Not For

I've been taking care of a 2 and a half year old who came in with general edema. Every morning when I get to the ward, he is in a fair bit of respiratory distress. Significant retractions. Essentially he blocks off his airway when he lies flat. I wake him up, the retractions settle, and I prop him up. Yesterday morning I grabbed the Reg, as he was having some stridor. We did a blood gas, which sure enough confirmed a respiratory acidosis. Fast forward to this morning. The Reg was called to see him (I had already rounded on him, woken him up and propped him up, left a note-again wondering about some diuresis). The Reg commented that we'd have to keep a close eye on him. And that he was "not for."

 

Not for resuscitation, or essentially mechanical ventilation. There would be little chance of him getting into the ICU and on a vent if he was intubated for this respiratory issue. That's just a fact of life. There are limited resources, and the decision of who gets aggressive medical care, and who is "not for" is, in some ways simple, but at the same time complex. I've asked a bit. Does it depend on HIV status? Does it depend on TB status? Does it depend on nutritional status (or malnuts=kids w/ malnutrition). How is this decision made. There isn't a magical formula. If the overall prognosis is poor, then it's pretty clear that the kid is "not for."

 

Our ward is on-call (or Intake) tomorrow. That means that today was "grand rounds" in which we rounded on every patient on our ward (what may be about 30 or so). We rounded with 3 consultants. One of them, Prof (not the main prof of the peds) was superb. Such a smart man. Very jovial and pleasant on rounds, asking tough questions and working through the answers. One of the other consults had more of a pimp style. They were night and day different. With the one, I felt what interns and residents in days past must have felt, feelings of inadequacy etc. Although, I will admit that half way through the round, I had to think that it's fair I'm not too sure what's going on, as I've never managed such malnutrition/HIV/TB meningitis/New onset heart failure etc.. etc.. etc.. I recognize that I'm here to learn these things, and that if I don't have the answers now, that's fine. (I also though, I'm here voluntarily to learn, I'm not graded by them, but rather am grading myself, and thus far, I think I've learned a good bit).

 

Anyway, I peeked in on this kiddo before leaving. During rounds, the Prof took one look and this kid and it was obvious to him that this kid was in heart failure, and needed some pretty urgent diuresis. (which I've been asking for 2 days). I chased up some results from the computer and was pleasantly surprised to see that his is HIV negative. I found the Reg and passed on this info.

 

The kid is no longer "not for."

 

 

 

 

Square One, and Hiearachy

I find myself in an interesting spot...
 
4 months ago, as a senior resident of the pediatric ward, I felt pretty comfortable in doing my daily duties. Admitting kids. Talking with parents. Supervising interns and medical students. Reporting to attendings...
 
Contrast to how things are shaping up for these next 2 months. I'm seeing medical issues that I have no clue about (HIV, marasmus and kwashiorkor-profound malnutrition states, meningitis-real meningitis) and things I suck at (blood draws, IVs). And I find myself a few rungs down the totem pole. Throw in the fact that I have yet to really grasp how the system works (blood forms, ultrasound forms, xray forms, discharging patients), and I find myself a bit out of the comfort zone where I was coasting nicely back in March.
 
I thought a lot about some of my colleagues back home. I recalled being on night float as the senior resident, and my "intern" actually had 2 years+ more experience than me, and how odd it felt. And I'm in his shoes now. I'm not too sure my registrar (my senior resident) has much idea that I've 1.5 years pedi training, and that I have  good deal of pedi knowledge, I just don't know much about the things they see on the wards here. It's all a bit humbling. But, thinking back to some of my colleagues back home, and even those who were fully qualified and ended up repeating internship level, I guess I can take comfort that there are many who have also been through this, and dropping down the hierarchy is going to get me the experience I came here for...
 
My gym membership starts today, so I'm off to the gym to expel some excess energy.

First Day

What I really need to do right now is go for a nice run to let some thoughts settle, but dusk is approaching, and I have a lot of stuff to read tonight, so Instead I've decided to sit on the back porch and jot down a few thoughts.

 

My schedule: Talked to Prof this am, and looks like I'll be spending 2 months on wards, then a month in the HIV clinic, and then a month in neonatology (I'm going to justify this in a later post because many remember the lack of love I felt for NICU back in January), and then back on wards for the final 2 months. I'm working on setting up some vacation for those final 2 months, and think that will the the trip to Kilimanjaro--for those who want to join.

 

Today: I rounded with one of the ward teams, which won't be the team I'm working with starting tomorrow Ward Teams consist of 2 Interns (these are second year interns-internship is 2 years of 4 month rotations in core disciplines), 2 MOs (medical officers, akin to SHOs) and 2 registrars (Senior residents specializing in pediatrics), and then there are 3 Consultant attendings to a ward. Intake/Call is q 4 nights. So today I rounded with a team post-call/intake. The consultant saw all the new patients from intake, and I was just awe-struck by the thoroughness on rounds. Fantastic teaching (give me a second and I'll tell more about the kids on the ward). After ward round w/ the attending, the post-call reg left, and then the registrar and the intern and MO who weren't on call rounded on all the old patients and made a list of things to do. When that was done we grabbed a bite to eat, then went back to the ward to complete those chores--which consisted mostly of blood draws, restarting IVs etc.

