Catching up over coffee...

In a Rut... Yemen Beckoning.

2011-03-06T23:14:00.005-05:00

I was sitting at Pablo's Coffee. Book open. Looking at the words on the page of one of my text books-- reading about the creation of medicare and medicaid. And the words had this piercing effect--like little stabs to my ethos.

This harps on one of my main issues now. Working in a system where, by default, all of my patients are insured, goes against the grain of who I want to be taking care of. Ug. It's not entirely true, we cover a certain portion of patients who do have medicare or medicaid insurance... but they are in the minority.

My job is great. I work with a great group of hospitalists, who are all sympathetic-cynical, dedicated clinicians, who all support each other. We take care of a tremendous variety of patients, including some sick ICU patients. And we work in a hospital that is esthetically pleasing, has abundant technology, and has the happiest group of nurses I've ever seen. And I get to take care of kids, and adults. And they --pay-- me to do this. A helluva lot better than residency.

But there is something fucked up about having had one day off in the past 10 days. The balance between work, life, school, family, friends, and sleep is skewed.

"It's not a race, kid." That's the advice of one of the senior members of "The Old Curmudgeon Club" at work. It's a Club I'm trying to become a part of. It is a group of five or six senior male hospitalists who readily accept their title. And yes, I mean senior in the sense of age and experience. They claim that I am not grumpy or cynical enough, or that I am not old enough to be a member. So, I resort to calling myself a Junior Member of The Old Curmudgeon Club.

Maybe I hide it well. But I'm in a Rut.

I have these odd flashbacks (helped mostly because I am, in fact, living in Denver again). I feel like I'm in college again. I come home from the hospital to a stack of studying and stuff to do. Wow. I remember sitting in the Auraria Library back in 1995 wondering when the hell this student life would ever end. There was a burning desire to fast forward and get on with life, be done with school, and just --be-- a doctor.

And now, sixteen years later (SIXTEEN), I find myself in the same spot. The exact same spot. I just want to be done. I want my NGO job, in some foreign country, practicing the kind of medicine I love best, taking care of folks who have real struggles in life, and finding myself in a place where I don't give a shit that I have worked 9 of the past 10 days. But I know that time is a few years away. I think back to my Curmudgeon Mentor: "It's not a race, kid."

It's not a race... I am enjoying the steep learning curve of being an attending, I'm actually enjoying biostatistics (I can see the future utility of it), and my public health policy class...

But there I sat at Pablos... Unable to scratch the itch.... I need out. I'm concerned that I'll have to forfeit my April/May vacation (when I'm hoping to go to Port-au-Prince) to get other shit done. And then I started to have thoughts of wandering elsewhere. When the hell was the last time I just grabbed my pack, and found myself somewhere new? Maybe I need a real break. Somewhere... Just get on a plane, grab a Lonely Planet, and rekindle some inner sanctum.

As I was finishing my coffee, pondering where to go, I reminisced to my Jo'burg days, being introduced to great African Coffees, thinking of my trip to Ethiopia, and wondering about Yemen.. And thinking about one of my top 5 cups of coffee ever.. That being the Yemen Roast from Blue Bottle Coffee Company (read my "Not Settling" post). And that is when I realized that I needed to be "picked up by the lapels, shaken, then tossed into a grimy Manhattan snow bank."

And I reread that post... I wrote it 4 years, 2 days, and 29 minutes ago.

I could have written that post today. It seems I'm repeating the same themes in life these days.

Off to Yemen. Maybe just coffee. Maybe a trip.

Broken Clutch

2010-12-21T23:42:00.002-05:00

I don't even know where to go with this one...

It's something related to shifting gears. There I was, sitting the the Liberty, back at DIA. Upset that my time in Haiti was cut short, unable to stop thinking about my friends, and my patients at JP and trying to justify why it was that I had changed my ticket, yet again--and had flown back early so that I could make sure that I would get back to work in time.

And ironically, as I started the jeep, tired/exhausted/frustrated, my clutch went out. I was stuck in neutral. Unable to maneuver into reverse, let alone into a forward gear. That was -me-. Stuck.

And I just sat there. The fucking jeep started. So why not just sit there and listen to music, let the heat run. I even contemplated just sleeping in the fucking thing. My friends in PaP knew I'd left, but outside of that very few people knew where in the world I was. I wasn't sure where I was. But -this- was defeat.

The irony wasn't loss on me. Jeep donated 8 Jeeps to JP. Four Jeep Laredo's and four Jeep Wrangler--and the clutch had burned out on three of them. As I was walking to my Jeep, the thought crossed my mind that I needed to get AAA-- my clutch was showing signs of fatigue. The universe beat me to it. My clutch was dead. I didn't have AAA.

I felt stuck in neutral. I didn't want to be there. I didn't want to be here. I'm in a state of lateral movement. I'm gaining skills and confidence as a physician, I'll start my MPH (Masters in Public Health) in a month, I'm putting money away for future rainy days, but every day I don't see the progress forward... progress toward finding that niche where I'm meant to be; be it in Haiti, South Africa, Sudan, Cote d'Ivoire, Lesotho.

People ask... but how do I explain. How do I explain what it is like to show up to PaP and see the level of fatigue on your friend's faces. How do I explain how phenomenal it is to see the amazing expansion of the medical services at clinic. H0w do I explain how fucking pissed off I feel that Haitians are lying on cholera beds puking their fucking guts out while having diarrhea--in TOTAL LACK OF PRIVACY AND DIGNITY, and even worse, families have survived the earthquake, shitty existence sine then, and then died from a completely fucking curable and avoidable illness???? How do I explain that tomorrow I'm rounding on a 91 year old female who has an incurable cancer, but whose family wants everything done to prolong her life?? This kills me.

And so, I'm stuck in neutral. I'm not making forward progress. I'm not slipping in reverse. I'm just iddling. A necessary evil til I can get the pieces in order to go forward. (And trust me, every single day when I wake up I look toward that next mission).

Ironically... Ironically as I was sitting in the back of my ride as we headed toward the airport in Port-au-Prince, we passed innumerable decapitated vehicles on the road. And I wondered about the owners. Some of those vehicles had tires missing. Some had the engines torn apart. There was likely little hope that those cars would ever get back into moveable shape.

And so I turned off the radio. I'm lucky. I got on my iphone and booked a rental car. I have the means to fix my fucking clutch, and I this is a minor annoyance, but totally manageable.

I'll be stuck in neutral for a bit... Til then, I'll continue to admire my pals who are moving forward and making the world better (Jack, Beth, Phil, Melissa, Maeve, Jeff, The National Docs, Pete, Bruce, and on and on)...

On the Eve of World AIDS Day...

2010-12-01T00:52:00.004-05:00

Who gives a fuck?

Have we forgotten that there are 35 million people living with HIV/AIDS?

Have we forgotten that there are 2.1 million children living with HIV/AIDS?

Have we forgotten that more than 2 million people die each year from AIDS?

Have we forgotten that there are 14 million AIDS orphans?

Do we not realize that there are 7,000 new infections every single day?? (Oh yeah, 1000 of those are in kids under 15 years of age).

Have we forgotten about the HUGE number of people worldwide who cling to hope that they may get access to life-saving antiretroviral medicines? I have seen people literally beg to start these medications...

For days now, I've been looking for a World AIDS Day event in Denver. There are paltry few events. December 1 will pass here as an ordinary day. And, I suspect that will be the case in most other cities in America.

But December 1, and the thought of World AIDS Day, causes me to stop in my tracks. I can't but help to think back to my experiences at Bara. Patients appear in my mind; their names may no longer be easy to recall but their faces and stories will never leave my memory. I will never forget KR's face--he was the most angelic 4 year old child I have ever seen; and I will never forget how shocked I was when I came to work one morning and found out he had died (http://javamania75.blogspot.com/2008/07/kr.html). While there were innumerable deaths, there were great success stories as well--mainly because those were the people who were able to get on ARVs. (Yes, that includes you JC- every time I think of you I recall our first meeting in clinic, and how amazing you are doing now).

As I try to write this, I flip back to old blog posts, and I get lost in this overwhelming feeling of hopelessness... Not helplessness, but hopelessness. I don't know where to go with this, but would hope that on December 1 2010, you think about those whom you know who have died from HIV/AIDS, or are living with HIV/AIDS, or think of how fortunate you are to be in a place where you would have access to treatment, or attend a World AIDS Day event, or find a way to donate (even a few bucks) to any of the bigger organizations (either those supporting events at home, or abroad). This year, I'm inspired to participate in the AIDSLifeCycle Ride (http://www.aidslifecycle.org/) in June (god willing, and i still need to buy a bike--you can also make a donation to me, but probably better to wait til spring to make sure I get a bike and get time off to ride).

That's my contribution until I can bet back to my South African home and resume my work there...

Peace.

Sticking Out

2010-08-23T08:10:00.000-05:00

Our eyes lock. Now I am sure it is going to happen. Confrontation is set in motion. I am not in the mood to play this game. I didn't mind playing it while I was living here, but not today.

"See them?" JC nods behind me. I don't turn around, it would be obvious. "Time for them to make some money. The end of the month is a long way off."

I resist the urge to turn around and look. I had seen the police truck slowly go down the road, and had seen it make a U-turn, now I could only assume that they had set up a road block directly behind us. I thought I could do it inconspicuously, turn around, see where they were. But I didn't do it conspicuously, it was obvious. And then as he had pulled over a car for no reason, he looked at me. I don't know if I really saw it, or sensed it, but there was a grin.

I equaled money. I bet he was certain I would pay the bribe.

Maybe it was all imagined, but I knew I stuck out. What white person would be hanging out in Soweto on a Sunday afternoon? What white person would be standing outside, next to his shitty Mazda rental, talking to another foreigner. A Zimbabwean. Was I a xenophobic-fighting sympathizer? Maybe I was a lawyer working for human rights, in which case the policeman needed to calculate his risk carefully. In my green Carharts, worn Asics, and t-shirt, I didn't fit the look. But still, I knew I was being targeted.

I remember the night I asked my friends how exactly I was suppose to approach bribing the cops. Ironically I asked at dinner one night, and then a few days later I was pulled over. I didn't need to flash some cash, in stead when the officers saw my stethoscope, I was immediately let off. Even though I had a valid drivers license, a fully registered car that was insured, as well as a car which has recently passed a safety inspections, I knew that none of those would mean shit if I were pulled over, and said policeman needed some drinking money. But I soon learned that having my hospital ID card, and a stethoscope would keep the cops respectful. Perhaps it was simply bad Karma to detain a doctor. Though, I should mention that my colleagues had plenty of stories of speeding at night, being pulled over, and simply lying that they were on their way to the hospital, often to try and save the life of a dying child, or a sick pregnant lady. While living here, I did learn how to manipulate the truth.

But I had no desire to lie today. I didn't have a stethoscope or my old Bara ID to back me up. (Though I almost brought it with me for just that reason). I had no desire because I was looking forward to spending the day with a friend and his family. I also was annoyed at having been pegged the sore thumb. It didn't seem odd to me to be here in Soweto. I had long grown accustomed to being the only white person at the gym, at the mall, or even deeper in Soweto. But all of a sudden, I was acutely aware of how much I stuck out; I knew I was going to be targeted. Fucking cop.

In my time here, JC taught me a lot. The focus of our conversation often went to politics. As I tried to figure out how the hell it was that Mugabe has kept such a long rein on Zim, and wondered why MDC hadn't been able to overthrow him, or why the people hadn't risen up against the government, JC would explain the deeper issues which precluded these actions from happening. I had deep admiration for him, and his wife. Would I have the smarts to flee my home, and figure out a way to survive in a foreign country? Not just survive, but to rebuild a life in a country in which a year earlier the local has sought to actively kill foreigners. Xenophobia was alive and well. And sadly xenophobia is alive and maybe still well? Ug. Months ago JC emailed me that he was working, as a teacher. This man continues to humble me. I couldn't wait to see him and his family.

The night before, I was having dinner with Juno, who had been one of the ID consultants that I worked with. When I told her I was going to be seeing JC the following day, she asked for his number, saying they had lost contact since she had left Bara. Ironically, when I saw JC earlier in the week, he said he hadn't been able to get in touch with Juno, and though he has lost her number. I didn't hesitate to give patients at Bara my personal mobile phone number, but I felt this made me stick outalmost as an overly sympathetic doc. This was frowned on by many of my co-registrars (residents), but to those in the HIV clinic, it was a standard practice. The ethos was that as their clinicians, the patients needed to be able to get in contact with their physician should problems ariseday or night, or even weekends. It was an ethos that I firmly believed in. For years I had told my clinic patients back in Massachusetts how they could get in touch with me via the hospital operators, who would then send us a pager method. It would happen, from time-to-time, that they would call for advice, for medication refills, and on rarer occasion when something else was going on, like depression or domestic violence. The pager, though, added an extra barrier level; they couldn't directly get in touch with me, and it afforded me a certain ability to screen their needs as well. But when my patients at Bara had my mobile number, the same number that my family, friends, and everybody that I knew had, it made me feel vulnerable at first. What would I do if I were constantly harassed by a patient? Would I go through the headache to change my number. The possible abuse that I worried about, never materialized. And after a while, it just felt natural that my patients had my phone number. And in fact, my patients knew that when they were hospitalized, that if I hadn't seen them by the afternoon, they were to call me, and tell me which ward they had been moved to. If I hadn't seen them by the afternoon, it was because I couldn't find them!

And so there I was, standing outside with JC; a white foreigner talking to a black foreigner, in a neighborhood in which "I didn't belong" while under the watchful eye of one of Johannesburg's-less-than-finest, looking to make some extra cash. I didn't want anything to interrupt my afternoon to catch up with my friend, and his family; but I was expecting confrontation. In the back of my mind I kept thinking of the story Carlos had told me days earlier when he had been pulled over. A Spanish National, driving with his Spanish drivers license was almost arrested when he didn't pay the bribe to the police officer. How was I going to spin the possible story that was developing??

JC, his wife, and daughter and I got into my Mazda, and backed out into traffic. The policeman was in the middle of the road. I felt my heart rate pick up; the adrenaline was certainly flowing a bit quicker in expectation of the confrontation which was moments away. Our eyes locked for a second time. Where my actions came from, I'm not sure, but I simply waved and smiled as I rolled down my window and said hello and just kept driving Confrontation averted, that time.

