological power to figure out what is going on.

 

On Friday, I felt like part of the team. There wasn't a division between resident/attending or junior doctor/consultant. We were all there equally, with the attendings there for problems we couldn't handle. And I'm so familiar in the clinic now that sometimes I literally forget that I'm not employed there, and that, in fact, I'll be gone from this clinic in May. I felt like I had the leeway to practice my own style of medicine. I changed HIV medicines on a few patients. Started different blood pressure medicines. I reveled in the autonomy of Friday. This does become a mute issue after I finish training, period, but it added to the overall pleasure of my work here. I could explain further, how part of the underlying issue is that the repercussions of litigation do not exist (which is not necessarily a good thing). I didn't have to worry that-even though I think I made the best clinical decisions possible, down the road some lawyer would find an article saying that when I changed a medicine or started another one, that I had made a bad decision...

 

And then the weekend... I have to preface this carefully, for it would never be my intention to disrespect the great friends I have amassed back in Massachusetts, back in Dublin, Back in Colorado, and now scattered around the globe (aside from Antarctica). When I lived in Dublin, one day a very close female fiend of mine lamented on how she felt she was missing close friendships with other women. And I was slightly put-off, which showed. What did imply for our friendship? That even though we shared this close friendship, it wasn't of the same caliber as a friendship with a woman? But now I get it. For the first time since I came out (way back), most of my friends in Jo'burg are gay men, and they are great guys. Their friendship is different than the friendships I've had when I lived elsewhere. Looking back, in the past many months, we've often had dinner twice a week, and rarely have we not met up at least once a week. There is a level of trust in our group (so much so that scandals are volunteered openly). It's not like the group of men I think of when I reflect on where I have lived previously. It's unique. And there is the international mixture as well, which adds an extra element to the group as well.

 

And of course, there is Jo'burg and SA itself. I am mesmerized by the workings of the city. I get motivation from seeing those who work so hard, yet have so little. And of course, there is Bara itself, a hospital unlike any other hospital in the world! I don't write this as a comparison to my place back in MA, and folks know that I think the hospital back in MA provides excellent medical care, and that it provides well for us junior doctors, and that the teaching there is top class. If Bara ran as well as that hospital the people of Soweto would be immensely lucky, and healthier.

 

So, this is why I find it difficult to leave here. I can't describe how excited I am to arrive back and see my family, my friends, and the newest additions to both.

 

This is why a part of me will remain a Jo'burger for life.