Hey Mrs. Potter

I'm driving home last night. Post call. Well, post-call hours before. It had been a hectic night. Kids crumping. Adult admissions. A full ICU. I went home. Slept for an hour. Met up with a friend for lunch. Met up with another friend for dinner. And I'm stuck on this song which I listen to on repeat the entire way home. I don't know why I mention this trivial detail, but I've included song relevant songs during the past many months, and this one gets added to the list.

 

"Mrs. Potter's Lullaby" by the Counting Crows:

well I woke up in mid afternoon cuz that's when it all hurts the most
dream I never know anyone at the party and I'm always the host
if dreams are like movies then memories are films about ghosts
you can never escape you can only move south down the coast

I am an idiot walking a tightrope of fortune and fame
I am an acrobat swinging trapezes through circles of flame
if you've never stared off into the distance then your life is a shame
and though I'll never forget your face, sometimes I can't remember my name

hey Mrs.. potter don't cry
hey Mrs.. potter I know why
hey Mrs.. potter won't you talk to me?

well there's a piece of Maria in every song that I sing
and the price of a memory is the memory of the sorrow it brings
there is always one last light to turn out and one last bell to ring
and the last one out of the circus has to lock up everything

or the elephants will get out and forget to remember what you said
oh and the ghost of the tilt-a-whirl will linger inside of your head
and the ferris wheel junkies will spin there forever instead
when I see you, a blanket of stars covers me in my bed

hey Mrs.. potter don't go
hey Mrs.. potter I don't know
but hey Mrs.. potter won't you talk to me?

all the blue light reflections color my mind when I sleep
and the lovesick rejections that accompany the company I keep
all the razor perceptions that cut just a little too deep
hey I can bleed as well as anyone but I need someone to help me sleep

so I throw my hand to the air and it swims in the bees
it's just a brief interruption of the swirling dust sparkle jet stream
well I know I don't know you and you're probably not what you seem
oh but I'd sure like to find out so why don't you climb down off that movie screen

hey Mrs.. potter don't turn
hey Mrs.. potter I burn for you
hey Mrs.. potter won't you talk to me?

when the last king of Hollywood shatters his glass on the floor
and orders another well I wonder what he did that for
that's when I know that I have to get out cuz I've been there before
so I gave up my seat at the bar and I head for the door

we drove out to the desert just to lie down beneath this moat of stars
we stand up in the palace like it's the last of the great pioneer town bars
we shout out these songs against the clang of electric guitars
you can see a million miles tonight but you can't get very far (x2)

hey Mrs.. potter I won't touch
hey Mrs.. potter it's not much
hey Mrs.. potter won't you talk to me? 

 

As for the ICU...

 

Status quo. The ICU dramas which I see unfolding are, in some cases, no different than ICU dramas anywhere in the world. And then there are dramas which shouldn't be unfolding. Such as the kid who had a perforation in his bowel, and was delayed getting to a referral hospital for an excessively long time. He's not doing so well.

 

We do a hand-over round in the late afternoon. The night team has arrived, and then we tell them about the patients and things to do and follow-up. This is one of my new favorite acronyms. KATH

Keep

Alive

Til
Handover.

 

Which, don't get me wrong, is implied for each patient.

 

This coming Saturday will mark the final 5 weeks here in South Africa. The theme for the last 5 weeks is Work Hard, Play Hard. Though right now it's been a bit lopsided...

 

B

 

More from ICU

I'm not really sure what day it is. But that doesn't bother me. I know I left work this morning, and that I go back tomorrow morning. I'm not sure why I am up still. My plan is to head back to the hospital in an hour or two and go back to the clinic where I was the last few months and plug away at the research. There is a new sense of urgency to this project, which is lingering more than I would like, as I must collect all the data before I leave South Africa. I can start the analysis while stranded in Abu Dhabi on my layover back to the US.

 

In typical post-call disorganized thinking patterns, I pulled into the driveway thinking that maybe I should consider doing an ICU fellowship. Maybe a pediatric ICU fellowship. It's been a steep learning curve the past few days... and this ICU business isn't so tough. Ok, that's a bit of a lie, but I'm going with it.

