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.

Kruger Pics

Check out: http://picasaweb.google.com/BackToBara for pics from Kruger

 

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Kruger Day 3

Here kitty kitty kitty..

I know I skipped day 2. Woke too tired to get out of bed. The goal had been to leave at 6am. Who the hell gets up at 6am on vacation, from a warm bed??? Ug. Drove around for a few hours once I did get up. Saw hippos, elephants, giraffes, and other things. No damn lions. Came back to my hut (I'm not kidding) did a bit of reading and a bit of work stuff, took a glorious nap, and then went on a night drive safari. Just like the TV show, had bright spot lights to look for the reflection of eyes in the dark. Saw a white Rhino and some other non-cat animals. Had to listen to the constant moronic babble from the people behind me. And wondered why I didn't bring whiskey along. Oh, and during the morning, as I came back from the communal kitchen with hot water for *gasp* instant coffee, a little twerp monkey ran away from my kitchen area (it's in front of the hut) with my yogurts!! And then a few hours later, as I was stopped at a picnic area, admiring the view of a river, a little twerp monkey jumped up from my feet (I didn't even know he was there, I was lost in thought-but people looking on witnessed the entire event) and grabbed my apple out of my hand and ran up a tree and ate in in front of me. Bastards. I am thinking that shooting monkeys may be permissible

I compromised with myself today, and decided a 7am start time was realistic. And low and behold, was rewarded with a few lions and cubs this morning. Well, not infant cubs, they looked older. Got some pics, and then felt let off the hook. I've seen 4 of the Big 5 Animals, just needed a leopard or cheetah (honestly, what's the difference) and was setting my expectations low. 4 of 5 is 80%. I can live with that.

Drove around a bit this afternoon. Stopped at a lunch spot and started reading "Left for Dead" which is Beck Weather's account of the failed 1996 Everest climbing expedition. And then I drove to a hide. I turned off the car, manually locked the door as I didn't want the beeping of the car alarm being activated to put me on bad terms with those in the hide. These folks are serious! Got to see some animals from the hide. There were some overzealous photographers there who were too serious... They got all pissed off when a car alarm beeped twice as the hit the button before getting in the car so that the alarm didn't go off. To which the serious photographer remarked to his wife "asshole using his hooter."

[note: hooter is South Africa for horn. Not like the American Hooters. Either form of the American Hooters]

Anyway. My laptop was in the back of my Bakkie. I have kleptophobia (the fear of having things stolen-ever since my car was broken into a few years ago), and so, I tried to remotely lock my car while I was in the hide. I figured the serious photographers wouldn't know it was me. I kept hitting the button, but did not hear the "beep beep" of the alarm turning on. C'est la view. When my kleptophobia got the best of me, I decided I would leave the hide. As I started to sit down in my bakkie, I wondered why the alarm light was blinking out of sync. Sadly, I couldn't stop the downward pull of gravity, and as I rocked the car, my car alarm went off.

Yes, thank you very much. I again, fucked up at the hide. Bye bye animals. I could almost hear the serious photographer mutter "asshole." Apparently, when I had hit the button to engage the car alarm, it had worked, I just didn't hear the beep beep.

When in Africa... I'm glad I've done the safari thing. It's been a successful trip. I've seen lots of game. Have finished one book, and am starting another. Have even gotten a bit of work done. But at the end of the day, give me my backpack, and mountain solitude, where not encountering animals is often ok (bears for instance).

You can take the boy out of Colorado, but you can't take the Colorado out of the boy...

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Kruger Day One

Wow. I'm in a fog. I got up just past 3am this morning to drive a few hours east to the Kruger Park. I wanted to maximize my time here in the park, and so wanted to arrive in the early morning in hopes of seeing some animals before the day-time sun drove the animals to seek shelter from the heat. I managed to get just over 4 hours of sleep last night, but of course, was post-call and hadn't slept all day. It had been a great day. Left the ICU, went to the gym, then went grocery shopping (for my trip) and then home to pack a bit, and then back to work to plug along on my research project.

 

Then, Celine (an ID fellow from Hopkins who is also here for a year), her husband, and few peeps doing Epi from Hopkins came by for a tour of Bara. It was great as we were able to make a general run through NICU, Ward 36, Ward 18 (where sister Nicah-one of my all-time favorites was on-duty), and then ICU and medical admissions.

 

About ward 18-the other day I was walking outside along the corridor, and as I looked into ward 18, this kiddo waved at me. He had the open-close hand wave. He's tiny! So I stolled in to ward 18, and picked him up and looked at his chart. Turns out he is 2 years old. Though physically looks more like a 14 month old, but developmentally is closer to a 2 year old (though with possible language delay) and has some hormonal issues that is affecting his growth (I didn't read his chart far enough to get the specifics). But he is such a ham! I enquired if he needed a home-in America. And when I saw sister Nicah-she said that Thando does haven parents, and that he has been in the ward for many weeks...