BPB

Reflections from Jo'burg

2010-08-16T09:55:00.000-05:00

[It has been a long time since I felt compelled to write. This is overdue, and a culmination of the influences of many friends, people, places, and experiences.]

At one point just over a week ago, I just sat down alone to contemplate the mess that I felt I had gotten myself into. "Mess" is a somewhat pessimistic word, but that is what it felt like. I was unsettled. There I was, in Port-au-Prince, doing the exact work that I want to do as my career, surrounded by some of the most unselfish, hardworking, fun people that I have ever met, working in a true humanitarian disaster, and I needed to figure out where I would be the following week.

I had a ticket booked to Johannesburg. I had a medicine board exam to take that I hadn't really been studying for. I had an apartment reserved in Denver. I had a job lined up in Denver. I had finally stopped panicking every time a pregnant woman, in labor, came into the clinic. I had received a phone call a day earlier from my recruiter at the locums agency who informed me that she had plenty of options for short-term contracts in Aspen, Vail, Denver, and elsewhere in the Colorado--I just needed to let her know when I wanted to start, and how long I would work for.

I tried to figure out which principles should guide my decision: professional goals/obligations, financial goals/obligations, my own ethos (the fact that I had basically given my word to a future job that I would be there on Sept 7). There were multiple options. Go back to the US, take boards, cancel my Jo'burg trip and return to Haiti for 2 more weeks. Go to the US, take boards, email my future job telling them I had changed my mind, call my locums recruiter. Not go back period?? I had already made one unexpected decision this summer (that being to return to PaP), and making another unexpected decision would not really raise eyebrows amongst family and friends. I could not come to a decision that day. I needed to sleep on a few things.

Somewhere over the Atlantic, I was two-thirds of the way through Where Men Win Glory¸ Krackauer's book about Pat Tillman. I was absorbed in the book. Furious at the US government/military, but also engrossed in the way Tillman made decisions. He was a man guided by his own set of principles, and when making decisions, it was his own dogma which dictated what he should do. And that is why I was on a plane headed to Johannesburg. The following day, after contemplating what do to, I realized that I had made a commitment to my future job and bailing out this late in the game wouldn't uphold the commitment which I have given. This was combined with the fact that my financial obligations really require some of their own disaster management. I had also planned this trip to Johannesburg long in advance, and since I wasn't sure when I would have time to visits Jo'burg down-the-road, it felt important to come back and spend time with my friends here.

As the plane started to descend, we flew just to the east of the city, in a path that went south past city center and then made a u-turn coming into the airport from the south end. Before making the curve back to OR Tambo Airport, I got one of the best overviews of Johannesburg. I could see the slow morning rush hour traffic on the M1 as commuters headed into the city center. Even better, I could see the new soccer stadium, and the famous water cooling towers of Soweto. And then Bara became visible. I tracked the road down from Bara, and saw Southgate Mall where I did use to go shopping, an even spotted my old gym. We flew just over my old neighborhood, and I was able to look down into the nature reserve where I use to run and hike.

And then it hit me, I was home. This is home. This is where I had the best year of my life (well, aside from the year I was 5, which was a pretty great year too). Some of my best friendships were made here. Some of the most meaningful work experiences happened here. I still picture many of my patients from Bara, and often think about how they are doing or if they are even still alive. Some of the most heart-wrenching deaths happened here, like the death of four year old KR. Some of the most bizarre things I have ever read happened here (cops vs. cops in shootout was a newspaper headline).

I felt an urge to get off the plane, get into my car, and just drive, at once, to all my favorite places. Instead, Andrew and David met me at the airport and then we went to lunch and had a great time catching up. When it took me two hours to get a new SIM card so I could have a SA phone number, I just had to laugh at the annoyance of going to 8 different stores in 2 different malls to find one. I was home.

I think that, somehow, I knew I needed to come back to Jo'burg for other reasons. My friends here would have understood had I bailed on my trip. But I knew that being here would give me some down-time to go back to those issues from above and to figure out my next game plan. I also needed to be here to spend time figuring out what the fuck happened in the year since I had left.

When I left, I knew I would be back. I was so certain of this, that I almost didn't bother to sell my car. I wasn't sure I would be back in South Africa; it could have been Lesotho, Botswana, or Swaziland, which would allow me quick regular escapes to Jo'burg. But I was sure I would be back in this area. If I hadn't needed the cash from selling the Bakkie (SA slang for a small pick-up), I'd be driving it now.

Days before I left South Africa, Randall and I had a really meaningful conversation. I remember it with perfect detail. It was Saturday morning. I had just made coffee, and was reading the NY Times on-line. Randall came onto skype, and we decided to catch up. We talked about his life in China and my impending departure to Massachusetts. He told me about the difficulties he was having in his personal life, but it seemed that things were getting better, and he was making plans for some changes. I whined that I wasn't ready to leave, and that I was envious that he had extended his contract in China. It had been a long year and then some for him, for me, and for us. I don't know how or why it happened that day, but during our conversation we seemed to have really re-connected. We actually decided it was time to fix things. He was no longer mad at me for asking him to not visit me when he had a vacation. I was no longer mad at him for abruptly ending things. And somehow we started to talk about future plans, dancing around the issue of other future possibilities. He wanted more time in China, maybe two years he said. I would spend a year finishing residency, and then I would work for a year in South Africa/Lesotho/Swazi/Bots . And then the following year we would both be back in Colorado. Two days later, as I departed South Africa, I knew I would be back in one year. A week later, Randall died. In the confusing time after his death, my plans to return here, to South Africa, died as well.

The highlights from the past year pale in comparison to the previous year (Bara, Nepal, Kilimanjaro, Ethiopia, Cape Town trip, backpacking trips and on and on). There was the wedding in Hawaii last July which included a luxurious stay at the Four Seasons in Lanai. There were some great dinners with friends scattered around New England. There was an impromptu road-trip to the cape, as well as to Maine. There was the joy of trick-or-treating with my nieces and nephews on Halloween. There was a great trip to California to see some of my dearest friends. There was the fact that I had finished residency, finally.

By far, the best highlights were my trips to Haiti. In February, working in Milot with earthquake survivors, had been one of the most challenging experiences I had encountered as a physician. When I was re-assigned to an adult tent (and pulled from the pediatric ward) , those 35 female patients were solely under my care. I was charged with managing their infections, their blood pressures, making sure they were getting their wounds managed appropriately, making sure they were scheduled for their cast changes, skin grafts, and revision amputations. The days were long, but the work was incredible. It re-affirmed that this was the kind of work I wanted to do.

My experiences, thought, in Port-au-Prince trumped Milot. Maybe it is unfair to compare the two. The services in Milot were entirely medical. While in PaP, I was part of a bona fide humanitarian mission. The organization I was working with, was responsible for managing a camp with 52,000 internally displaced persons (IDPs). The NGO had to provide/coordinate shelter, security, water, and medical services (among other things). The team in PaP was loosely split into "medical" and "non-medical." There seemed to be an honest admiration for the work that the other team was doing. Neither was more important; both were essential to providing for the people of the camp. And that was refreshing. To know that there was a larger mission than just medical care enhanced feeling like part of a greater team. I felt lucky, that in my month in PaP, the "non-medical" and "medical" teams enjoyed having dinner together, hanging out on Sundays (the day off) and drinking together.

What was most impressive though, was the almost-sacrifice-type commitment that people had made to be there. People were volunteering there because they wanted to be there. Everybody had paid their own airfare to be there. Some were using vacation time. Some were on summer breaks between college or masters programs. Yet others came to PaP in-between careers, and one made a career change partly influenced by being in PaP. Upon that background, volunteers slept in tents (either on cots or sometimes just sleeping pads), often showered under a garden hose, and spent most of the time confined to the camp where we were working. It was a pleasure to work with that crew, they were perhaps the most down-to-earth hardworking team I've ever worked with.

There was another element which I hadn't experienced, and that is one of the full humanitarian roll-out process, and working amongst the presence of so many different aid organizations, both governmental and NGO. At times I was amazed at the lack of coordination amongst the large groups, all working in their own microcosm in the middle of this city which has been destroyed. The allure of the UN was also enjoyable. Meeting UN soldiers from Bangladesh, India, Brazil, Nepal, Morocco, Philippines, and hearing their stories about being away from home, often away from families was inspiring. One of the best parts was being the invited guests to one of the Indian UN base camps, meeting their commanding officers, and being wine and dined for a night, which included fresh, authentic Indian food. Delicious.

I departed PaP on a Friday, arriving late to my place in Massachusetts that night. On Monday I was sitting in front of a computer screen, trying to answer questions about medicine, in the hopes of becoming board certified. A minutia question of differentiating the cause of anemia popped onto my screen. Are you kidding me? I know I'm suppose to look at this picture of red blood cells under a microscope and know if this anemia is from B12/Folate/Iron deficiency, Thalassemia, or some other cause based on how the cells look, but I don't care. This is not practical. A few days prior, as I pulled down the lower eyelids of malnourished, feverish child, and saw how pale the conjunctiva were, I diagnosed the child with anemia. I didn't know how low the hemoglobin was, I'd guessed less than 10, easily. I didn't need a microscope to know the cause of anemia Malaria. Malnutrition. Why wasn't this on my test. I kept thinking back to my pals at J/P, knowing that it was Monday, they were short staffed, and they would be getting swamped that day. What the fuck was I doing in Massachusetts, taking this ridiculous test?

Less than 48 hours after the exam, I was on a flight to South Africa.

I'm envious of my friends who are still working in PaP, more envious of those who I know will be returning there before me, and still even more envious of those who are doing humanitarian work, as their career. I am humbled by those who are forging ahead and making it work. I look forward to the day that I can rejoin my J/P pals, on a permanent basis, sleeping in the tent, wondering if the chicken we are eating were the chickens that were alive out back a few hours ago, bracing for the onslaught of another Monday clinic. I look forward to the day when Chris calls me from Darfur (or what ever conflict-du-jour is taking place) asking if I can come set up a mobile clinic for his IDP camp. I look forward to the day that Matt/Jack/Jeff/Andy are only a radio call away as I call them because the hospital electricity as gone off, again, and I need electricity for the nebulizer machine for the child having an acute asthma attack. I look forward to endless hours of Frisbee with Mark and Lee, maybe not on the LZ, but across a rice paddy, or on the savannah. I look forward to the day when a crashing patient shows up in clinic, and Paul/Andrew/Annette/Mellissa/Jodie/May/Lindsay/Beth/Lee are there to help. I look forward to Sonia calling to say she is going to help bail me out, again.

And so, I find myself again contemplating where things are headed. This time, I am not sitting in the tortuous heat of Haiti. I am sitting on the back deck of Siza and Scott's house. It has taken me a few days to finally unwind and relax. The influence of good friends, and great wine have brought me to the point where I can finally sit back, in the warm winter Johannesburg sun, and realize how it is that I am here as a visitor, not as a resident. I am reminded that I am very fortunate. I have great friends (who are scattered around the world at this point- Sapna: where the hell on the globe is Chuuk anyway?), good health (even though my legs burn from running yesterday), a great family (who will be disappointed when I leave Colorado, but will always be supportive), and a profession which has plenty of job options. I still don't know for sure where the next move will be, but I know which direction I will be heading; it will be toward humanitarian relief work. It may be Haiti, South Africa, or it may be where MSF/UN etc places me. All I know is that as soon as I can, I'll be back out in the field.

Keep a tent open for me, I will be back.

Soon.

BPB

Passion. Is it Dengue or Malaria? 100 Days.

2010-03-14T01:06:00.000-05:00

PASSION.

I couldn't sleep the first night. I was amazed that I was actually in Haiti, amazed that I was able to sneak out of residency for a week to actually contribute my skills in Haiti. I couldn't sleep because of the buzz about the place. How was it that I had ended up in Milot, working with some of my colleagues from Massachusetts. The buzz of new people arriving daily to help, of people I'd just met the day before who were now leaving. I'd walked into the pediatric ward, shocked to see a room crammed with not only 45 pediatric patients, but parents, siblings, aunts, uncles, and in some cases, complete strangers taking care of children. I'd picked up Jamesly, who had a "spinal fracture" and noticed that he was breathing way too fast for his age, looked at his spine xray, and seen that his lung fields showed a classis picture of PCP pneumonia. He had AIDS. The back fracture was Potts Disease (TB in the spine). This kid was in trouble. I was working with two pediatric ED attending from my hospital back in MA, but here I was, the expert about this child's condition, and treatment. Jacki was flown in from the USS Comfort missing a large portion of his skull, which was removed because of infection. The USS Comfort had sent him here with 6 weeks of an IV antibiotic. Fat chance of keeping an IV in this kid for 6 weeks. Maybe in a hospital set up to place more permanent IVs, but we didn't have that luxury. Looking over his notes, there was a better choice, which he going get as a once daily injection into the thigh (for when he lost his IV). I made the change to his chart (and later confirmed with 2 infectious diseases docs, who agreed). Our pedi team had gone back to the tent after our 8pm staff meeting, making sure that evening meds were given, re-examining the few kids with active medical issues (meaning those who had more than just orthopedic issue).

After the night round, we all hung out talking about what was going on. There were almost 400 earthquake victims here. The place was abuzz. We were all here, most having taken unpaid leave from our jobs, some paying their own way here, all with the same purpose. To provide what we could to those who were affected by this horrible earthquake. I couldn't wait for morning, for a chance to get back into the tent, to get a better understanding of what needed to be done for all the kids who had casts on, all the kids who had external fixation of their fractures, all the kids who had bandages covering their wounds and their skin grafts.

The days quickly because 16 hour days. There were minor victories (no more bandage changes, seeing the physical therapists getting amputee kids up on crutches), and set backs (not being able to treat phantom limb pain, not having mental health counselors to deal with those most severely traumatized by the earthquake).

When word came that I was going to be pulled out of pediatrics and be sent to Tent 4 my colleagues from MA went to the director to protest. "He can't be pulled from peds, that's where he is needed, he knows what's going on with all those kids." But I saw Tent 4 as a challenge. 35 female patients. And a test to flexibility. That's the gift of being dually trained in internal medicine and peds, I can treat both. So when the schedule came out in the morning, I went to Tent 4, starting anew with women who had shattered pelvises, shattered femurs, nasty wounds, hypertension, diabetes, and one with extreme heart failure. (Tent 4 had been run by a doc from MA who had been in the first med-peds class where I do my residency. 23 years ago, she took a year off from residency to work in Kenya for a year. She and I are the only ones to ever take a year off from residency-we bonded quickly). The temperature in the tent approached close to 100 degrees on the worst days. But the work was so invigorating...

