24 hours

24 hours ago I was at a dinner party.

 

S&S invited me out for dinner 2 weeks ago, and then I had dinner w/ them again last week, and they decided then to have a dinner party last night. I walked into their home. They have one of those homes that I think I had probably dreamed about owning at some point in life. There's a small courtyard, a small pool, a fireplace, a gorgeous dining room, and a very chic kitchen. At some point in life, I think I wanted a home like this. Or like the home B&B have in CT, or the home H&R have in Boston (and the cape). A sort of elegant sanctuary. Now, I'm just happy to have friends who have these gorgeous retreat-like homes, and would rather just show up and enjoy their homes from time-to-time, rather than the thought of ownership. The thought of owning a home gives me a choking sensation. The thought of having friends who own nice homes, makes me smile.

 

It was such a stimulating night, I didn't want to leave. And when it was 2am, and I knew I had to be up in 4 hours, I decided that I really had to leave!

 

People I met last night:

 

V: Who was at the dinner 2 week ago. A lovely Belgium pediatrician who has been working in SA for the past 3 years or so. I've made a mental note to ask him how he became licensed in SA. Nice guy. Very humorous.

 

D: Fascinating! UK Doc, who works more in the microbiology aspect of the STD world. SMALL WORLD HERE! My boss from Denver Public Health was here a few months ago working with D!!! WHOA! And, D is good pals with all the head honcho Docs of DPH! Everybody I worked with back in 1998-He knows, and works with some on international committees, etc. This is just exciting. I'll at some point mention my other small story world.

 

T: Is a college prof, who works with Human Rights Watch, and has done most of his work in Rwanda. Stayed in a certain hotel before it became famous. Lives part time in Cambridge, MA with his partner. Use to live next to a certain famous sex columnist-who actually wrote a great book about 8 years ago, which I have read. Fascinating guy!

 

D: From western Pennsylvania, who has lived in London, Sydney, and now Jo'burg, works in business, and had some of the funniest stories!

T: Cute, but not really worth mentioning. Mostly smiled the whole night, a little too young to be at the adult's table.

 

S&S: Elegant Hosts, who have been so generous the past few weeks.

 

Fast Forward to 6am. I'm wrecked.

 

I'm on the road to Bara, and for the second morning in less than a week I see the cops pulling people over. I notice a car pulls away from the road check. Cops are indicating for random cars to stop, and then it happens, they point AT ME!! I'm scared, but also really excited. I have my R 100 bill in the ashtray, and am FINALLY going to get to bribe a cop. Unless something goes wrong, and then I may end up with a fine, but who cares.

Cop: Drive's license please.

Me: (There is a slight pounding in my temples-my issues with authority trigger massive epinephrine releases from my adrenal glands).  I fish around for my wallet and grab my MA license, the cop is looking into the car as I open my wallet. Of note: there is about R300 sticking out of my wallet, and now it is going to be sooooo obvious when I go for my R100 bribe from the ashtray and try to tell the cop that I don't have any more cash--- he's just seen my loot.

Cop: Doctor? Are you on your way to work. (He saw the stethoscope on the passenger seat).

Me (aka Doctor-thinking it not wise to be a smart ass): Yes, I am (and there are sick babies that I need to perform emergency life-saving surgery on in the next 5 minutes, and I'm late, tired, and maybe have a slight titch of hang over).

Cop: Ah, sorry Doctor, you may go.

Me: (Membership, again, has its privileges). Thanks.

 

 

I arrive on the ward. We had a day off..

 

The night nurses like to play this game called patient shuffle. There may be rules, but I haven't figure them out yet. There are roughly 10 cubicles that have the beds/cribs in them. Generally the first two cubicles are freed up for the new admissions, which in part, lends shuffling of kids, but oddly enough, kids have been moved into these cubicles. There's also really no list to where the kids are, you just have to wander around and look for familiar faces.

 

I'm sitting at the computer checking labs. And I glance over to cubicle 3 to where two of my kids were, when I left on Friday.

 

My cutie jaundiced biliary atresia baby is there. But in the other bed, where of one my kids use to be is a now-unfamiliar face. So I get up and walk and peek into the other cubicles.

Death #5.

 

Damn.

Damn.

Damn.

 

I owe Indian food to my coworkers.

 

Sister (aka nurse), when did KM die? (Because it is obvious, to me, that he died, I don't see his face anywhere, and there is no other possibility of where he would be).

Oh Doctor, early in the morning yesterday morning.