 

Anyway, back to Kruger Park. The Prof of the ICU has already told me, explicitly that she will not give me an ICU bed if I get attacked by animals. This was her response when I asked exactly what people did here at Kruger. I assumed it would be like most parks. Some hiking trails, walking around etc. God I need a good hike about now, and was also looking forward to doing some running this weekend. And I was quickly told that in the park, you stay IN THE CAR! What?? What the hell kind of park is this where you have to stay in your car. Apparently, it's a park with lions and other cats that could/wold eat people??

 

Culture clash. I was driving along the dirt road about mid-day. I'd seen a bit of game. Elephants. Giraffes Buffalos. Birds. Plenty of miscellaneous antelope-things. And figured, as everybody has told me, that the cats are not really out during the day. So I was driving along, enjoying being on a dirt road, pretending I was driving my JEEP, ipod blaring, leaning out the window kind saying "here kitty kitty kitty," I was thoroughly entertaining myself, when I rounded a corned and came upon a "hide" and some disapproving stares of folks who had probably been sitting there for hours in the peace and quiet hoping to see animals. Well, they did. Doctorus americanus cum africanis, exhibiting the combined behaviour of being post-call from the ICU, sleep deprived, and enjoying being in nature. Oops.

 

I'll be on good behaviour tomorrow.

 

 

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Blurred Vision

It's 3am. I am wide awake. I did my 2am round on the trauma ICU patients. They were all were still alive, bleeding controlled, vent numbers appropriate. Here was my chance for 2 hours of sleep, barring any unforeseen emergencies. I laid on the bare bed of the call room. No sheets. No pillows. And I stared at the ceiling. In my mind, I couldn't put down the book I had been reading, but I wasn't going to give into my inner-child's curiosity and piss away a chance for 2 hours of precious sleep to continue reading. This book is giving me some clarity into future job prospects, and now, at 3am in the ICU, I can't stop thinking about what I want to do with my life; at least my life for the next year, or maybe even two.

It's 10am. I have half a dozen eggs in one hand, and sweet chili sauce in the other. I'm sweaty and smelly. I got home from work at 9am, debated going to bed and sleeping away the morning, seeing as how I wasn't able to sleep when I had the chance during call. I had a cup of coffee before leaving work, a red-bull when getting home, and then another coffee, and still lacked the motivation/energy to go running. But the thought of going to the grocery store, buying fresh strawberries and making home-made strawberry pancakes was enough motivation to get me to take off my scrub top, change into running shorts, grab my ipod and head out the door. My legs are sore. I ran along a greenbelt that I would normally avoind in late afternoons, and at all costs in evenings, for fear of safety. But, I really enjoyed running along the greenbelt this morning. I live by the mantra that serious crime doesn't happen on Saturday and Sunday mornings. After a pathetic start, I hit my stride and settled into an enjoyable pace, lost to the beat of itunes, and lost in a kaleidoscope of thoughts. And right before I headed into the grocery store, I decided to make a brie omelet with sweet chili sauce-which is what I ordered for breakfast yesterday. I took a R100 bill note with me, and shoved the R79 into my pocket as I headed out the door and started salivating at the thought of a scrumptious omelet for breakfast. I walked past the guys selling sock, who seem to only be out selling socks on weekends. And then I passed a guy, who I guessed was blind, and an amputee sitting on a piece of cardboard, staring off into space. I didn't hesitate to reach into my pocked and fish out the spare change. He startled when I stepped on a piece of the cardboard (confirming my suspicion that he was blind), and stuck out his hand when I said, "here ya go." And I walked on. And immediately, I wondered two things. Why hadn't I just given him all of the R79? And why do I readily give handouts here in SA (and Nepal and Ethiopia), but not back in America? The reason, I've concluded-as I've been thinking about this for a while now, is that here, as in Nepal, Ethiopia, etc there is no real provisions for the destitute. No real welfare-to speak of...

It's 1pm. I'm in Maponya Mall, in the heart of Soweto. I'm fulfilling a promise, to join JC and meet his wife. When his family was here at Easter, including his father who was in town from Zimbabwe, he'd invited me over to meet his whole family, and have a braii. Painfully, I had to decline, as that was the weekend I was headed to Swaziland. And so we made plans to meet today. I'm on American time, he and his wife are on African time. We meet half an hour later. I'm blurring the accepted "doctor-patient" boundaries that North America has taught me. He already has my mobile phone number-as do a dozen or so patients, as well as my email-as do a handful of patients. But meeting outside the confines of work seems to be outside the "norm" of doctor patient relationships. I note, to myself, that I am no longer his doctor which makes it seem fine to meet him.