The 16 hour days continued. I'd pop into the pedi tent to check up on the few kids I couldn't let go of (was Jamesly getting any better?), and then head to Tent 4. After the evening staff meeting, one of the nurses and I were back in Tent 4 for an hour, giving meds, checking temperatures on the patients who were teetering on sepsis.

Getting back to the staff compound after rounds, it would be time for social rounds. After a few days, it felt like I'd been there for weeks.

I laid in bed the last night, petrified that I would sleep through my alarm and miss my ride to the bus station (to take the bus back to the Dominican Republic). I was beyond exhausted. But unable to sleep. What would happen if I showed up a week late to residency and stayed another week. How could I go back. How could I leave the most meaningful work I've done since I left Johannesburg???

It was painfully clear. This is the work I want to do with my life. I fight an overwhelming urge to call my future employer and tell them that I made a mistake, that I don't need an income, that I don't want to work in a fancy hospital with MRI available at all hours, and let them know that I'll be working in Haiti, or back in Sub-Saharan Africa. Sorry for the hassle. My bad. [Though, of course, the job is a done deal, and it's a necessary step for professional reasons as well].

I like the chaos. Chopper landing with new patients, our tent is basically full, but we're getting 2 more patients. No problem, we'll scoot the cots even closer together and make room for 2 more patients. What, we're going to get three patients?? Fine, we'll scoot the cots right next to one another.

I like the challenge. I went on a drug search for my patient in extreme heart failure. What drugs are available? The smallest lisinopril tablet is 10 mg? Fine, well cut them in half and start at 5mg. There's no spironolactone, anywhere? Fine, what other diuretics do we have (this is post lasix diuresis for NYHA Stage IV). Somebody thinks they saw carvedilol tablets a few days ago in a plastic bag in tent 1? Great, I'll go find a stash for my patient.

Watching a random group of doctors, surgeons, nurses, therapists, logisticians, translators, carpenters come together and work non-stop in less than ideal conditions, working for free, all to help out a group of people who have been marginalized for a long, long time, in a attempts to save lives and alleviate suffering after a horrible disaster, and meeting a group of patients who define resilience and have so bravely taken on the challenge to get better, and to go on with life was one of the most profound experience of my life, and I'm utterly humbled to have been able to play a small part.

Is it Dengue or Malaria?

It started the night I got back. The fevers were sky high. The chills so bad I couldn't keep from shaking. The sweats to bad I had to change clothes. The fatigue so bad I had to sleep in my Jeep before driving to clinic. Coming back from Haiti, sick, was not part of the plan. I'd been pretty careful. Had taken my malaria prophylaxis. Had gotten my typhoid vaccine (though a bit late). Had used plenty of DEET for the few mosquitoes that were around. But something was kicking my ass. Bad. The treatment for Malaria didn't help. The dengue labs would take a week. A bunch of my labs were outta whack. My doctor (one of my clinic attendings) was consulting an ID doctor, I'd seen an ID doctor the day she'd been out of the office, and that ID doctor was consulting the Chief of Medicine. Always a joy to be the mystery patient... my PCP, plus 3 specialist in infectious diseases... It took a week, and the verdict was Mono. Thankfully dengue was negative! Somewhat ridiculous to get mono at this age. And having mono during residency is less than ideal, nothing like adding fatigue to the picture, as if the job wasn't tiring enough. How I got mono remains a mystery, and of course the rumor is that there was some secret romance in Haiti... If only my life were that exciting. In a weird way, it was good being sick. It can be easy to minimize the symptoms that patients complain about, so it was a good reminder that it really sucks to be sick.

100 Days

I have 100 days of residency left. ONE HUNDRED. It's so close I can taste it. The next phase is coming... and it's exciting. Back to Haiti for 2 weeks. 4 weeks to study for medicine boards (some pedi studying) and to figure out what will get moved to Denver. Medicine boards and then 2 days later back to Jo'burg for 2 weeks. Then back to MA and leaving the following day to drive to Denver. And in all honesty, as much as a part of me doesn't want to be in Denver (my adolescent side), part of me is really excited (my adult side); excited to be close to nieces and nephews, back to the Rockies, a place where I can walk to things (and maybe even bike to work here and there), and part of me is really excited for the job that I'll have-I'm going to learn tons and become a better doctor, and have flexibility to keep working abroad (most likely Haiti) a few times a year. It'll help me get to the next place in my career.

BPB

2010-02-21T12:50:00.001-05:00

Please ignore the typos etc in the post below, i was slightly horrified to reread the message last night. It was composed on the bus as we pulled into santo domingo

Departing Haiti

2010-02-20T16:55:00.001-05:00

I am on the bus, headed back to Santo Domingo in the DR.

For days i dreaded leaving Milot and the Crudem hospital. It was perhaps one of the most intense, moving, and meaningful experiences. I have been on the bus today napping, and thinking about "my" patients. The 50 kids we took care of on peds, and then the 35 women i took care of the past few days.

I dreaded saying the goodbye. Trying to imagine how it would feel top be in there shoes, a constant change of doctors and nurses coming and going. Building a relationship, and then then departing. I became quickly attached to many people, patients, fanmily, and Haitian staff.

I was afraid i would lose my composure when i announced to the peds ward, and theb my female tent that i was leaving. But by the time i made my last round at 8pm last night, i was so exhausted that it was a non-emotional goodbye.

I know it won't be long until I am back.

Impending Departure

2010-02-18T06:51:00.001-05:00

I have a tough time describing the experience here. Moving is probable the best word.

I wont be ready to leave. It will be tough to say goodbye, and i will wonder what happened to the kids who have been orphaned-who have had their parents killed. I will wonder about our amputees and if they get their prostheses. I will wonder about the women in my adult tent with their pelvic fractures who are bed bound.

When i leave, part of me will remain. But I am sure it won't be long until I am back here.

Haiti

2010-02-12T23:48:00.001-05:00

Will have lots to tell. Have ended up in milot, sacred heart hospital, run by Crudem (google it). About 400 + patients, will be working with some docs from baystate, doing peds for the next few days. Good supplies, lots of doctors. Pretty devastating to see so many kids who have had limbs amputated..

Off the Grid

2010-02-11T00:02:00.000-05:00

I'm headed to Haiti. Cap Haitien specifically. Will be going with Haiti Marycare. Though I have just head that 2 pedi ED docs that I work with are in a town about 30 miles from where I will be. It's a small world!

It was a bit of a long shot to be able to get the time off to go, but somehow it worked out, so am headed out tomorrow. The blog has been pretty silent for a while, not sure that there will be a lot of posting from Haiti, but will see what I can do.

BPB

Decision

2010-01-11T23:42:00.000-05:00

I made my decision on January 1, 2010. After months of agonizing, examining the decision from financial perspectives, career development perspectives, my own personal drive and desires, and the need to live somewhere sustaining (for a while), I decided to take a med-peds hospitalist position here in the US.

It's a 180 degree about-face from where I thought I was going to be that day I got on a plane to move back to America. I was certain I would be moving back to somewhere in Africa in the summer of 2010. I-Was-Certain. It'll be good to make some money to appease the student loan people. It will be good to spend some time growing as a physician. It will be good to spend some time with family (especially nieces, nephews, godkids and all the other kids). But it won't be long... Won't be long til I'm driving on the left side of the road, or taking off somewhere where I don't speak the language..

BPB

Losing Clarity

2009-12-20T00:24:00.000-05:00

In the periods last year when I didn't keep a blog, I kept a travel journal. The writing is vastly different from what made it on the pages of the blog. The writing is more focused more like making notes to document what I was thinking at that time.

While sipping some Johnnie Walker, I decided to flip open the travel journal, and pinpoint where I was a year ago. Where was I in my thinking about where my life was headed. And where in Nepal was I?

I was in Bardia National Park. I had spend the day on a rafting trip. It had been cold. We didn't see much in the way of animals. I would be leaving early the next morning for Lumbini, the home of Buddha. I sat outside my room in the cool evening, writing a few pages as night settled in, finally writing by candle as I waited for the generator to come on.

I wrote some poignant things. About my future as I saw it then. After days of trekking, being stranded on a bus strike, and floating down a river for a day, I'd had enough time to reflect on what it is that was driving me. I'd felt this incredible enthusiasm for work, for medicine. And I wrote my plan for July 2010. I wouldn't be working in the US. There were some possibilities. NGO jobs. Baylor Pediatric AIDS corps. Locums and MSF. It's a decision that was made with complete clarity.

I've set January 1 as my arbitrary date to make a decision as to what I will be doing on July 2010. The plan that I had made a year ago got lost in the confusing period after Randall died. This past week I've discussed the job situation with many close friends (ie, my advisors), and I've narrowed it down to 2 possibilities. I have come up with a new plan, maybe plan z by this point. And I'd finally become comfortable with that plan. But reading back to what I wrote exactly a year ago from today, and made me lose, once again, that clarity. Argh.

I read on in the journal. It's the day before Randall's birthday. And I knew that I had some clarity at that time about things.

I can't help reading about where I was a year ago, when I seemed to have had answers; answers which are now gone.

The decision I am making in January 1 isn't going to be ideal, in many ways. I'll be making a decision to give me a path to follow for the short term, while I wait for some clarity...

I'm not just picking a job

2009-12-06T08:07:00.000-05:00

I'm not just picking a job. I'm defining myself-to some degree. I can't recall the last time I agonized so much about a single decision. Choosing residency was easier than this. The decisions for university and medical school didn't have much competition.

May 28th, 2008 I took a hike. It was a Wednesday. I had been on night float the night before. Had gotten off of work. Been to the dentist. I must have taken a nap at some time. And it was a gorgeous day, so I made a break for a trail. Just a chance to get out and get some fresh air, and maybe a fresh perspective. I stopped into a bagel shop, grabbed a bagel sandwich, popped into a liquor store and grabbed a cold beer, and hit the trail. I ended up sitting down on a rock in the middle of a small river, and watch as the water crashed over a waterfall hitting a pool below. And I just sat, enjoying the solitude contemplating.

Contemplating bigger issues.

Why did I go into medicine.

What did I want to do.

I made a list of the things I wanted to do:

-work with MSF

-work on Everest Base Camp for a season

-work in a rural hospital

-work in an inner city hospital

-complete a tropical medicine course

-volunteer with UNICEF

-have a faculty appointment somewhere

-work in Alaska over the summer

And there are a lot of things that aren't on that list, that have crept into my thoughts since then. I'm trying to juggle income, finding the job which will allow me to take care of kids and adults, the patient population I want to take care of, the ability to have time off to get back to Southern Africa/Central America/South America.

[Courtesy of White Snake]:

Here I Go Again
I don't know where I'm going
But, I sure know where I've been
Hanging on the promises
In songs of yesterday
An' I've made up my mind
I ain't wasting no more time
But, here I go again
Here I go again
Tho' I keep searching for an answer
I never seem to find what I'm looking for
Oh Lord, I pray
You give me strength to carry on
Cos I know what it means
To walk along the lonely street of dreams
An' here I go again on my own
Goin' down the only road I've ever known
Like a drifter I was born to walk alone
An' I've made up my mind
I ain't wasting no more time
I'm just another heart in need of rescue
Waiting on love's sweet charity
An' I'm gonna hold on
For the rest of my days
Cos I know what it means
To walk along the lonely street of dreams
An' here I go again on my own
Going down the only road I've ever known
Like a drifter I was born to walk alone
An' I've made up my mind
I ain't wasting no more time
But here I go again
Here I go again
Here I go again
Here I go again
Cos I know what it means
To walk along the lonely street of dreams
An' here I go again on my own
Going down the only road I've ever known
Like a drifter I was born to walk alone
An' I've made up my mind
I ain't wasting no more time
An' here I go again on my own
Going down the only road I've ever known
Like a drifter I was born to walk alone
Cos I know what it means
To walk along the lonely street of dreams

Guns and Russian Food

2009-11-27T23:28:00.001-05:00

It wasn't even about the guns. It was about doing something different. Must of us don't own guns. But to tick that box that says "has shot a gun at the smith and Wesson factory," that seemed worthwhile. But I was wrong. Nobody showed up. Nobody.

Last Saturday while killing time driving around waiting for a party to start, I found a Russian restaurant. Which wasn't such a surprise because I live in the Russian/Polish part of the city. But this place was open late. Very late. And there were people inside. This place looks authentic (and like a mafia hang out). And I am desperate to go. I suggested it to a few co-workers, a few of whom seemed interested, but more than one said "but I don't even know what they eat."

And that's the point. I don't know what it feels like when you shoot a handgun. I don't know what it feels like to sit down in a Russian restaurant (where I may damn well stick out like a sore thumb), and order something that I may have no clue about. That to me, is the reason to do both.

I was able to leave work early this afternoon, a damn rarity these days. And all I really wanted was to be in Johannesburg. Thinking of the time difference, I knew that the guys would already have decided where to go for dinner. It'd be too early to eat. Maybe I'd be in the gym, or out for a run, thinking about which of my few shirts I'd wear to dinner. And then a few hours later we'd be gathers, and would be out for ages, trying new places to eat, enjoying a night out. Later on, as I was tempted to call my pals in Jo'burg, I realized it was getting a bit late. But as I thought about it, I imagined a Friday night in Jo'burg, it's summer, I bet they were sitting outside on the patio of S&S, on the umpteenth bottle of wine, listening to music, and just making the most of the night.

Fuck. Why can't I be there. Every single day I find myself thinking about where I was a year ago at this time. And every single day I wish I could go back. I have these great friends here, but the confines of residency, plus the effects of perpetual fatigue, and a cohort of friends who are mostly married/partnered (+ kids) doesn't allow for the randomness and social scene which I so dearly enjoyed last year. And that, I have realized was sustaining. This is not. I'm slightly disappointed in myself though, I must confess. I am a solo traveler, and so often have been more than content to strike out on my own, be it for a day, a week, or a month. I use to find things to do, places to go, and do them, and go there. But being back here, where I have a few great friends, and know tons of people, I end up feeling that it's not worth my time to go solo. When in fact, it would be much less disappointing to strike out on my own..