 

I'm fairly sad. Then it dawns on me, that I didn't see my 3 month old who had a congenital heart defect, who was getting a sepsis work up on Friday, and had a horrible looking chest xray. (Though, who knows what her baseline CXR is).

 

Death #6.

 

Well, that's the only thing that made sense to me. And I'm taking this a bit personally.
 
Sister, what happened to KP?
Oh Doctor, that baby was discharged home yesterday.

 

Interesting for a variety of reasons.

 

Sister, there is no way he was discharged.

Oh Doctor, he was, I am sure.

Sister, was he discharged home, Alive? (Now I'm thinking that discharge may, in fact, include expired).

 

KP is dependent on supplemental oxygen (which appears to take about a month to get home oxygen sorted), can't bottle so gets fed through a feeding tube, was looking septic so was going to get at least 48 If not 72 hours of antibiotics, and we didn't work yesterday, so there is NO WAY he was discharged.

 

I let it go. He will show up somewhere, or I'll hear the story later. And it turns out he got intubated, and is being a bit of a pain in the posterior! Well, just refuses to be oxygenated.

 

He is not, #6.

 

I admitted 2 kids before I left this evening.

 

One is a 4 and a half year old who is heart failure, HIV positive, started anti-retrovirals earlier this month. Lives with grandma who is raising him and his 14 year old sister. Mom died of HIV when the baby was 2 months old. Grandma is a champion. She knows his antiretrovirals, give a great history of his illnesses recently. Is basically the one who took this kid from Dad because he isn't such a great parental unit, took the kid to get tested, and has been the motivating force, and the stability needed, for the kids to get meds!

 

Anyway, this kid is a cutie. He's in a little too much heart failure right now to smile and be interested in anything other than breathing and staying alive, but I bet when this kids feels better, he's going to be running all over the ward giggling and bringing joy to others. You can tell this kid brings joy to grandma. And hopefully in a few days, to Ward 18.

 

Good night.

I'm tired.

 

.

 

TGIF

It's Friday, and then end of a 12 day stretch!

 

I can't complain. I actually got out early, and have had a lazy afternoon. I'm sitting outside, just finished a Castle (popular SA lager) and munched some biltong (a SA meat jerky). I'm actually not sure what kind of meat it is-check out: http://en.wikipedia.org/wiki/Biltong. I almost made a break for the Drakensberg mountains this afternoon, but would have gotten down there about dusk, and then would have needed to head back early afternoon. Could have maybe gotten a quick hike in, but I also read about this amazing place to watch the sunset, and figured that I wouldn't be there for the sunset.. so am postponing. Maybe until next weekend. (If I can get my car all registered by then).

 

My 1 year old is still alive. His sats are better today, he looks a bit worse overall, but seemed more alert. It's really tough to know if he is suffering. In one sense, how can he not be suffering, yet he doesn't raise much protest. Though, he may well not have the energy to protest much. He is still eating, still peeing, which I take as good signs. He finally did get a chest xray at some point yesterday, after we had left. And it looks horrible, but he actually sounded clearer this am. I'm thinking there is a slim possibility that he may make it. I think this kid has got to be a bit of a fighter, he's been neglected for so long to get in this shape. One of the other docs thinks I'm crazy to think this kid will make it. She may be right, she has loads more experience. So, as crass as it may sound, we have a dinner bet on if the kid is still alive when we get back to work on Sunday.

 

Between yesterday and today, we've started TB treatment on half of my kids!  I'm learning the diagnostic criteria for TB.

1-positive PPD (skin test)

2-TB contact

3-abnormal chest xray and has a cough

4-weight loss and TB contact

5-exposed to somebody w/ TB and _______ (fill in the blank)

6-positive gastric aspirate or sputum for TB

7-Kid's been on antibiotics, isn't getting better, must have TB

 

Ya kind of hate to label kids with diseases, but the diagnosis of TB is very much a clinical one, and I've been trying to stick to objective criteria, but am learning that TB sometimes just has poor objective tests, or tests whose results take too long (TB cultures take weeks).

 

Have a good weekend.

Adios AL

A.L. Reaching for my camera
My pal

Farewell to my buddy. When I left, I discharged AL. I can just look and this kid now, and he'll start to laugh. He's been a tough cookie to crack, but he just needed some constant attention, and lots of tickling to make him perk up. Fingers crossed that he doesn't fall through the holes (they are larger than cracks) of the system.

