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....
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