Recently, I've realized the need to take the above into consideration for jobs... The job that pays a boat-load, in the middle of nowhere sounds attractive, but the long term longevity of that job would be poor. Unfortunately one of the jobs which I thought was a sure deal has hit a bit of a snag-and that caught me a bit by surprise. I'm very close to tossing in the towel on the job search, talking to my locums (aka travelling fill-in doctor) agent, and going that route which will allow me the freedom to travel.

In the meantime, I'm going to go shoot some guns and eat some borsch. (Maybe on my own).

-

Running, Again? Running, Away?

2009-11-15T20:16:00.002-05:00

I don't think it was a whim, but I don't know why I stopped out of the blue to buy new running shoes. I hardy run these days. But I did, and I shelled out the bucks for the new shoes (the current version of the shoes I've been running in since August 2004), as well as some fancy socks and a shirt. And then I came home, chatted with my flatmate, had a glass of wine, and pondered going to bed. Realizing that I should put those new shoes to use (if anything to justify the ridiculous price of 75 US$, I mean that'd do a long way for some friends back in SA), I abruptly stood up from the table, finished a generous gulp of wine, and went and changed to go running.

I put on my ipod to my running mix, the same mix of 164 songs that I've had for years, and set off. I turned the corner and headed down Route 5. I don't know what it was that took me back in an instant to that first night I ran in Dublin. Maybe it was running along a busy road (there, it had been South Circular Road), maybe it was the cool, misty night air. Maybe it was knowing that my legs were going to be sore in the morning, as I was biting off more than I should by hitting the pavement, but I felt like I'd gone back in time. And for a few blocks, maybe a mile (I wish I could say a few miles), I kept having flashbacks to my running progress in Dublin. After that first run, I couldn't run for a week. And then I ran around a park for a while, a meager few blocks, and then I was running more. Running along the River Liffey. Running through Dublin-no longer embarrassed to be out running. As I changed my running route, I discovered new areas to run in Dublin. New Parks I had never explored. New pubs which I made a mental note to check out, though usually forgot about once I got home. When a certain song plays when running, I can recall exactly where I was in Dublin during certain runs...

I turned the block, and ran past an Indian restaurant. And that triggered a flashback to a night when I went running during my intern year. A cold night. I'd run from my flat, down to the hospital, and around a neighborhood. I'd run past Gabby's house- and saw she wasn't home, and I wasn't sure why she and I had not talked in a few days-both busy I'd suspected. The Indian restaurant I was passing is where she took me for my birthday, and the conversation that night is permanently etched in my memory. We were going to make the world a better place. She wouldn't let me sell out, and as I ran, I thought what advice she'd be giving me now. "Fuck those job offers, are you kidding me, there are people out there who really need our help." She didn't hold back. And I miss that. She gave me coffee and a tie for my birthday. I don't wear that tie nearly enough. Maybe I'll wear it tomorrow.

I was lost in thought. Am I running to somewhere? Or am I running from something? For months I've agonized where my paths is going. I've solicited (both bluntly and circuitously) the insight from friends, sometimes hoping that one or two of them would pin me down and spell it out for me. Because I cannot see the path anymore. When my world crashed in July and August, all I could think of was Denver. On more than one occasion in the past 4 months, I contemplated flying out to Denver the following morning, fuck residency. Having the support from my family when I did see them in July, and the joy of hanging out with nieces and nephews, combined with the awesomeness of Denver made it clear, that Denver is where I thought I needed to go, and the ball was set in motion. On a Saturday in September, after Randall's memorial, I was sitting outside drinking margaritas and chowing down Nachos, surrounded by a great group of people; it was again evident that Denver is where I was headed.

I was lost in thought, until I saw a dodgy person on the sidewalk with a German shepherd. I'm in a residential neighborhood, in a safe part of town. This is not Johannesburg. I am safe here. He nods as I run past. More than once, in Jo'burg, I had crossed the street, or taken a turn and changed my path when I was running and saw a group of people on the street at night. It had taken me months to work up the courage to run there. I miss running in the nature reserve; I miss seeing zebras and wildebeests on runs. I miss Jo'burg, period. And then I heard Gabby again, and I wonder if I am running from the thing I really want to do, to oblige the banks who loaned me the vast sums of money so I could get to this point.

As I reach the driveway, the only Jewel song in this mix, Who Will Save Your Soul starts playing. I smile as I stretch. Maybe the answer is neither. I'm not running to nor from somewhere/something.

I'm just running...

BPB

90 hours

2009-10-13T23:20:00.000-05:00

I worked 90 hours last week.

Tonight I was re-reading some old posts, and I looked through old pics posted on here (and on the link to old photos). I miss where I was last year. I miss my Jo'burg pals. I miss working at Bara...

I'm meandering along the status quo route right now. Just keep plugging along... I have some interviews lined up, a few in Denver a few elsewhere. Balancing a calling back to the Rockies.. but also a fear of settling down, waking up in 5 year, 10 years, wondering why my passport is blank, and how it is I ended up settling down. That's my fear.

I'm back to work in a few hours, I suspect sleep, not pondering life, would be good for me at this point. So, I shall abruptly cease this post, and cave to fatigue and the comforts of my flannel sheets.

BPB

False Start

2009-09-14T22:34:00.000-05:00

I hope this isn't another false start.

I feel compelled, all of a sudden to get back on track. No in a manic get a million things done at once, but slowly getting caught up on things like email, going through a mounting mail stack (it's all junk) etc. But also trying to get back on track academically... trying to settle down, get back in the groove of reading about my patient's conditions, preparing for upcoming exams, and just trying to be a better doctor.

I don't have much to show for the past 2 and a half months. A few extra pounds thanks to ice-cream and wine, a few more grey hairs, and a reminder that life is precious.

I did manage to send off my CV to a few random sources. Just kind of testing the waters really. I have one more place to send it, and then my first tier will be complete. There is no longer a definite post-residency game plan. There were plans A, B, C, D (and maybe an E-G). Kind of an if this happens, then go with this plan. If A doesn't pan out, then B.. but most days, A-D all seem great. Last week B was my favorite, and then for a bizarre reason plan C jumped to the front of the queue on Friday afternoon. The anxiety about being clueless in July when everything was happening no longer freaks me out. None of the above plans have to be permanent.

On another note, I eliminated a plan. The honeymoon phase of being back here is over. I have some great friends here. I absolutely love the hospital I am in. But this area is not for me. I'm not straight. I'm not in a relationship. I'm not one to sit idly by and be content at home. This area doesn't offer me the things I need outside of work. And so, staying here--which was the safe, comfortable option, is off the table. It is no longer an option. And I anticipate leaving here at the end of June. 9 months for now.

What's that song lyric, "I don't know where I'm going, but I sure know where I've been..."

I hope this isn't another false start.

Blogging in my sleep

2009-09-03T22:13:00.000-05:00

I had a dream this morning, that I was writing a blog entry. It was a good post.

I'm getting caught up on "things" very slowly.

Getting some emails out (BK, OA, HG, JD etc etc etc-they are coming)

paying bills

doing taxes

laundry

unpacking

planning my life

There really will be more blog posts to come...

More soon.

BPB

A Bump in Karma. Rebounding.

2009-08-23T15:53:00.000-05:00

Friday's call was not pleasant. 14 admission, 11 of those were between 1030 am and 7pm. I had to call in a back-up resident to help bail me out. Not that I should have had to do that.. I should have had an intern assigned to me, and then wouldn't have had to call for help. Also, if there were any sense of team work amongst the senior residents this month, it would have gone a bit more smoothly. But alas...

At midnight I finally felt caught up. All of the admission notes were done. I'd rechecked a few of the sick kids who had been admitted hours earlier. And I started the tedious process of starting the discharge notes for the admission that had come to by team. This use to be the expectation, that you'd stay up on call to get these things done, which would help facilitate the discharge, as quite a few of the kids who were admitted would be going home on Saturday, a few more I suspect will go home today. I found out, however, that this isn't really what happens anymore. The ethos of residents seems to have taken a bit of a dive...

We finished signing out to the team who would be on call on Saturday, and then I headed to the post-office. I had a notice for a package, and was glad to know that the computer battery I was expecting-shipped from Colorado by my computer guru (aka Dad), had arrived. The old battery would only last for about 30 minutes before dying. And so I took my slip to the counter and waited for the package.

Maybe it was the fact that I'd been up for 27 consecutive hours, had survived a painful call, felt like I'd provided good care to my patients and their families, and the realization that I have only one more f*cking week of this lame schedule, but as the post-man walked to the counter with my packages, and I realized that my "stolen" packages that I had mail from South Africa almost 5 months ago were miraculously before me, I felt an almost giddy euphoria. Maybe it was fatigue.

The past 8 weeks have been rough. Really rough. I had to move away from a place which I loved, leaving behind one of the greatest group of friends I've ever had. Randall died, and with his death ended mystery of knowing what the final outcome between us would be. And with his death ended the plans that I had made for the next year post-residency, that being to return to somewhere in Sub-Saharan Africa for a year of work. And on top of that, my residency program did an unprecedented move (to fill a hole in their schedule), and took away the intern on my team-so that I get the joy of doing the work of two people. There's also been a karma deficit which has affected some of my close friends. It's been a shitty 8 weeks, where the literal goal has been to get by on a day-by-day basis, and to not think about what the next day would hold.

I felt victorious post-call. I'd made it through a long night. My kids were doing well. The nurses let me know how glad they were that I'd been on call. Well, aside from the fact that I have a huge black cloud. And when I saw those packages, for some reason, the suffering of the past 8 weeks just seemed to melt away. As if the universe was aware that there'd been a huge Karma Deficit, and that this was a way to prove that things were going to be ok. And I raced home to open the packages. Months ago, when filing out police claims for theft, I couldn't remember the specifics of what was in those packages...

Taking out my Tibetan Prayer Wheel, and spinning the prayer wheel brought be right back to a chilly evening in Pokhara, when my friend Dilip and I were talking to the Tibetan Refugee women from whom I would eventually buy the prayer wheel. I open my Ethiopian Lonely Planet and looked at the pages on which I'd made notes about cool streets, and where I'd made note of hidden cafes. I laughed that I'd mailed back a book which I doubt I'll ever read again. I'd come to accept that I'd never see these things again...

I slept a few hours post-call, and then went to join some friends in NoHo for lunch. And then I headed to Boston to have dinner with a couple (H&R), one of whom is on my "panel of advisors" about my post-residency plans. I've had to debate where I'm headed, and what I plan to do. And in the past 2 weeks I'd spoke to a few of my advisors about things, and the possible evolution in my plans, and the algorithms which I've diagramed out. There is not a Plan A, with a back up of Plan B, etc. But rather there are Plans A, B, C, and D. All of which are fine, but none of which excite me to the level that they should. The plan that excited me the most, is no longer in the cards. Anyway, H&R and I had a great evening, gourmet burgers, good margaritas, and plenty of discussion about options.

And as I drove home on the Mass Pike, with a U2 CD blaring, things seemed to have finally started to pick up, as if I'm rebounding from all that has happened in the past 8 weeks.

Finally.

Flashback

2009-08-20T21:02:00.000-05:00

Tomorrow is my first overnight peds call of the year. It's quite remarkable to think back 4 years ago to my first peds call as an intern. I never thought I'd hit the comfort level that I have finally reached...

I'm actually looking forward to the call...

Thanks Rob...

2009-08-16T00:07:00.002-05:00

Aquarius Horoscope for week of August 13, 2009
(from freewillastrology.com)

In the days ahead, you may not realize what you're looking for until you find it. I advise you, therefore, to put into action the following five-point plan. 1) Suppress any know-it-all tendencies you might have. 2) Revive your childhood talent for being voraciously curious about everything. 3) Ask more questions than you've ever asked before. 4) Figure out how to be receptive without being passive, and how you can be humble without muffling your self-confidence. 5) Consider the possibility that you have a lot to learn about what's best for you.

My Horoscope from the infamous Rob Brezsny.

1-yeah sure, that sounds fine in principle
2-I don't have the energy for curiosity
3-There's already an overflowing list
4-think I have this one down
5-No shit, really?

I laid under the stars at Tanglewood tonight (www.tanglewood.org) thinking that I hadn't written in a while, that I should make a note of what's been going on since I got back to the US.

But it's just not stuff I really care to write about right now, so in a burst of insomnia, went back to my old friend Rob for some amusing answers to why the universe has been all outta whack... Think I'll check back week for a better response.

-

Square Peg

2009-08-04T21:03:00.000-05:00

In a round hole.

I snuck into noon conference to get lunch yesterday (with no intention of listening to the talk-did I mention the lunch is free) and saw David. David who is now a real doctor. Making real money. Taking care of patient as a real doctor, not having to discuss his every plan with an attending. I couldn't help but have some slight envy when I saw him. Ok, I'm lying it wasn't slight. It was pretty good envy.

I have a small talk which I am suppose to give tomorrow, and a small talk to give on Friday.

I'm on call tomorrow.

I no longer have an intern assigned to me.

I'm making money, but squat compared to that attending salary David is getting.

I'm tired of having to precept my management plans with attending doctors.

But I guess this is a small price to pay for having been able to be away last year. If I could go back in time, I'd do it all again--in a heartbeat.

Everyday I see people whom I haven't seen since I got back. And they all ask the same question. "Are you glad to be back?"

Am.

Glad.

To.

Be.

Back??

It's a loaded question.

Recently the answer is no. Yesterday I was helping the intern do a spinal tap, and we needed more numbing medication (like the stuff the dentist gives). But in order to get more lidocaine, I had to take off my sterile crap, go out of the room to a computer, and put in an order which would allow the electronic-computer-controlled-medication dispensing machine release a vial of it.. all so that the charge would be passed on to the patient. They whole process took 5 minutes. Which was 5 minutes of more discomfort for the patient (and the intern who was already sweating).. and for what cost?? To save the hospital a few bucks.

Recently the answer is yes. On the rare time that we'd want to use lidocaine in SA, it would likely be impossible to find some. There was a secret stash in the ICU, which was used for more intensive things, like central IVs, but we wouldn't waste lidocaine for small things, like spinal taps.

It's hit and miss. And I feel like the square peg, fitting into a round hole. I can fit into the holes, but it's not an ideal fit... That's just one example. There are many, on a daily basis.. but as it is, I need to go finish these talks that I have to give this week..