 

What has been enjoyable, is that when I'm there during the day, I'm taking care of adult patients. Half medical, half surgical. During the day, the 2 pedi residents who are in the ICU are usually taking care of the pedi patients. Makes sense. But at night, my co-residents have absolutely no interest in covering the kiddos. So, I get to cover the kids at night. For me, it's a win-win.

 

But last night was slightly shaky. Lots of kids, most on vents. A few sick trauma kids, a few sick medical kids. Problems with the blood gas machine (basically not working)- which made it more challenging to manage vents. A problem with nursing (oh come off it, I hardly every speak bad about nurses back in America, but I'll have enough stories from the nurses here to write a separate blog. Which I don't mention in the blogosphere because that would be slanderous-which isn't really appropriate. Buy me a drink, and I'll tell you stories that will FREAK YOU OUT). Where was I... Oh yeah, I couldn't sleep last night, because a few of the kiddos were fragile enough that I didn't have the confidence to let the nurses oversee the care and so I basically hovered like a hawk.

 

Anyway, aside from the lack of running water for a few hours-which made it impossible to make coffee, the night was par for any night in an ICU.

 

We did our hand-over round this morning, the consultant agreed with my management during the night, and all the kiddos were still alive.

And in my hypo-caffeinated, post-call victory, sleep deprived state the idea of a PICU/ICU fellowship made sense.

Enough rambling for now.

More soon, I'm sure.

See One....

See one.

Do one.

Teach one.

 

The old mantra of teaching in hospitals. See a procedure done. Do the next one. And then teach others how to do one. It has kind of fallen out of favor back in the US. More like. See one or two done. Be observed while doing a few. And then teach to the interns/junior residents next year.

 

"When was the last time you did one?"

"Oh, when I was here at Bara in 2003."

"Great, you scrub, I'll walk you through it."

 

I think medicine has become less invasive in the US. At least where I train. We aren't as aggressive about placing central lines (an IV into the neck or some other big-ie, not arm- vein), or other invasive procedures (like arterial lines) unless really needed. But here, entrance into the ICU almost guarantees a central line and an arterial line. You're likely already intubated.

 

I went to see what the recent blood gas showed on my patients. He'd been rather ok at 8am, but we were making strides to get him off the ventilator. When I dropped by earlier he was somewhat agitated after being suctioned. But when I went by again later, he was in respiratory distress. 6 days ago, he was hit by a car. He has lung contusions bruises, bilateral hemothoraces (blood accumulating between the lungs and chest wall) and still has in one chest drain (to get the blood out, the other drain was removed the day before), a clavicle fracture, and a head injury. Oh, and now he's in respiratory distress. Shit.

 

I assess him. And he sounds full of fluid in the lungs, and it is spurting out his breathing tube as well. I try to dry him out a bit, and to sedate him a bit, but I don't make much progress. I had ordered his daily chest xray hours before. But it has not been done. I call them again. I get one of the other residents to come assess him well. We escalate our treatment and give some ketamine while we wait to switch vents so we can also give some nebulizer treatments as well. We call the attending to ask to sedate and paralyze the patient; which he vetoes.

 

The xray folks kindly show up, almost and hour and a half from when I called the first time.

 

And shit, he now has a new pneumothorax (air trapped between the lung and chest wall) on the side which we'd heard the worse crackles. While it is nice to have an explanation for what's causing him to (quickly) decompensate, it would have been nice to know that an hour ago.

 

And there I am, cutting his skin like the internist that I am. Gingerly. I'm thankful that the brash trauma surgery resident who is also working in the unit is post-call and gone, for if she were guiding me through this, I could imagine her level of irritation at this point. And I dissect down, splitting the layers of muscle and poking between the ribs to release a gush of air and old blood.

 

Well, isn't this what I signed up for? Yesterday I placed a central line without the comforts of ultrasounds. I learned the anatomy of where to stick the needle in the neck to hit the jugular vein. And on the same patient I placed an arterial line as well. And today I inserted a chest tube. Next time I do these, I should, by historical training guidelines, not only do them alone, but teach somebody how to do them. I don't feel like the expert who could teach somebody how to do one.