He arrives with his wife, their daughter is off playing with a friend, but I'm told we'll pick her up later. We walk the few short blocks to their place. It's a single bedroom. It is smaller than my bedroom here in SA. And has one bed, a fridge and a stove, and a TV. There is no running water in the room, and the toilet is outside as well. It's what I anticipated, well except that it has electricity. I immediately make myself at home, sitting on the bed and we catch up since we haven't chatted in a while. Coincidently, I'd talked to his Infectious Disease Doc a few days ago, who gave me updates on a few patients that I had been taking care of, so it's easy to shy away from asking about his meds and his CD4, viral load, and TB cultures. Instead, we quickly delve into politics. SA has elected a new president since we last spoke, and The Mugabi-Tsvangirai Coalition have pleaded Zimbabwe's case for international donations. We have lots to chat about, especially because news coverage of Zim has fallen off the radar and I've lost track of some of the current events. As we're talking, Rumi makes sandwiches for all of us. The awkwardness that I was worried about, doesn't seem to be materializing. It's as if we're friends who just haven't seen each other in a few months.

As we finished eating and as the political discussion mellows, Rumi brings our old photos. I stare at a photo of a younger man, in a graduation ceremony.
"Can you pick him out of the crowd?" she asks.
No. No I can't. None of the three of these men look like JC. Except for his distinctive smile. Which I can pick out in the photo.
"That's him."
"Can you believe it? Look at that photo. Look how different he looks today. Look how much weight he lost."
I look at JC. He's gained 10 kg (22 lbs) since I admitted him to the hospital in February. But his physical stature is completely changed from the person in the picture.
"Every day I thank god that you saved him."
I swallow, unsure how to respond. "I'm thankful he's doing so well."

We finish looking at the photos, and then we take a drive, going through neighborhoods of Soweto that I'd be uncomfortable to drive through on my own. We pick up their 5 year old daughter. I make a fuss over her new braided hair, which has happened since I last saw her, and she giggles and grabs my hand an pulls me toward the bakkie. We head back to Maponya mall, where the activities include taking an anchored hot-air balloon ride for an aerial view of Soweto. It goes 120 meters high, and you get to be up there for 15 minutes. We hop aboard, and JC points out places in the area. I'd been to Soweto last weekend to see some of the historical sights, so it's great to be getting a better overview now, with the history of Soweto fresh in my minds. We snap photos from the top, and photos of us.

After the balloon lands, we head into the mall to print pics, and then we get KFC. Friends of theirs are coming over to join for dinner, so we're getting some KFC to compliment some fish that JC is going to bake for dinner. We walk through the mall, their daughter is practically attached to me, grabbing my hand, or my shirt. In the line at KFC, their daughter is trying to teach me a few words of Shona. She doesn't understand why I don't speak any Shona, or even Zulu. JC and Rumi enjoy the show as I slaughter the pronunciations. We collect the photos out as we walk out of the mall and head back to their place.

"Have you noticed it" asks Rumi.
"What?"
"You're a celebrity today. The reaction of the people seeing a white person walking around here. Especially with T grabbing on to you."
My vision is blurred. I didn't see it. I no longer see this. Being the sole white person in the gym, or the mall no longer registers in my mind. And today, there seemed nothing unusual about going to the mall with friends and their daughter.

We get back to their place, and LJ, his pregnant wife, and their 6 year old daughter join us. We tear into the KFC as JC prepares the Tilapia for the second course. LJ went to university with JC. We're all the same age. It's small chatter for a while, talking about the balloon ride and the events of the day. I tell LJ that I want to know what JC was like in university, I want stories. I try to break the ice a bit...

"I've known this man for a long time. I could barely come to visit a few months ago..." This isn't really the ice-breaking story that I was hoping for. LJ continues and tells me how depressing it was to come to visit, watching JC getting worse and worse. LJ had lost hope, thinking JC wasn't going to make it. His eye-contact drops off as he talks, but his eyes meet mine when he thanks me for taking care of JC. Again, I swallow hoping I can keep myself composed.

The next thing I know, the Tilapia is gone. The KFC is gone. And 2 hours have passed. In that time we've discussed South African, Zimbabwean, and American politics. As well as the failing healthcare system here in South Africa, especially as it pertains to Bara, as as it pertains to a friend of LJ's who died this week. We debate affirmative action. I try to just memorize this moment. I don't want this moment to be blurry. I want to remember it in absolute clarity, for the rest of my life. Sitting here, invited into the home of a patient/friend, a friend who, up until recently was an illegal Zimbabwean immigrant, sharing dinner with his family, and his friends, on a cold Johannesburg night, has been one of the most meaningful experience of this year, if not the past many years.

LJ and JC walk me out to my car. I make plans to see JC and his family soon, and pass along my number to LJ, so that he and his wife can call me if they have any problems when she goes into labor in a few weeks time. I drive home, still listening to Mrs. Potter's Lullaby... My blurry vision seems to have cleared up.

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