I can't wait to be done. I just want to be a doctor.
Where-I'm not sure.

Doing what-I'm not sure.

11 F*cking Months

2009-07-31T15:08:00.001-05:00

Well, it was nice to be back to work for a few weeks. Until I found out I was getting THE SHAFT at work next month-in that I'll be working solo. Not that I mind so much, because in 11 months I won't have an intern to do the scut work for me, and not that I'll mind much because I'll have a real salary, but what I mind is the unprofessional way in which the program has been handling things...

11 Fucking Months left. Until residency is over.

I was sitting in a meeting today, listening to whining, whining, whining.. all about work load and hours that we work. It's freaking pathetic. Don't get me wrong, I am pretty vocal about things I don't like, but not one to complain about working hard, or long hours-it's our job.

Not that Bara was perfect, but god I wish I could be back there. Shit happens. The job is hard. Like it or get the fuck out.

2 year ago in July, I was a pediatric ward senior resident. We had a great month. I'm not getting the same feeling heading into August.

-

Moving on

2009-07-27T06:14:00.001-05:00

I'm in chicago, on my layover headed home from Hawaii.

The wedding was fantastic, the whole trip was a great distraction from life. We had a blast, did lots of relaxing and laughing, and made new friends. It was also just great to be away.

But now i am headed back to reality. I think I am ready for what lies ahead. As for work, I'm getting SHAFTED in august as they have taken away my intern so I get to do the scut work that the intern does. As for post-residency plans, i am still trying to sort through options... August will be busy.

More soon.

To the beach

2009-07-21T05:29:00.001-05:00

hello

Had a great, but quick, stealth trip to denver over the weekend. It was great to be surrounded by family (and a few friends), and the new additions to the family are gorgeous!

I am now headed, out to Hawaii for a wedding. will be back to Massachusetts on Monday. But for now, i think a few days of sunshine and rest are well deserved given recent events...

more soon.

Auto pilot

2009-07-14T23:38:00.000-05:00

15 days ago I had the answers. I knew the job I was applying for. I knew what I wanted to do for the next year or two. I came back with expectations to coast for a year-when I got back to the US.

And Randall's death has confused me. And all of a sudden I am not sure what I want. I am not sure about my professional plans. I am not sure about my personal plans.

I am just on auto pilot.

But it is oddly refreshing to be back at my home hospital. I am enjoying a comfort zone there; a comfort zome that I have never experienced before. It's a comfort zone with my ability to function as a doctor, and a comfort zone being back in an institution where I'm so well known that people think I'm an attending. I have found it oddly comforting being back in such a familiar surrounding.

I'm going to Denver on Friday. It's a trip that has been planned for a few moths now. I can't express how much I'm looking forward to being in the presence of my family. In the troubles of the past 2 weeks, knowing that I am going to be with them is what has kept me going--that I am going to be with my brothers, my dad, and their wives, as well as seeing my nieces and nephews has been keeping me going.

In the meantime, please don't ask me what I plan to do down the road. All I know is that I doing tomorrow. It's day-by-day for now.

RIP Randall

2009-07-06T23:26:00.002-05:00

Dec 20, 1976 - July 7, 2009
I know there are no guarantees in life...

Blog postings on hold for a bit.
Randall: http://randallchina.blogspot.com/

Almost Back

2009-06-28T10:13:00.000-05:00

Somewhere over Europe is when reality seemed to hit me. Well, actually, according to the flight map display in the airplane, we were over Northern Ireland at the time. I am going to be back in America in about 5 hours. I will be back to my residency position in less that 72 hours. My upcoming days in the ICU and on the medicine wards provoked a bit of anxiety as I tried to get myself to think through clinical conditions which I may confront. I have not taken care of somebody having a heart attack in over a year. I have not managed an adult diabetic patient in a year either-and cannot quite recall when they are suppose to have routine diabetic care stuff done. Wow, I may be a bit rusty. I am sure, though, that I will settle back into the swing of things quickly, with a few bumps and "Oh yeah, now I remember" moments.

I will have just 2 days to get some errands run when getting back. I need to upgrade my phone/PDA as it appears my palm pilot is on the fritz. I also need to get clothes out storage. I came here, to SA, with 64 kilograms, in 2 bags. I am heading back to America with 69 kilograms, which is contained in 3 bags (and sadly cost me US$150). I am not quite certain what is actually in those bags. When I was in my Jo'burg room, I began to appreciate having so few worldly possessions, and was quite amazed to find that it took 3 bags to pack up. But, I had neglected to realize that my new backpack, tent, sleeping bag, and outdoor clothes added to the accumulated goods. To manage, I also had to voluntarily redistribute some wealth, and that was in the form of a filled trash bag. After wearing the same clothes for a year, I could no longer stand to look at some of the shirts which I have word day-in, and day-out to the hospital. So, among those shirts, and the ones that I never seemed to wear, I packed them up, and stopped by to see JC, my favorite Zim patient. I am thrilled that he is likely the only person walking around Soweto in a Colorado T-Shirt, as well as Banana Republic and GAP clothes. Though I did ask him to distribute clothes amongst his friends and others in his situation. I have realized that I accumulated a ridiculous amount of clothes in my few years of residency, so was more than happy to redistribute goods. It will be nice to unpack clothes which have laid dormant for a year.

I also find myself eager to start to seriously contemplating what lies ahead for me post-residency. I have not really made much progress on an actual plan, as I have been deferring looking at real possibilities until I get back to the US, and can meet with a few of whom I have dubbed "my team of advisors." They have all known me for different lengths of time, as well as at different points from pre-med school, to medical school, to residency, and from SA, and they are all is vastly different positions (and even non-medical). Last week, I was asked countless times, why was I leaving. That was an easy explanation, but answering why I would not be back was difficult. It was difficult to explain that I will not be back in SA because I just wouldn't make enough money to pay student loans, and to pay rent, car stuff etc. It aggravates me that I have to factor in finances to what I would like to do. I would never contemplate taking the $200,000 a year hospitalist job just so that I could make a boat load of money, but I would contemplate it so that I could make a huge dent in student loans.

Running into the Sunset

2009-06-25T18:18:00.001-05:00

I debated, hard. Opening my bottle of Meerlust and watching the sunset versus a run. I needed something. I needed to appreciate the dusk. It was a perfect cloudless Jozi evening, and the sunset was going to be superb, and I was not sure which would be the better way to appreciate it, a glass of fine wine, or sweating and pounding the pavement.

I gave my Swiss housemate a ride into town today. He is going to be leaving the house and will be living on part of the Wits campus--the old Johannesburg College of Education Campus. At JCE, I showed the guard my Wits Staff ID card, and we drove into the campus. And I dropped him off outside Gyrton Hall. And unexpectedly, a flood of memories were unleashed. Almost exactly 5 years ago to the date, I was dropped off, outside Gyrton Hall, by a taxi, and a few days later I would be getting ready to start my rotation at Bara, as a medical student.

From there, I left and headed over to 44 Stanley, home of my favorite coffee roasters. When I was there a few days ago, the head Barista and I were chatting and he told me I must stop by again before I leave Jozi. So I popped in this morning to enjoy my new favorite coffee drink (a PICCOLO- a strong, sweet latte served in a 90ml glass), do a bit of work, and then chat with the Barista. It was slightly embarrassing a few days ago when we did finally chat. For some reason, when he found out I was leaving, we just ended up having this great spontaneous conversation about being foreigners, and life etc. Turns out, he is a Zim refugee, who was a high school teacher before he was forced to flee Zim. (Does this sound familiar)? Anyway, when I headed to the till to pay, he handed me an SA music CD, as a gift. Needless to say, I was shocked at the kindness of this very humble ex-teacher-now-barista.

From there I may my way to Parkhurst, where I had a late breakfast with one of my ID attendings. We chatted and ate for 2 hours, catching up on clinic business, as well as possible future plans for pursuing a Trop Med course (she's pushing for me to consider the program where she went). Suddenly it was approaching 1pm, and I was overdue at the HIV clinic for lunch. We parted and headed to Bara.

I joined the HIV team for lunch, AK and I chatted for a bit, and then we walked to the xray department to consult the radiologists on a patient he was seeing, I ended up in clinic and made a round to say farewell to the other consultants, as well as the counselors, and then I headed to Ward 18, my old ward. My favorite pediatric nurse and I chatted for a bit, took some pics, and while I was there, the Registrars I worked with were there for a pedi infectious diseases round, so it was marvelous running into them and having a bit of closure. And then I departed for home.

And driving home, thinking about packing up my room, it just suddenly hit me that this was, or is, my last night in Mondeor. I made a cup of coffee, mulled over things, and then it was obvious-I could time it perfectly so that as I ran away from the house, I'd see the blue-purple haze hit the hills, and when I reached my turn back point, I'd capture the best part of the sunset. And that's what happened. Finally, after many attempts, I capture it perfectly. I went to the nature reserve, stopped to watch the stars, and the brushfire off in the distance..

Now it is late. Very late. I'm half packed. The bottle of Meerlust has enough wine for one glass (I took it to my landlord's house as we watched SA lost to Brazil and discussed life and their departure for Kili in the morning).

That is it. Off into the sunset. A year at Bara is over

One Last Time.

2009-06-24T08:37:00.000-05:00

I want to do it one last time... "It" is a long list.

I want to do for one last sundowner at the Westcliffe.

I want to spend a summer evening at Lulu's after work, sitting outside reading and drinking coffee.

I want to be having breakfast at Espresso, hung over (mildly), laughing about the previous night.

I want to go back to Simply Blue on Pride night.

I want to sit outside at Mandela Square, during the week, in the middle of the day, eating sushi.

I want to take the minibus to work.

I want to see the Apartheid museum one more time.

I want to drive on the M1, amazed at the people walking along the highway, on their way home from work.

I want to be back in Nepal, back in Lesotho, back at Vic Falls, back in Cape Town, back in Clarens.

I want to be back in Ward 18 (especially now that I know so much more than a year ago).

I want to run through the nature reserve, stop, look at the zebras wildebeests and blesbock, and still be shocked that they are down the road from my house.

I want to the miracle of people coming to the HIV clinic weeks later, healthier, not dead.

I want to be in the pediatric cath lab with the peds cardiology team, learning and laughing.

I want to be at the airport, seeing the look on S&S face. Not sure if they are more confused because I've returned with only the clothes I'm wearing, or if they are more amused that I can't figure out how the hell to get to where I parked my car.

I want to spend a Saturday at Bean There studying and reading, and then meet up with friends in the afternoon, and end up back at home Sunday night.

What do I still want to do.

-nil-

-nada-

-zip-

-zero-

-zilch-

I've done it all. I'm cleaning and starting preliminary packing, and I just saw the list that I made a year ago. I did every single thing on that list. Life is too damn short to make lists of things to do, places to see and to not scratch items off that list regularly.

Back to cleaning..

New Pics

2009-06-22T18:02:00.001-05:00

Pics from the Sani Pass and from my farewell braai are now up:

http://picasaweb.google.com/BackToBara

Bakers Chocolate

2009-06-21T12:36:00.001-05:00

This is what I remember. It was winter, and we were on winter break. I was in third, maybe fourth grade. Our grandmother was visiting, and she was legendary for her cooking. And her baking. Our parents were at work, and she was baking away in the kitchen. I'd been hanging out, hoping for left over brownie batter. It doesn't get much better than having warm freshly grandmotherly-baked brownies on a wintery Colorado day during school break. Well, maybe it would have been better had the brothers not been around and I'd gotten both of the beaters and the brownie batter.

But I remember watching her put away the chocolate as she cleaned up the kitchen while perfection was cooking in the oven. And I made a mental note to remember where the chocolate had been stashed. And enjoyed knowing that the brothers didn't know about this secret stash. And at the opportune time, when the house was quiet, I made a break for the goods.

It's the anticipation of chocolate that I like. Knowing that I'm going to be enjoying one of the most pleasurable tastes of sweetness. Taking a bite of chocolate and letting the chocolate melt as the butteriness of the flavor comes to life is as blissful as that first sip of a great cup of coffee.

That's the level of sweetness that I felt on Friday. I was in my surrogate home, the place which has been my refuge while here in Jozi. S&S and I were setting up for my farewell braai (http://en.wikipedia.org/wiki/Braai), and Scott and I were talking about what I was looking forward to, when I get back to the US. And how sweet it will be to see my family and friends again.

As I grabbed the bakers chocolate, I took off a piece, for eating the whole thing would raise suspicion. And with that first bite, the shock of the bitterness of Bakers Chocolate was an unwelcome surprise to the expected sensation of sweetness.

Why the hell would there be such a thing as "bitter sweet." And why wouldn't they make that more clear on the damn package.

I came here to Jo'burg this year, and had one simple goal. I wanted to learn about TB, HIV, and pediatric malnutrition. Those were the absolute goals. There were other minor goals, but those only involved travel plans. As we sat around and ate Friday, I realized that this year has been far more rewarding than I could have ever imagined. I remember those first few weeks when I arrived here, having a few contacts from mutual friends, but having not really met people, and thinking that it would be a monk-ish year, filled with days at the hospital, then evenings of going to the gym, then reading about patients in the evening.

I would have never imagined that Jo'burg would become home. And that the emotions of preparing to depart are emotions I last felt almost 9 years ago when I left Colorado. The work has been rewarding in ways that are much different from practicing medicine back in the US. But on Friday, I realized that I've been fortunate to amass a beautiful collection of friends. And as I've thought about my impending departure, I though about how much I'm going to miss them. On Friday, my friends were South Africa, Dutch, Swiss, Spanish, Argentinean, American, British, Belgium, (and maybe one or two that aren't coming to me right now). And there I was surrounded by my closest friends as we had a farewell Braai The mixture of friendship, feast, and wine was perfect.

Like the bakers chocolate, there was bitterness. Bitter that I'm leaving this behind. The friendships will continue, the work will be here shall I be able to return in the future, but all of a sudden I find that I am not ready to head back to the US, and slightly bitter that my departure is now less than a week away...

Whoa!

2009-06-17T09:33:00.001-05:00

Back from the Sani Pass yesterday. Was beautiful. The 4-wheeling was great fun.