 

I swung by Ward 36 after work to say hello to a friend who is on-call for pediatrics tonight. It was a zoo, and I had fond memories. She was in the treatment room. I headed in there and tried to sooth an infant as she tried to jab in an IV. Jab isn't a nice way to say it, she was being the skilled doc that she is. I saw the thrush. I saw the lack of tears and very dry mucous membranes. I saw the increased work of breathing and fast breathing rate. I felt the enlarged liver. The kid looked appropriately nourished.

 

"Let me guess. HIV exposed, not tested yet, gastro and pneumonia?"

She smiles.

"Want to stay and admit kids tonight?

 

She didn't get the IV. "What's wrong with this one" I ask as I hold the infants hand which has an IV in it.

"It's not working."

 

I try to flush it. She laughs in an I-told-you-so manner. I remove the tape at the IV site. Pull off the tubing connected to the IV catheter, and I try to flush it. The saline goes in nice and smoothly.

"Dr Brian!"

They never flush IVs, they clot off all the time, and you just have to replace the tubing which allows you to keep the IV site and then you don't have to poke the kids again. I just smile. They are getting nailed. She has brand new interns on tonight. It's going to be a long night.

 

I head to the car. I had been in such a comfort zone the past few months, that I forget what it was like to be somewhere where almost everything is foreign to me. I know the physiology. I know the diseases. I am marginal at managing the vents. I don't know the technical procedures. I don't know which medicines they use. I don't know how to prescribe the drugs as milliliters of drug, and not milligram of drug. But I'm learning And I'll learn fast. When I stepped into Ward 36 ten months ago, I didn't know how to place an IV in a kid. I didn't know about HIV....

 

Sometimes I just forget that I'm here to learn.

 

 

BPB

Brain-Ache

My brain is actually sore. Good to be back in acute medicine, but very rusty. And having to learn new trade names of drugs (Trade Name= Tylenol, Generic=paracetamol) etc. Different treatment protocols. And different vent terminology.

 

Off to take some ibuprofen and read!

 

 

Changing...

Wow, seasons are changing here. It's cold, and overcast today. It is really fall now. I have this urge to go by some pumpkins, to have chai tea latte. Instead, I brewed some of the tea that I bought in Nepal (thanks D). It's a spiced tea. I think drinking tea/coffee was the only way to get warm some of the time. So it seemed fitting to brew a pot of this cherished tea, and just enjoy a Sunday doing nothing much other than reading the paper, finding new music on itunes, and getting caught up on a few emails.

As mentioned, I'm changing to the ICU, and will start in the morning. Though, thankfully am not on-call for a few days. I've had time to review some medicine/pediatric topics, going over ventilator management, ABGs, EKGs, septic shock.

I'm being bumped out of that comfort zone. Headed to a unit where I'll, once-again, be the outlier. Having to explain- -again-why I am here at Bara. And even more tiresome, explaining that I am both a pediatrician and an internist. That yes, it is possible to do both. That's part of what I am looking forward to tomorrow. I have no idea if I will be taking care of pediatric ICU patients, or adult patients tomorrow. The unit is a combined pedi-adult, medicine-surgery unit. I'm really looking forward to the mix. It's basically what I'm training for--the ability to manage and understand the disease spectrum and the differences in physiology etc between kids and adults.

Here are some random pics. I noticed that I really haven't posted pics in AGES. (But astute followers will know that the picasa site with my travel pics has been updated regularly, the link is over there to the side).

This is a photo taken out of today's paper. This is TRUE. We've seen it in our clinic. People are so poor that they'll stop taking their HIV treatment, in hopes that their CD4 count will drop, and they will quality for a disability grant. It's a largely held misconception that a CD4 count under 200 will quality people fro disability. Desperate times call for....

Full Circle. This makes me feel like I've been here the almost year that I have been here. The return of brush fires. And they've been great recently. It's dry again, the summer rains brought lush green grasses which have now died and turned into ripe tinderboxes. This is a shot taken on Thursday night as I drove out of town.

I'm off for an dusk run. I love when it gets dark early in fall, it's great running weather. For the umpteeth time since moving away from Dublin, I'm trying to run regularly again.

Hope you had a great weekend.

200,000 and 7-1-10 (or 1-7-10 for those outside the US)

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....

 

-

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.