This morning was a bit hairy. I walked in and noticed that my 1 year old malnourished, neglected, HIV kiddo was on a face mask for oxygen. And looks much worse. (his labs reflect it with a white blood count over 30 now, CRP over 240, platelets down to 27). He lungs sound horrible. His sats, on full supplemental oxygen were 68%. Somebody mentioned get an ABG. Why? What are we going to do different w/ those results. This kid is "Not For." I called the Reg to inform her. I really didn't think he'd make it another hour or two. He has these beautiful brown eyes. It's the only expression of personality that he has. He's too weak to make sounds (though he lets out a tiny, tiny cry when he gets blood drawn). He's basically too weak to reach out as well. An hour later he stopped making eye contact, he would barely crack his eyelids when touched. Somehow, though, this kid was still clinging to life when we left this afternoon. I want to be optimistic that, but...

I went for a great run this afternoon. As mentioned before, there is a nature area close by, and I hit out and instead of running the path that cuts through two big hills/slopes, I took the path that went up one of them. My plan was to see the surrounding area, and wait to the last minute possible to see the start of the sunset, then high-tail it out so I made it out of the park on time. I have a nice wipe out headed up hill, added a nice right next to where I gashed my leg while running a trail a 2 months ago. Of course, in my self-conscious nature I looked around to see if anybody had witnessed this, and sure enough, there were a few people down in the valley who must have seen, cause they were staring at me. I waved and kept going.

I'm looking forward to my day off on Saturday!

Driving

While at dinner on Sunday, I asked Scott-another expat on what happens on getting pulled over. The only ID I keep on my is my MA drivers license. I ask because I barely missed a road block a few days back (I decided to go home rather than head into Jo'burg and run an errand).

 

I guess a 100 Rand (15 USD or so) is the going rate for a bribe to get out of a ticket, whether there is a legitimate reason or not.

 

I'm keeping a ZAR 100 bill in my car...

 

Strike Three

AL didn't have surgery today. Strike Three. The herculean task of getting an ICU bed for his post-op day wasn't the issue. The anesthesiologists refused to do the case, on some whim, but basically saying they didn't think he was optimal (note: if her were optimal, would he need surgery?), and want to wait a month. The excuse they used was concern that he had been admitted for pneumonia (or rather what we learned was heart FAILURE). What-ever. The thing is, this kid is looking fantastic, and it sucks, but he's laughing, happy, he looks like a normal kid. I would take this kid home in a heart-beat. So, we're going to discharge him tomorrow, to follow up at the ENT clinic in a month (when the gassers have decided-albeit arbitrarily). This kid looks sooooo much better than we I met him on July 1, that I really have a tough time sending him out with a prescription for lasix, potassium, and a prescription for good luck in not getting lost in the system.

 

My jaundiced kiddo.. turns out to have... Biliary Atresia. I've gone 3 years without seeing a kid w/ biliary atresia, and now we have 2 on our ward?? Whoa! She's adorable, and smiles. And is likely off to the OR on Monday.

 

Pleasant surprise of the day: My extremely malnourished 1 year old is.. HIV negative. By PCR. It's official. He's not doing too well. His CRP (measure of inflammation) is now over 200 (normal < 10), and still going up. He's at least feeding. He's so sad looking. He makes eye contact, but that's about it. Ug.

 

We admitted to kids with meningitis tonight. One has meningococcal meningitis---another turbid tap. The other is strep pneumoniae. I have my stat dose of antibiotics to take since we were exposed to the meningococcal kid. But, I'm having a beer right now, so wasn't sure alcohol and the antibiotic were wise. Decided to leave the med for the morning, thinking the beer was more beneficial right now.

 

I think I've previously mentioned organophosphate poisonings.. Wiki it, but it's a nasty chemical which is used as a fertilized. I found out today that it is readily available. Sold in clear plastic bags. They are small black bead looking pellets, and are used as poison for rats etc. Which help in realizing how kids accidentally ingest them. Hell, if I saw a bag of them on the desk I'd likely pop a few of them in my mouth. Candy?

 

Except that my patient who I admitted w/ organophosphate poisoning this evening is a 13 year old who intentionally took the OD after she had a fight with her Aunt.

 

 

Just Another (Not?) Normal Day

This morning before I left the house, the lights flickered.

I don't even know where to begin. So, I will just go chronologically.

I arrive at 7:30, and first assess my three month old with jaundice who is going to have a liver biopsy at 8 am. I run the blood form to the blood bank so that the fresh frozen plasma is ready for her biopsy (it'll keep her from bleeding out after the biopsy-her liver dysfunction is keeping her blood from coagulating normally). Also, at 8 am, AL is suppose to go be seen by the ENT doctors, so I make sure to have seen both of them by 8 a.m. It is 745, and in my neurotic need to make sure that everything goes smoothly this morning I plan to remind the nurses that AL needs to be headed out the door to be at outpatient clinic. Unfortunately, the nurses have just begun singing, and their shift report will happen afterwards, so now I feel screwed knowing that nothing will be ready until 845.