But now, it's full throttle right now. Like a maniac, I'm trying to sell my car (and wow, what a fun experience this is turning out to be), trying to finish my research project (and wow, I'm even further behind than I thought, after talking to my advisor today), trying to decide what to pack (and wow, I have a lot of crap, a lot of which is outdoor equipment I already have in the US), trying to get the post office to find my stuff (and wow, they may give some reimbursement-too bad I can't really recall what was in there, as well as the fact that the most precious thing has no value).

I'm in a bit of a whirlwind right now, and am so aware that these minor hassles are a small "price" to pay for such a great year...

I slept under the stars Monday night and tried to reflect. I couldn't really reflect because I had a migraine headache, was sleeping outside because the B&B was too noisy, and it was freezing. I thought watching for shooting stars and reflecting about the past year would bring me to some profound thought that I could summarize, and would help my migraine go away. My migraine didn't go away. And I didn't have profound thoughts. But I did see, perhaps, the most brilliant shooting star of my life. And for some reason, enjoying the moment solo, cold, and in discomfort was perfect.

The next few days are occupied with the above tasks. Selling my car. Packing. De-cluttering (just will let you guess what that means). Haggling with the post office. Finishing my research. Enjoying time with my friends. Implied in this, is drinking boat loads of coffee (and likely wine).

Departure from Jozi: Saturday June 27

Back to work (in the ICU for a few days, if you can believe that one) July 1.

Briefly

2009-06-11T16:27:00.001-05:00

Last official Bara shift starts in 8 hours.

I need to finish packing for my last adventure in SA.

Back in a few days.

BPB

Deflated.

2009-06-08T13:12:00.000-05:00

Mail theft.

That was the straw that broke the camel's back today. Long night in the ICU, with a few hairy hours due nursing oversight, 4 calls in one week, getting scammed by the auto-dealership (they tried to replace a part which they replaced last time, which seems to still be working fine). And then finding out that packages that I mailed to CO and MA are gone. Gone. Gone. Gone. That little tracking number means nothing.

I have purposely not given out my address so that I wouldn't be disappointed when things got stolen before coming to me, but had falsely assumed that stuff I mailed out should be safe.

Sadly, boxes of books, a box of gifts, and most of my Nepal mementos are likely on eBay or some similar website. In a lapse of judgment I packed up some of the relics I had purchased from the Tibetan Refugee women, including the prayer wheel that I'd finally found, after days of searching for one that I liked. And it had more meaning than that...

I topped off the lackluster, post-call day, with a great run in the freezing drizzle. (BK-my motivation to run). I craved some comfort food. Mom's meatloaf would have been great. Grilled cheese was a decent second place.

4 more official shifts at Bara. And then that is it. A year at Bara is over.

Making the Call

2009-06-06T16:17:00.001-05:00

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...

PICU Bedtime

2009-06-04T03:12:00.002-05:00

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.

And to which our attending replied "please change the order, to turn off lights when patient is asleep at night."

ICU madness

2009-06-02T15:01:00.001-05:00

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

2009-05-31T16:11:00.001-05:00

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

Kruger Day 3

2009-05-30T11:36:00.000-05:00

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...

-

Kruger Day One

2009-05-28T13:48:00.000-05:00

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.

-blog

Blurred Vision

2009-05-24T14:19:00.003-05:00

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.

-

Hey Mrs. Potter

2009-05-21T10:42:00.001-05:00

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...

More from ICU

2009-05-14T03:15:00.001-05:00

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....

2009-05-06T11:24:00.000-05:00

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

2009-05-04T10:35:00.001-05:00

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

2009-05-03T10:48:00.001-05:00

Check out my Bara Blog (http://notesfrombara.blogspot.com/) for a post that I didn't duplicate here.

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

2009-05-01T15:39:00.000-05:00

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

2009-04-29T16:46:00.001-05:00

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.

Fighting

2009-04-22T14:29:00.001-05:00

The politicians are fighting in SA. Well, fighting for votes. Zuma is likely to win this fight. Having escaped corruption charges to be able to officially enter the ring. It's a scary thing. It's great to be in a foreign country for elections. A chance to witness the culture of voting. I've been in Mexico during a national election-where alcohol sales are banned for 24 hours before, the day of, and 24 hours after the election. Of course, I was in Ireland during elections. And now to be here. The ANC is going to win this election. This is the party of Mandela. A party which has brought good changes: lots of housing, and basic essential to those most marginalized by Apartheid. But it also is the party of Mbeki, the present of SA who is directly responsible for killing (murdering, genocide...) some 300,000 men, women, and children. (http://news.bbc.co.uk/2/hi/africa/7716128.stm) Way to go ANC! In SA, the president is not elected by the people. The president is basically appointed by the party which has the largest majority in government. South Africa faces lots of issues presently, and even more serious issues in the near future, and it is electing a future president who has been tried for rape (and then "showered" afterwards so he didn't get HIV), and who just barely escaped corruption charges. Oh, and a president whose formal education stopped at Grade 6. (Not to point fingers, as one must wonder when GWB's education really stopped). Anyway, its been appalling to me that the ANC is going to win such a victory. But my perspective changed a bit last weekend when Andrew and I visited Lillieslief farm. Seeing the room that the then-leaders of the ANC used to coordinate efforts to rid SA of Apartheid, the room where Mandela slept as he lived under the guise of a hired hand on the farm-even making and serving lunches, the videos of how horrible people were treated during Apartheid, and it made me realize why so many of the people will vote for the ANC...

The Doctors are fighting in SA. I attended a meeting yesterday about the possible upcoming strike. Doctors have been in negotiations regarding, mainly, salaries, but also general conditions in hospitals. And they are on the brink of strike because of the lack or progress in negotiations. And in fact, north of Jo'burg, some doctors in hospitals went on strike today. I struggle with this, as I think it's almost deplorable for doctors to strike. To abandon patient care, to me, is against the moral fiber of the duty we have to our jobs, our patients. Patients suffer. The impending strike is complex. The public sector is very understaffed, there is little motivation to work in the public sector. The work load is heavier. The patients-I think-are sicker. The services that can be provided are restricted. The conditions in public hospitals are shitty compared to the private hospitals. And, of course, the pay is less. Much less. I will earn more money next year when I return to my residency salary, than does AK-the head of infectious disease here at Bara. A man who is a silent hero in Soweto. A man who started the ID/HIV clinic 20 years ago. The man who I am sure spent this national holiday today working most the day at home researching topics, writing papers. Taken in context, thought, student debt is very low, cost of living is low, and doctors do well, financially. But there is a drain from the public sector to the private sector due to the low pay. So it's tough. There needs to be a way to provide a larger incentive for doctors to want to keep working in the public sector.. I am hard pressed to think that a strike is the best way to force changes in this area.

We had our ID grand round, where we go to the bedside of a patient who is being seen by the ID service. And we examine and discuss the medical condition of a 26 year old woman from "Mozambique" who is hospitalized for an enlarged spleen. The spleen is a small organ, under your left rib cage which is involved in blood and infection processes. Sometimes it gets large, and you can then feel the spleen as it creeps past the rib cage. But with this woman, her spleen went down to her waist level. It is absolutely MASSIVE. But she's a total mystery. The enlarged spleen isn't the main mystery, the patient herself is. She showed up to the hospital with a note from a doctor in Mozambique asking for her to be assessed and treated for her enlarged spleen. But nobody has been able to communicate with this woman. No English. No Zulu. No Portuguese. No Xhosa. No Sesotho. No Tsonga or Tswana. No French. No Spanish (I tried). No Amharic. No Swahili. But what amazes me, is that this woman, on her own, made it from Mozambique to SOWETO, to see a doctor. Who knows where she is really from... She's basically fighting for access to medical care.

And I'm fighting fatigue.

Goodnight.

Cruise Control

2009-04-16T17:09:00.001-05:00

Not a whole lot to report right now.

Swazi trip was good. Great weather. Camping under the stars was lovely. The "trail" on Sunday was not lovely, and I have the scratches and cuts to prove it. The company was great. I drove through Mbane, the main city-well one of them- 5 years ago. I didn't remember it being so hilly, and nice-appearing. We made it there in about 4 hours, so that was nice.

I am taking care of a patient I admitted at the end of last week. Pretty tough situation. Young woman who has progressive neurological deterioration. She defaulted coming to the clinic in March, and showed up last week emaciated, weak, and with worsening coordination. When I saw her Tuesday, she looked much worse to me than when I had seen her last on Thursday. Yesterday her brother called me, and I asked him his opinion-and the thought she actually was looking better. "Help me, I'm dying" is what she told me today. Sadly I think she is right. I was talking to her main clinic doctor on Tuesday the gist of the conversation being what happens when a patient says they are dying. For on Tuesday-I certainly came to the same conclusion that the patient verbalized today. Our consensus was that, when a patient says they are dying, they're usually right. And the goal is to get her home so that she doesn't die in the hospital. She's booked for an MRI tomorrow. It's quite a tragic story, in this land of endless human tragedies.

Wednesday I saw SM in clinic. He's gained 8 kgs (16+ lbs) since I hospitalized him in Feb. He is back to work. He looks amazing. I've been breaking the news to the patients that I've gotten to know since January, that this is my last month in the clinic. (Though I confess, there is an overwhelming lack of motivation to find the head of ICU to coordinate my starting in the ICU in May). And so I told SM and his wife that this would be the last time I see them in clinic. They were disappointed. "I have my husband because of you." How does one respond to that? Guilt because the work here is endless, and it feels like betrayal to leave patients that I've gotten to know well, in such a short time. And anger-because SM didn't get the care he deserved and that all I did was admit him back to the hospital and literally throw the kitchen sink of antimicrobial treatment at him hoping to kill anything that was living in him, a treatment that should have been done weeks before he ended up in my examination room back in February. Thankfully, one of the consultant/attendings will take over his care when I leave, and they have a great rapport with her as well.

I was going to write a bit more, but there have just been some gunshots in the neighborhood, and it's late, so perhaps it's a good time to turn out the lights and go to bed. Oh, and this is the second time, in as many weeks, where there have been gunshots late at night. I'm slightly annoyed, because I staunchly argue to my friends that I live in a very safe area. And since last weeks gunshots, I've decided that running after 8pm isn't such a good idea now that it is getting dark out.

Happy Easter

2009-04-10T01:46:00.001-05:00

It's a 4 day weekend here, and the town will be deserted by this afternoon, me included. Cecile, Myr, Thomas and I are headed to Swaziland in a few hours. We'll stay in a B&B tonight, then hit the trail tomorrow and be back late on Monday. It'll likely be the last big hurrah... And the last backpacking trips (sniff sniff) til I'm back in Massachusetts.

The week flew by, and I meant to stop many times and make a post. But obviously the posts stayed in my head, and didn't make it here.

In a nutshell... (I'll expand on these next week, ideally).

Economics of Poverty: Sat in on a very interesting meeting where AK met with the NGO which largely funds the clinic, and was an observer to the economics of HIV/AIDS, specifically to how US funds are being used for our clinic. Some readers have read the book. I've enjoyed pointing out that I am paying for this clinic through my US tax dollars

JC: Popped into my office yesterday, looks great. Have invited me to come to a braii and meet his family.

There seemed to be some more things, but I was due to leave the house 15 minutes ago, so better head out.

Happy Easter.

This is why...

2009-04-06T14:58:00.001-05:00

[Disclaimer: this is more of a personal post, but I'm throwing it into the blogsphere. I don't hide my uneasiness of my upcoming move back to America, but perhaps in recent posts I haven't fully explained why Jo'burg has-so completely-caught me off guard. This may not be the most eloquent post-but I'm going with it.]

As I was driving home Sunday evening, I couldn't help but obsess that I am under the 3 month mark. It had been a non-stop 3 days. An almost maniacal pace to making sure to enjoy my weekend. Work. Friends. Fun. Not wasting the present moment, aside from the drive down the M1 toward home, wondering how I make sure to squeeze every drop out of my last months here.

JT (clinic doc I work with) "What's Holy Cow?" she asks me as we both walk down the hall. I'm caught slightly off guard.

Me: "A cow in India?" I assume there must be a joke here. Then I realize I'm being culturally insensitive. "Actually, any Hindu cow."

JT: Smiling. "No really, I've never heard this expression before."

Me: "Huh?"

JT: "You just said 'Holy Cow' a minute ago in the hallway."

Me: "Did I? Oh. Well, it's a more polite way of saying 'Holy Shit' if you really want to know."

I'd just come out of my examination room, and ran into SM. He's the guy I admitted back in February, who came into the clinic having been sent out of the hospital in January with a whammy diagnosis of AIDS and PCP pneumonia. He had to wait a month to be seen in our clinic. And when I saw him that day for his initial visit I admitted him back to the hospital, thinking that his PCP wasn't getting better, that he likely had some TB as well. What the hell, I figured, he looked so bad that I decided we'd just treat him for everything but asthma.. When I left for vacation, I'd just seen him in the clinic, and he was breathing better, but still looked like crap. And so there he was in the hallway, he'd put on weight, he was able to talk without having to stop and catch his breath. I don't know if the "Holy Cow" was when I saw him, or when he asked for a letter saying he was ready to go back to work. That was Thursday.

Then on Friday morning, as usual, there were folks milling about outside the entrance the the clinic. The packed waiting room was to be expected. There were already charts pulled, people were ready to be seen by the doctors. It was going to be a hectic day. But hectic is the norm for this clinic anyway. Friday was hectic to a new level, given that we were short four doctors. But really, that didn't induce stress or concern because all that we could do was just plug away and know that at some point we'd get through seeing all 185 patients. I managed to see just over 30 patients during the day. Most were fairly routine. A few were complicated: failing treatment regimens, sick visits, questionable TB diagnoses. In addition to HIV, I meddled in routine management of high blood pressure, diabetes, and epilepsy. But I enjoyed the day. And as I packed up my stuff, I thought back to some of the patients I had seen, and that's when it dawned on me, that I hadn't discussed any of the patients with an attending. Which isn't unusual, per se, but almost invariably I look for guidance on managing an issue, or turn to my attending for help when I'm stuck. But, things had just clicked during the day. There were times when I didn't know for certain exactly what my attending would do in such an instance, but I was confident that I was making good decisions.