 

Blood Draws: I've made it know that this is a skill which isn't something we do well. Although, I figured give me a butterfly needle and I may be able to hold my own. Alas, no butterfly. Also, routine phlebotomy from arterial sticks rather than veins. Also from external jugular veins. Going to take some getting use to this practice. And for those back home, certainly no child life..

 

Kids we're taking care of: First off, pediatrics is defined as up to age 14. That's a little bit different. I want to avoid the gross-guess what I saw statements that often come across in writing...

 

As expected, lots of kids are HIV+ and lots of problems related to this as well. I did see a pretty routine bronchiolitic kiddo, and one or two with gastro. But the others have issues such as Potts Disease (TB of the spine), Reyes Syndrome (Traditional healers crushing up aspirin, acetaminophen, motrin, and using in traditional medicine preparations), multiple kids with meningitis-including one with a strep species. There are sick kids right now on the ward who would be in the PICU back home. Sadly, though, getting into the ICU is limited here.

 

I kind of hesitate to write more at this point, because I don't want to lose sight of the big picture which is that I'm uber-impressed by how smart the docs are, and in the context, I think the care is really good. I'm not sure how to write without making my point seem more of "look at this suffering." And since blogs are in a public domain, I don't want things to be portrayed unfairly. SO I'm going to leave it at this for now.

 

Cheers.

Cops vs Cops in Shootout

And this comes from... the headline on today's paper. I am not sure this link will work, but try: http://www.thetimes.co.za/News/Article.aspx?id=791079 for more information. And here I thought the cops were for safety...

 

Not much else really going on. Low key day. Went into Melville and scouted out a few restaurants, ended up hanging out on a coffee shop for a few hours and read a while. Speaking of coffee.. I've been back on instant coffee. And every more sadly, the instant coffee I bought is tainted (I use that word correctly) with chicory. I have coffee w/ chicory once before, and vowed to never drink it again. Well, that vow is up. I've been drinking it. So, imagine my delight when I found a single french press coffee maker in the cabinet yesterday! Woo-hoo. Don't get me wrong, I'll keep slugging the instant crack form of coffee, but sometimes ya just need a good cuppa. My stay here is too short to invest in a larger coffee press, and my budget this year won't allow for buying good coffee often, but I'll appreciate the occasional cup of single press when I do have it. Let me also mention what a great flatmate JW was for being a fellow coffee fiend and often times having a cup ready for me in the AM!

 

I got an email from the prof today, and looks like I may even be able to start on Monday. It that happens, will be more observational, as my indemnity insurance won't start until July 1, and as of right now, I'm still not licensed.

 

I'm getting a fair bit of reading done on HIV and other topics I don't know much about (malnutrition, congenital heard disease), and also reading a bit on pediatric infections. I'm using a SA text (which quite honestly I think it the best pedi text I have ever seen), and the antibiotic coverage is somewhat different. I think that is going to be one of the big adjustments is getting use to different meds. But hey, that's why I'm here.

 

I'm about to send off an email to our Pedi ID doc to ask her some questions about stuff back home. When was our last case of congenital HIV? What treatments do we use? How is it that I don't know the answers to these questions???? 2 months in the newborn nursery and this issue never came up? Oye!

 

Anyway, I'm sitting outside, the sun is going down. I'm going to make fresh cup of tea. I won't be out long, as soon as that sun is down it's chilly!

 

Cheers

 

 

Take your phone-in case you get mugged

[Disclaimer: Don't freak out, and I will apologize now if any of this seems like trite American in foreign place shit]

 

I actually didn't have any errands to run today. I'm pretty well settled in. I need to go back to the the med school campus one last time to get my staff card photo taken (exciting), and will combine that with a trip to one of the trendy-artsy areas (Melville).

 

Today, I decided I'd visit the Apartheid Museum. It was very humbling being in the museum, and to just know that human nature can be very cruel. The museum is full of photos, news clips, and stories. Sadly, I forgot my camera. There were exhibits of hanging nooses to represent people who were executed by the government (or who "committed suicide" in prisons or jails). Also, re-creation of solitary confinement. It was inspiring to watch clips of the Soweto riots as well. I left the museum, and then on my agenda was to explore another area of JHB.

 

So, I arrive in Newtown which is much different that what I had pictures, and quite frankly, different than my trusted Lonely Planet had depicted, and decided that the area was perhaps a bit out of my comfort zone to go walking around. Silly, possibly, but quite frankly I'm not bold enough yet to go places that I'm not entirely sure I'm good to roam around, solo.