Moving on... I go back to the blood bank after seeing KP. KP is my two month old who had heart surgery shortly after birth due to a congenital heart defect. Goal number five for today is to find a small size nasal cannula so that he can get weaned down on his oxygen, and hopefully get transferred back to the referral hospital. Much to my delight, a nasal cannula has magically appeared since I left yesterday. But, unfortunately it is not pointing into his nose but rather is pointing at his chest. [As an aside, I have been using adult size cannulas and trying to snip them shorter to fit children.] Now, KP is quite dependent on supplemental oxygen and he tends to get a bit fussy, and a bit blue without his supplemental oxygen. I checked his pulse ox while putting his nasal cannula into his nose, and let's just for the record note that it was way less than 70; his goal is to be greater than 70. In fact, it was very far from 70. Let's just say we set a new level for LOW pulse ox-and the reading was real/legitimate, it correlated with the heart rate I calculated. But, he quickly perked up into the 70s range with the oxygen. I taped to the cannula in place to prevent oxygenation attempts via osmosis through his chest. [Another aside, I'm getting really use to seeing sats in the low 80s, and in fact, I actually haven't been alarmed recently. I may have to have some re-entry training to get alarmed by low sats when I return back to the US].

I run to the lab and pick up the fresh frozen plasma. Biopsy time. In the room where we draw blood is where we are going to do the conscious sedation for the liver biopsy. The lights flicker-the power is threatening to quit. That wouldn't be good. Biopsy in the dark doesn't sounds like fun to me. I know, I know, where's my sense of adventure?? Regardless, iIt actually went quite smoothly.

I head out and check on my remaining patients. I glance at my watch after the biopsy is over, and get a little anxious realizing that it is creeping up on 9 a.m. AL still has not gone to the ENT clinic. I remind the charge nurse (aka sister) and she tells me that someone will take him shortly. I finish seeing my remaining patients, including my 8 year old friend to was discharged on Friday. It is now about 10 a.m. The senior residents have gone to one of the other wards to see a patient, so I have not rounded with them, yet.

One of the senior residents comes into the Ward and I tell her my plan is to round on my patients with her and then I will take AL to ENT clinic myself. I've been told this isn't necessary, and that I could be there for hours...

So, we finish rounds and I find where I have to go, which happens to be about a 10 minute walk. I debate carrying AL, but decided that wheeling him in a small mobile-crib-like-thing is better. And Jesus, let me tell you that this made such an intense squeaky noise that people down the road looked back in order to see what was so damn loud. Let me describe the noise. Take 500 children with long finger nails, let them scratch their nails on a pristine chalk board at the same time that 300 vultures devour small animals at the same time that 200 kettles start whistling. It was that loud, I don't exaggerate.

For the next 45 minutes, we would generate plenty of stares. Not only did the hideous noise from the crib force people to look, but the fact that this white doctor was carrying a black African child-I felt so Angelina/Brad/Madonna-generated plenty of additional stares. I managed to find my way to the ENT clinic, conveniently located on the 3rd floor. I grab my friend and up the stairs we go. And then I was slightly horrified to see about 30 people in a tiny hallway waiting to be seen. Not that I really care about waiting at this point, but lunch time is approaching, and I'm hungry. Oh, and one more minor detail. AL is on LASIX, a great diuretic. And it kicked in. For a minute, I wondered if I peed myself, but no, it was AL's soaking diaper. And I didn't think to bring a new one.

We got our number, number 80, and I decided what the hell, I had nothing better to do than to hang out with AL and 30 of my closest friends waiting for the ENT docs.

But, thankfully membership has its privileges, and we were taken by the next available doctor after about 20 minutes. And to my non-surprise, the ENT doctor quite quickly decided that AL needed his adenoids out. And to my pleasant surprise, he scheduled the operation for Wednesday-in TWO days. I hate to admit, but after two weeks of a frustrating lack of progress, I felt a bit giddy that AL was finally on the path to some useful treatment. Of course, then I freak out realizing that I haven't seen family at AL's bedside for a week now, and who's going to consent for the surgery? Maybe AL and I will go drive around Soweto looking for them! (Not).

We take the long way back to the Ward, and we had a nice stroll. I actually contemplated going via the cafeteria and sitting out in the warm sun having a play lunch with my pal, but decided that if the prof walked by, this may not be well received.

Then things go slightly downhill from here...