We, miraculously, finished clinic at 4 pm. And I walked out with AK, and Dr. T (the other clinic consultant), reflecting on the day in general, but also on how busy the clinic continues to be, with no end in sight, and likely escalation of services. (There are some 500,000 people who still need to get on HIV treatment in SA!). And then there was talk of other clinic business, a conversation which maybe wouldn't involve junior staff in many places. The whole event of Friday's clinic made me feel like I'm an employed doc there. This is why I'm dragging my feet on setting up a new rotation for May and June. I could easily stay in the clinic for two more months. Though, after chatting with AK and Dr T, I went to the wards to try and find a patient that I had admitted, and ran into the Chairman/Professor of Medicine. I hadn't seen Prof in a while, so we chatted about the clinic, and also about my schedule for the rest of the year. We also had a great chat about Kili, and Machu Picchu, and travels in general. And I almost died when he suggested I take a few days off to go travel to the Okavango Delta, in Botswana. [Jean-I hear you].

I was home for about an hour on Friday, chatting to my new house-mate (a Kenyan anesthesiologist) and then was out the door to go visit AC. AC was holed up in his house, having had some kind of "face surgery" on Wednesday. I'd been lying to friends all week, saying that AC really had Botox and that it had gone bad and he was too embarrassed to see the world. So I headed up to his neck of the woods, and we had a great evening eating take away, catching up, and watching episodes of Little Britain and other mindless crap on the TV. But it was nice to just have a night in.

And then Saturday... I went to the gym in the morning, which I NEVER do. But I knew it was going to be a gastronomic day, so decided to do a little damage control before the damage was had.. And then CB and TB and I (CB, TB, BB-whoa) went for High Tea at the Saxon hotel. Talk about chic. Talk about lavish. Talk about fun. Sitting outside, on a beautiful fall day, sipping champagne, eating scones, cucumber sandwiches, and other heavenly desserts while planning next weekends upcoming backpacking trip in Swaziland was pure bliss. The bill was 630 Rand. That's roughly 63 dollars. For all three of us. Twenty bucks per person for high tea at one of the classiest hotels in Jo'burg. This is why...

And then there was a bit of excitement. We were all in separate cars, driving to the outdoor gear shop at the mall, when we came up on a car wreck. A truck had overturned. Thankfully, CB is also a doc. We walked over to Moses and took care of him for the HALF AN HOUR that it took for an ambulance to arrive. Moses had pretty nasty head wounds, which were bleeding pretty profusely. He wasn't really all that bad, aside from blood everywhere, which included on my khaki pants by the time we were done. And we proceeded to shop, all the while I was hoping people wouldn't notice the blood on my pants. This being Jo'burg, who knows what people would think.

Thankfully, I had packed a change of clothes. One never knows when they'll have to render first aid and get all bloody in the process. So I headed over to S&S house to change. Actually, the plan had been to have dinner with S&S, and just before leaving home earlier I'd grabbed some extra clothes, kind of thinking that we were long overdue for a late night in which I usually just crash at their place. So I headed over to their house to just relax on the porch and have a chance to catch up with them. While we were hanging out, David called. He's this lovely guy from Argentina, married to great South Africa guy who had left that morning to start his new job in Abdu Dhabi. So of course we quickly told him he was joining us for dinner.

Dinner ended up being 6 of us, with S&S, myself, Clifton (whose boyfriend-the Belgium pediatrician-was out of town, skiing in Europe), Argentina David, as well as British David. The food was decent, the wine was superb--and flowed freely, and the conversation was fun/hysterical-and flowed freely. We must have finally left the restaurant sometime after midnight, and then headed out to go clubbing for a few hours. A few of us ended up back at the house, and we crashed for the night. Well, Siza and I decided it was necessary to continue drinking wine til just past 5am. The morning after usually consists of breakfast, and then we all depart on our way. But after breakfast, we went back to the house, lounged around, and then headed to an Art Show. Not that I have any appreciation for art, but it was fun people watching. As that wrapped up, we bumped into more friends there, so then we all went for coffee, and then ended up back at the house for a bit, and then headed out to dinner. Finally, well past dark, it was time to head home.

This is why... I'm having my cake, and eating it too. I know this cake is going to be gone. And I have a hard time thinking that the next cake is going to be this delicious.

On Thursday, I got to see SM, in person. To see that he really is better. That he feels better. That he is actually going BACK to work. It's powerful to see folks, who are close to the brink of death from HIV, make these recoveries. And sure, it sucks to see those who don't make it. I find this immensely gratifying. I contrast this to the work I do back home, which I do find gratifying as well, but to me the outcomes back in Massachusetts/USA are more certain. I feel like there is more of a guarantee that folks will get better, but that here, that guarantee is gone, and so there is a level of pleasant surprise when people get better. There is also more of a challenge practicing medicine here. Labs may not come back quickly, x-rays are slower. CT scans are days away, and MRIs are almost nonexistent. You have to make a clinical diagnosis, and plan your treatments, and weather the storm while waiting to see if you're on the right track or not. And it's gratifying to have to use more cerebral power to take care of patients, than to use technological power to figure out what is going on.

On Friday, I felt like part of the team. There wasn't a division between resident/attending or junior doctor/consultant. We were all there equally, with the attendings there for problems we couldn't handle. And I'm so familiar in the clinic now that sometimes I literally forget that I'm not employed there, and that, in fact, I'll be gone from this clinic in May. I felt like I had the leeway to practice my own style of medicine. I changed HIV medicines on a few patients. Started different blood pressure medicines. I reveled in the autonomy of Friday. This does become a mute issue after I finish training, period, but it added to the overall pleasure of my work here. I could explain further, how part of the underlying issue is that the repercussions of litigation do not exist (which is not necessarily a good thing). I didn't have to worry that-even though I think I made the best clinical decisions possible, down the road some lawyer would find an article saying that when I changed a medicine or started another one, that I had made a bad decision...

And then the weekend... I have to preface this carefully, for it would never be my intention to disrespect the great friends I have amassed back in Massachusetts, back in Dublin, Back in Colorado, and now scattered around the globe (aside from Antarctica). When I lived in Dublin, one day a very close female fiend of mine lamented on how she felt she was missing close friendships with other women. And I was slightly put-off, which showed. What did imply for our friendship? That even though we shared this close friendship, it wasn't of the same caliber as a friendship with a woman? But now I get it. For the first time since I came out (way back), most of my friends in Jo'burg are gay men, and they are great guys. Their friendship is different than the friendships I've had when I lived elsewhere. Looking back, in the past many months, we've often had dinner twice a week, and rarely have we not met up at least once a week. There is a level of trust in our group (so much so that scandals are volunteered openly). It's not like the group of men I think of when I reflect on where I have lived previously. It's unique. And there is the international mixture as well, which adds an extra element to the group as well.

And of course, there is Jo'burg and SA itself. I am mesmerized by the workings of the city. I get motivation from seeing those who work so hard, yet have so little. And of course, there is Bara itself, a hospital unlike any other hospital in the world! I don't write this as a comparison to my place back in MA, and folks know that I think the hospital back in MA provides excellent medical care, and that it provides well for us junior doctors, and that the teaching there is top class. If Bara ran as well as that hospital the people of Soweto would be immensely lucky, and healthier.

So, this is why I find it difficult to leave here. I can't describe how excited I am to arrive back and see my family, my friends, and the newest additions to both.

This is why a part of me will remain a Jo'burger for life.

March Madness

2009-03-31T16:40:00.001-05:00

[disclaimer: I'm too tired to proof and edit]

Lucky died. That's the news I received today, when I went back to work--a day early. I was sitting around my house this morning, feeling discombobulated, with an unstructured schedule for so long that I stared at a pile of paperwork, and just decided that I needed to get back to work. So I showed up to the tea room, and there ran into AK (head of ID) and we headed off to start rounding. It turned out to be a stellar Grand Round. We reviewed patients who have differential diagnoses of cysticercosis, hydatid cysts in the liver, and other conditions, which quite honestly I haven't even though of since I was a medical student sitting in a tropical medicine course. It was fascinating stuff, and a part of my brain which has largely been resting, jumped up and was enthused to resume its cerebral functions.

As we were walking between wards, I pulled out my sheet of patients whom I had handed off to my colleagues a month ago, and asked them how these patients had done. And that's when I found out Lucky had died. Was it shocking to hear? No, I didn't think he would survive. But also yes-because I was rooting for him. I had some hope that he would make it. The last thing I did at Bara in Feb was to go to his bedside and be with him. I couldn't shake our last conversation and interaction. On the third day of my Kilimanjaro trek, I sat outside the dining tent in the afternoon, sipping tea, and wrote about that final encounter with Lucky. Shaking his bony hand, telling him I'd see him in clinic when I got back, seeing the fear in his eyes, I walked away knowing that I would never see him again. But hearing that he had passed today, still left me disappointed. I will say, that he lived for 2 more weeks in the hospital after I left.

JC is well. 5 Days ago, as I was having my morning coffee in Clarens, before driving into Lesotho and losing phone reception, I got a text message from JC. He told me that he's gained 5 Kgs (10 pounds), and that "you won't recognize me when you get back." And sitting there, in the beautiful town of Clarens, I felt perhaps one of the most moving victories thus far, in my time here in SA, but also in my short time as a doctor. He is going to make it. This man who fled his home after organizing protests against a tyrannical government, who sold handmade crafts, who was a professional teacher, and who was neglected for 6 months in a clinic is getting better, and is going to live. And honestly, it floored me that he sent me a text message, to let me know he is better.

Even on vacation, I found myself drawn to my work here. On the trails of kili, drinking coffee in Ethiopia, clubbing in Cape Town, I felt guilty knowing that the clinic at Bara was still going, swamped by patients. And even more, my patients were on my mind regularly. So today, much to the wonder of those at work, and those here, I showed up to work early. I was done playing, and ready to get back to business.

I provide you now, with a report of the March Madness:

Kilimanjaro:

There were two definite "to do" things on my list for the year that I am spending in this part of the world. One was to visit Victoria Falls-done. Two, climb Kilimanjaro. I will confess, that I'm not sure how I came about the decision to do these. Vic Falls, due purely, in part, to see the spectacular falls themselves. But Kili?? Maybe it was when I heard a fellow intern talk about his conquering Kili a few years back. This is also where I confess, that while I knew Kili was the highest point in Africa (5895 meters), up until a few months before I didn't know much else. When I booked my trip a few months back, I didn't even look into all the different route and what were the pros and cons, but rather I popped into my local outdoor guru shop, and asked them which route they thought was best. And that's how I ended up doing the Rongai Route- which is a more direct, less used approach, and is suppose to be pretty challenging.

After my good fortune of trekking in Nepal-where I carried my own pack, I felt pretty confident that I'd make it to the top. Which I did. [Insert Robert Persig quote: about the side of a mountain sustaining life, not the top].

I stood on the summit of Kili at just after 5am. It was pitch dark, and reported to be -30C. Ideally, the summit time should happen at sunrise, which is closer to 6:30am. People talk about the beauty of the sunrise. But I'm more of a sunset fan, so not seeing the sunrise wasn't an issue. What was an issue was that it was too cold to stay at the top for more than 10 minutes. All 6 layers that I had on-thermals, fleece, down, wind stoppers, weren't enough to insulate me against the cold, and my guide would have been happy to leave after one photo shot and 20 seconds. So, the major disappointment was completely missing the view from the top, and missing the view of the glacier etc. There is a small stoke of the ego, knowing that I was the first to summit Kili on that day, and it was mildly entertaining to hear my fellow climbers tell me later that day how discouraging it was to see my headlamp so far up the mountain. But little did they know, I envied that they really got to marvel the experience being at the top of Africa.

The trek was plagued with issues... My tent leaked. So much so, that one night as water accumulated in it (during a viscous storm which turned to snow around 2am), I actually put my down sleeping bag and as much gear as possible in my water proof pack cover, and then tried to sleep for a few hours on my sleeping pad-which I imaged was going to double as a water bed by morning. My guide was mediocre. The cook was a nice guy, constantly stoned, and who actually served me batter and friend bread-more than once. I contribute my need for antibiotics directly to his level of pot usage, in thinking that he was too stoned to boil my water properly, and the murky "pond" that we got water from for 3 days had plenty of organism swimming around in the water, and then my GI tract to make the last few days of the trip somewhat less than ideal hiking conditions. I had never experienced such drastic windburn.. and for days was unable to smile because I was afraid my lips/cheeks/chin would crack and that my face would fall off in parts. But the nice thing was, we all suffered together.

In the end, I'm glad I climbed Kili. I learned some valuable lessons: check out the trekking company thoroughly, take my own tent, make sure I treat my own water (which I did 75% of the time given my lack of confidence in stoner cook). I do feel slightly cheated, and if somebody wants to climb Kili.... let me know. I arrived back and had a day to run errands, and then it was off to Ethiopia.

Ethiopia:

Ethiopia was somewhat random. A while back, a friend called me to tell me that she was adopting a child in Ethiopia-which had been in the works for a while, but that now she was matched with a child. When I heard her dates for being in Addis Ababa, it worked perfectly into my schedule, and so I quickly booked a ticket. This I knew: Ethiopia is the HOME OF COFFEE, and the home of LUCY. Fantastic.

What struck me most about Ethiopia, was reading about the history before I even got on the plane. I confess, that the only history I usually know of a country is that is provided in Lonely Planet. In fact, I think that there should be World History courses taught entirely by what is written in Lonely Planet. Really, you don't need to know more that what can be summarized into a few pages. My attention to world history details is short enough that I may wonder if I have ADD.. but usually I figure that all of that stuff is in the past, and largely irrelevant to my purposes. But for some reason, when reading the history of Ethiopia, I took notes in the margin, remembered the names of rulers, and felt like I hit the ground with a better knowledge than I mage have of, oh say, American history.

My first impression was, I have to admit, dark. But that is because it was nighttime. My friend met me at the airport, and we made our way to the guest house, where we chatted and I was brought up to speed on how the child was doing. Suffice to say, I've been privilege enough to review the medical information provided, including issues pertaining to some more recent medical issues. We strategized a plan for the following day, and the week that I'd be there.

My second impression was not much better. Largely because I found the coffee served at breakfast in the guest house to be uninspiring, and the portion of scrambled eggs barely enough to feed a school child. I made a mental note to get a real breakfast every morning elsewhere.