 

This was similar to when I went driving yesterday afternoon. I needed a study break, and decided to actually drive down to Bara. I kept going down the road a bit, and after a few miles realized that I didn't see any other white people driving, or walking, or anywhere for that matter. 

 

This afternoon, while reading, I was starting to feel stir crazy. I needed to get out and expel some energy. I needed to go for a run or something. Incidentally, I did join a gym down here, but that membership doesn't start until July 1. So, I talked to Jemma, who lives in the house, and has grown up here. She said it was safe to run, and pointed me in the direction of a small park, and also of a close by nature reserve. I had known about the nature reserve, but didn't realize I was as close to it as I am. So, I decided the nature reserve would be great to check out. And it's literally a few minutes down the road. So, I'm headed out the door, and Jemma adds:

 

"Take your phone, in case you get mugged."

 

And it dawns on me, that if I do get mugged, the only thing they are going to get is my phone! Well, maybe my running shoes too. I point this out, and then Jemma convinces me to take it in case I get lost.

 

The run was great. I ran through the a neighborhood to the nature reserve, signed in, and ran until the park closed (5pm). It was nice and cool out. On the outbound portion there weren't any building to see, and the area opened up to this nice meadow. There are hills around Mondeor, which thankfully break up the skyline. On the way back the sun was hitting the horizon, and the hills took on a reddish hue. Running back, out of the park, I was greeted by the 4 or so white people who were out and about. This struck me as soooo unusual for various reasons. In Dublin no strangers say hi. In Springfield, no strangers say hi. I said hi or nodded to others who weren't white, and kind of got strange looks.. Interesting.

 

I'm sure I'll be sore tomorrow.  

 

 

 

 

Mantra

The mantra for today: "Stay Left."

 

It's really tough to make your brain continually do something the opposite way, when it has been doing something for so long. They dropped off my rental car this morning at 11 a.m. And initially, I was disappointed that it was an automatic. However after driving just a short distance, it was nice to not have to navigate shifting while getting familiar with driving on the left side of the road again. I managed to make it to two shopping centers, and to the medical school in downtown Jo'burg. On my taxi ride home last night, I spoke with the taxi driver about the cost of petrol. And, I think we figured it out in that it is about five dollars per gallon. It was a little bit painful to fill up at the pump this morning.

 

For those who want to now, both my bags made it. This is in contrast, to the little brother who's bags failed to reach their target twice on his recent trip with their family.  Having already unpacked.   am quite impressed this time. I don't think I packed anything to ridiculously unnecessary for this trip.

 

The house is nice. Right now, and the owner's daughter is staying here as well. Otherwise it is just she and I. There is plenty of space here. I will try and put some pictures up, but it will depend on the Internet situation.

 

Speaking of the Internet, I paid a small fortune for access to the Internet. I had to buy an adaptor which will connect me to one of the mobile telephone companies, and subsequently will pay per kilobyte of download. This is an expense which I suspect will be well justified. I went a time without home Internet access, and think that having home access to e-mail is essential. There are some downfalls, mainly there won't be much ability to surf the Web aimlessly (which may be a good thing), but also will affect my ability to upload lots of photos-well, at least from home. And, I don't think Skype will be all that great with the connection speed I will have.

 

I went to the medical school today to find out the next chapter in the saga of my quest to obtain registration with the Board of medicine here. To recap, initially, I was to have received my registration back in March. And then there were some minor issues which I will not bore you with, but suffice to say my license was supposed to be issued by June 13. It has not been done yet. Which, really isn't all that surprising. There is a good hope, that it will be done before July 1, and now that I am physically in the country, it seems to give some credibility that I actually deserve the license because I am here. Regardless, I will be starting July 1, and will have activities tailored to the presence or absence of a license.

 

It's nice to be back abroad. A change of scenery. Languages I don't understand. Constantly realizing I don't know the norm (whadda mean I don't pump my own gas).  I'm sure there will be more on this later.

 

PS -- Jo' burg is 6 hour ahead of Boston.

Abu Dhabi

I'm in Abu Dhabi airport, had a great flight here. Watched 3 movies. Hats off to Ethihad airlines. Wonderful service as well.

 

While over Belgium, I really began to settle down. I looked out to the cities below (well, the lights of the city) and had this sense of adventure, and finally began to feel excited again about this upcoming experience. The planning details had been all encompassing recently...

 

Anyway, my battery is about to die. So this is short.

 

Here are a few pics from the sendoff. My bon voyage entourage spent some time with me at the airport before leaving me at security... It was great to see a few friends for drinks the night before, and then to be driven to NYC. Thanks to Lucia for the great hospitality, and letting us barge in at 2am!

 

http://picasaweb.google.com/BackToBara/NYCSendOff