A patient was transferred to our Ward this morning as a TURF. Meaning that this kid has previously been taking care of on our Ward. And therefore the way the system works is that any child who is readmitted, goes back to the ward were they have been admitted previously. It lends a new meaning to the term turf wars. Anyway, this new kiddo, KM, was assigned to me. So I go in and read through his chart... After the past two weeks, I felt like I was beginning to develop a bit of a thickened skin and that not much would really surprise me at this point. I was wrong for two reasons.

Reason one: one of the ward sisters behind me says "doctor, do you know this baby? I think this baby is dehydrated." She was not talking about the Turf Kid I was seeing. To which I replied, after barely glancing at the baby, "no, I don't know him but I can look at him in a minute, or you can ask one of the other doctors." Now, the definition of dehydration can be interpreted in different ways. That baby was de-hydrated, in the eternal sense. He was one of our severe malnutrition kids. Who at some point in the past hour or two had actually died. And that was it. No calling a code, no resuscitation, no getting excited. This is life, plain and simple.

Death #4.

Reason two: Now, back to KM. KM is 1 year old. He has been admitted twice before, once for failure to thrive, and once for pneumonia. He weighs four kilograms. He weighs a kilo more than his BIRTH WEIGHT. He should weigh at least 10 kilograms by now.

He is not in good shape. I made a list of his problems, they include:
1--pneumonia
2--tuberculosis exposure
3--failure to thrive/marasmic-kwashiorkor
4--social neglect
5--anemia
6--thrombocytopenia
7--hyponatremia
8--hypoalbuminemia
9--sepsis/leukocytosis/elevated CRP
10--immunization delay
11-thrush
12-deformed ears (which is important because there could be renal deformities)
13-hypotonia (likely because of NO muscle mass)
Any, by report he is HIV negative.

He is a train wreck. And honestly, I am not sure I have ever used the term TRAIN WRECK for a pediatric patient before. For an adult, sure, all the time. That is normal for adult medicine admissions, and normal medicine admissions usually have more than 5 problems. Train Wreck.

Problem 14 would be the profound sense of helplessness I feel when thinking about this kid.

Shit.

Turbid Taps

So, it ended up being a relatively quiet on call. There were only seven admissions yesterday. Apparently, up until about a month ago, this had been the usual number of admissions for a month or so. There have been lots of guesses as to why admissions have fluctuated and have gone from numbers around five or 10 to well over 20. (Last night was likely low because it was so miserably cold). The nursing staff believe that there had been a drop in the number of admissions because people had fled during the xenophobic attacks a few months back, and now that admissions are back up to usual numbers, they believe that it reflects people moving back to the area from the refugee shelters that had been set up. One of the profs believes that we had seen a natural lull with a mild RSV season. Who knows?

 

We had 7 year old who came in yesterday afternoon looking quite ill. Her spinal fluid, which should be crystal clear, was actually fairly turbid looking. And sure enough, she has meningococcal meningitis. She has the classic definition of board like rigidity, meaning that if you put your hands behind her head and pull upwards, her neck doesn't flex. I'm not sure how long she had been unwell, but hopefully we are seeing her early enough that she may make it through this, and remained neurologically intact.

 

I arrived on the pediatric ward at about 5:45. Every morning that I get to work, the lights are on. And, a 6 a.m. round of porridge or bottles have already been handed out. Part of me has wondered two things recently. One, are the lights on all night long? Two, do they really really wake kids at 6 a.m. to feed them? And the answer to those questions are yes, and yes. While not all the lights were on the early in the morning, most were. And, I watched as A.L (my two year old who needs his tonsils out) was woken up and give and porridge at 6 a.m. I thought about this while I was at the gym this afternoon, and it does seem a bit cruel to wake of the kids for a 6 a.m. feed... but, part of the reason I am sure it is because there are very few parents on the ward, and the nurses are responsible for feeding the children. So by default, feeds occur on a scheduled basis and everyone eats at the same time. I suspect that give the level of malnutrition these kids live in, they must be hungry more often than not...  

 

My eight-year-old to has pulmonary tuberculosis for the second time is still here. I technically discharged her on Friday. I was slightly annoyed to see here here yesterday, and quite frankly expected that she would be here this morning. Apparently, they cannot reach her mother to come and pick her up. The one functioning number on her admission facesheet, doesn't appear to be the correct number. Her mom hasn't actually been in the hospital to visit at all since she has been admitted. I suspect, like many of the parents, and that the cost of a taxi, or bus, has been too expensive to come for regular visits. I'm not sure know, when she'll head home.