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..

 

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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.