And then we arrived at the orphanage. It's been very insightful to see, second hand, what the adoption process has entailed-on all levels. What prospective parents must endure, how the process is actually conducted, and as well as all the factors that play into international adoptions. And then I saw the orphanage. I confess, that the pediatrician in me cringed at how crowded it was. But it was evident that the children were adequately taken care of, and that the place was dealing as best as it could. I couldn't help by watch/hold/play with infants assessing their development, looking for the subtle signs of HIV etc. I enjoyed meeting my friends future son, but decided I wasn't going to need to revisit the orphanage daily.

As for Addis.. It was refreshing to walk around a city. Walk and walk and walk-the best way to experience a new city. It's a bustling city. It's fairly well developed, though that being said, the major roads are tarred, but the side roads are dirt roads which have pocket marks which can engulf small cars and children. Riding by taxi is challenging. What caught me off guard, though, was the amount and persistent of inner city poor, who at times literally lined sidewalks patiently waiting for handouts, by which to survive. I feel fairly seasoned at travelling these days, and have been in resource poor areas for a while now, but the sheer volume, and at times the level of aggressions for handouts did wear on me by the end of the trip. I was taken aback by the number of adult polio survivors who limped around the city. I felt like the "Ugly American" in that at times all I could do was to keep on my sunglasses, look straight ahead, and not even acknowledge the pleas that grabbed my pants or hands looking for assistance. But, the people were pleasant. The stores were interesting. The markets were great. Even Merkato-the main market which is suppose to be known for tourist scams and pickpockets was easily navigated and explored.

As for the coffee. Holy shit. Mecca. Wow. Now, don't get me wrong, not every cup was a heavenly blissful feast for the palate... but most were. Coffee is espresso style, macchiato style. Shots. Short and sweet. I buzzed from café to café and silently thanked the powers that be that I was paying 20 to 30 US CENTS per cup of pleasure. But I made it a goal to seek out some variety, and hunt for the best cup. And I have to say, that the bible of travel, Lonely Planet, has nailed it. Tomoca is the most nondescript coffee house I've ever seen, well, aside from the aroma literally hemorrhaging out the door from the coffee roasting going on in back. So, I was skeptical that LP had rally found the best coffee in Addis. But they had. And the locals in the shop swore that it was the best cup to be had in the city.

As for Lucy... the famous Australopithecus aferensis skeleton found in 1974. She is the most complete human ancestor, and stood 3.2 meters. I'd learned about Lucy back in undergrad antho/archaeology courses, so to be able to see the museum where she now rested was pretty cool. Except that she is housed in the basement level, in a room with bad lighting, no windows, and worn carpet. Now very posh. (The the real Lucy is not on display).

My friend and I took a quick flight to Bahar Dar, which is situated on Lake Tana, almost 600 km NW of Addis. Ask me sometime how we scored very cheap flight tickets- you can negotiate for anything sometimes. Lake Tana is famous for some 22 island monasteries, so we had to visit. I was hoping to meet a nice young monk to settle down with.. Of course, this isn't funny given that Ethiopia is one of the most homophobic countries in the world.. But I was open to the possibility or living on a lake. We left Addis at like 7am, and were on the lake by 9:30 am. Saw a few monasteries. And then just past noon we were in a van headed for Gondeor, which was 3 hours north of Bahar Dar. Gondeor was the capital of Ethiopia circa 1620, and has some amazing old castles. And during our 2.5 hour van ride back, the driver tried to scam us for some money which he had planned to use to buy chat/khat, a mild hallucinogenic plant that you chew.. He did end up buying Khat a little while later (not with our money) and then seemed genuinely shocked when we protested that he wasn't going to be chewing any Khat while driving us. We eventually made it back to Bahar Dar and checked into a hotel. It was a day of flying, boat trip, and 6 hours in a van-I travel hard!

More to Ethiopia... I covered Addis Ababa. But there is so much more to Ethiopia.. I'm thinking I'll need to go back, with a month to spare, and money to hire a 4WD and driver and go for 2-4 weeks and explore the area more.

On the flight back to Jo'burg, I was shattered. It had been early mornings, up late caffeine fueled exploration. And in Jo'burg, Kevin was exploring the worst neighborhoods awaiting for me to touch down so that we could hang out. The minute we re-united in Jo'burg (not in the CBD where he was spending his tourist time), the fatigue disappeared and we jumped into a frenzied conversation to catch each other up on the going-ons of the past few weeks.

Cape Town: What happens in Cape Town...

The departure for Cape Town set the tone. We were delayed for hours. And were booked on 4 different flights. Yet, we were on holiday, had no agenda, and no plans (other than to arrive, pick up the rental car, and wait for Lorcan to arrive). We literally laughed and entertained ourselves for the hours we were delayed. I'm sure our fellow passengers though we'd been drinking most of the morning, I mean who the hell laughs and has fun while getting delayed to head to Cape Town. That was us.

Cape Town. Rented BMW. We're going to be the classy gays. Irish Doctor. American Doctor. Irish consultant. We're here to let loose and enjoy life, in the beautiful surroundings of Cape Town. Clubbing til morning. Late start to the next day. Taking the tram to the top of Table Mountain. Walking for hours, having a confession about the night before, having a confession about life in general, making plans for the next few hours, making plans for the next few days, and making plans for the next few years. The Irish head to an Irish pub to join their fellow Paddies watching Ireland gloriously take the 6 Nations Title, while I sit on my balcony watching the sunset in Cape Town, listening to my ipod, lost in thought. Another night out, but not til the early morning. And then a real Sunday Cruise, to Cape Good Hope-the southern point of SA. The night retired at an Indian restaurant sitting outside at Camp's Bay. Monday entering the wine lands, and having lunch in Franshhoek. Seeing Lorcan off at the airport. Checking into our new boutique hotel for the night. Immediately being met in the hotel by an American, from Denver. We escape for dinner, and walk for hours, returning to the hotel to spend a few hours talking to other hotel guests, all of us sitting around drinking wine. And then departure day. Sitting in Cape Town airport, the departure gate symbolizing the end to this 5 days of fun. 5 days of nothing but pure enjoyment. Wine. Clubbing. Luxury hotels. a BMW. Ice-cream (even for breakfast one day).

Lesotho:

The plan had been to rent a 4WD and cruise around Lesotho for 4 or 5 days. I arrive back in JHB, get back to my apartment, which feels cold and empty after the sun and friendship of Cape Town. No point in wasting time. I leave in the morning, but know that I'm going to shorten plans. I'm disconnected. On the plane back to JHB, I think of the calls I want to make, people I want to check in with, and then also the realistic commitments which I'm letting slide.. a pediatric case report which I wanted to have written last month, my research here at Bara, a growing list of topics of things I'm reviewing. So I cut this trip short. I spend a great day in Clarens. I zoom down, check into my B&B-which is so gorgeous, with a plus king size bed, and a balcony overlooking the town square that I ponder just spending all day in the room reading, with short jaunts to get coffee. But, I have business to complete here. I was cheated out of hiking the last time I was here, a day of hiking cut short by helping an injured hiker be rescued from the mountain. I ditch my bag in the room, fill my water bottle, and am on the trail. 4 hours. Not another single hiker. Along the ridge as the afternoon starts to end, I'm watching herds of springbok and blesbok run in the meadows below. Why didn't I just bring a tent? I force myself to leave, thinking that the trail will not be forgiving to attempt in the dark.

It is the next morning that I get a text message from JC. I cross the border, and make my way to the town where I'll stay for the night. If it weren't for the meeting I have, I may have been tempted to just stay in Clarens. I explore a bit, wondering what my options are. I'm thankful that there is plenty of time to decide what the hell I'll do when I grow up, but this is on the list.

I'm back in my own bed.

I am back home.

Am.

Back.

Home.

I am aware that I arrive back home, exactly 3 months to the day of when I will have left this home, and arrive back in the US. I've spent the past 6 hours listening to music, driving on the N3, trying to recall what it was like 3 months before I left my Colorado home, 3 months before I left my Dublin home, 3 months before I left my Massachusetts home. This is the first time I am leaving one home, to go back to another, and that give a coating of sweetness, to appreciate the reunion with those back home. It'll be a coating of sweetness which may take away the bitterness of leaving Jo'burg.

And now...

It's back to reality. Work. Life. Future. Taxes. Things that were on hold for the past month...

I have pictures posted: follow the link over there ->

Hiatus Ending soon

2009-03-30T18:32:00.001-05:00

March Madness

4 trips

4 countries

10 flights

1 mountain summit

2 courses of antibiotics

Sunburn/windburn/frostbite

New friends

Details to follow.... Hopefully on April 1. (no joke)

Thanks,

Brian

Reposting

2009-03-19T02:00:00.000-05:00

http://javamania75.blogspot.com/2008/03/haunted-halls.html

March Blogging Hiatus & Experiment.

2009-02-24T17:30:00.000-05:00

Dear faithful blog reader,

This is the 343rd post to this site. When I posted on March 23rd, 2008. Just under a year ago, I had absolutely no idea if I would follow through on what would become this amazing experience. At the time that I made that post, I shared my concerns privately with some. Would I sink or sail when the time came? Was this a wise or unwise decision?

In a posting in April, I was packing up my beloved apartment. I packed up memories of the friends who had stayed there. I packed up my outdoor equipment. I packed up the few worldly possessions which have any value to me-old family photos, completed journals. I packed up journal articles not yet read, and martini glasses which have never been used-a shame, I know.

In May, I posted about the meal Lucia and I had in Manhattan. A meal at an Ethiopian restaurant, where we chatted for hours, consuming the injera bread and a sweet honey tasting wine, while talking about our shared experience as medical students at Bara, as well as a mixture of reminiscing memories of Ireland, of excited discussions about future plans...

And then it was June. It was a whirlwind. At the hospital I had the amazing pleasure of working with one of my mentors on the wards (this person doesn't know it), of having a farewell dinner with my other mentor (who knows it). I made quick trips to Vermont and New Haven while trying to wrap up finishing details for my impending departure. The next thing I knew, I was at JFK Airport, surrounded by a cadre of friends who saw me board my flight. Little did they know, that as I watched them walk away, I still wasn't convinced I was making the best choice.

And since then, via this blog, I've shared.

I've shared my personal experiences at the world's largest hospital, treating a population rocked by economic deprivation, on a background history of racial discrimination, and a population burdened by one of the highest rates of HIV/AIDS in the world.

I've shared about kids whom I took care of; some who got better, and some who died. I don't think I'll ever forget the morning I heard KR had died. And I'll never forget S, the Ward 18 mascot when we took him to tea break one day, or when I carried him on my back around the hospital. I've shared what it was like to see so many kids brought into the pediatric HIV clinic by their grandparents. A generation is being raised without parents. I'll never forget how furious I was the night I had to keep checking the heartbeat of a 400g baby, who had been delivered by c-section. And the sense of injustice when I certified his death 3 hours later. I didn't share enough about what was probably the most incredible month of learning as a junior doctor, and that was the pediatric cardiology service at Bara.

And I shared about life outside of Bara. I shared about trips I've been fortunate to take-trips to Clarens, The Berg, Zimbabwe/Vic Falls, Lesotho, and other weekends trips. I've shared about how I've made friends here who provide refuge when I need some luxury and an escape. I shared a bit of Nepal, and how incredible it was to look up at the surrounding Himalayans and to be looking down as I knelt before the Buddhist monk as I was blessed.

And over the past 2 months I have shared what it has been like to work in the adult HIV clinic, as well as my overall introduction to medicine at Bara. I have shared how I can't believe that what I see today seems to parallel what was seen in the US almost two decades ago. Medically stuck in black hole... Not having "the resources" to treat the country which has the LARGEST NUMBER OF PEOPLE INFECTED WITH HIV IN THE WORLD!

And since then, there are things I didn't share... And they aren't going to magically appear now.

I go back and read these posts often. Sometimes I can recall being at the gym as I thought about how to write what would eventually end up as a post. Sometimes I remember sitting with a glass of wine or whiskey or coffee and getting lost in a train of thought midsentence, or going back and re-working a post and removing the blame which I had written in the post, which may have been misguided. Often times, I cringe at the typos and grammatical errors.

What may not be apparent, is the time that goes into this blog. Not that I mind, at all. But I find myself needing a bit of a break. I take immense gratification knowing that what I write, has been read. That I have been fortunate enough to share a bit, so far, of this amazing year. That, unlike one or two close friends of mine who also keep blogs, I haven't received criticism from anything that I have posted.

I find myself with a lot of things on my plate, and a lot of great plans for March. (Heading off to climb Kilimanjaro, meeting a friend in Ethiopia-as she meets her future adoptive son, heading to Cape Town to whoop it up with a dear friend from Ireland, and then returning to the mountains of Lesotho). I find myself needing a bit of a break from keeping up the blog, thought I will try to add a tidbit here or there of what I've been up to on these travels.

But, that is where you come in. This is what I'd like to do: For the month of March, I'd like to open up my blog, for you to post. It's quite simple. You merely send an email to javamania75.guest@blogger.com and that email will instantly appear on this blog. The post will be anonymous (unless you add your name to the email). For example, all of the posts that I have made have been from my hotmail account, using the address. [note: if your work email adds a privacy/security clause to the bottom of the outgoing email, it will automatically appear].

I ask that you please, please, please do not post about me. Please post about something which you think is in the spirit of this blog (being outraged at the conditions in Zim, or your own neighborhood, an experience of disparities in care/treatment/service). A joke. A News clip. Your favorite recipe. A new coffee shop. A post from about a day at your work. A post on your reaction to what I've posted over the past 8 months. There will be a guest moderator who will removed or edit posts as needed. You never know what whackos are out there who stumble across this site (or are reading this site) and will post some kind of advertisement for lengthening of a part of the male anatomy, or pills which will cure problems with that part of the male anatomy, or some guy in a foreign country who needs your bank details so they can put one gigabillion dollars in your account while they sell a kidney and then you wake up in a burned forest with Elvis.

May March usher in the start of spring, or fall depending on where you are in the world. I'll be back, full force in April when I will resume posts from the Adult HIV clinic at Bara.

Strike Three & 2 Months

2009-02-24T11:20:00.001-05:00

I make my way back to clinic this afternoon. I'd seen a patient earlier in the day when I had a free moment to pop into clinic. I sent him off to get some urgent labs done, wondering if he was having lactic acidosis, an adverse reaction to one of the HIV medications. It would be something that would have to be dealt with this afternoon if the level was high. So I sent him to the lab, and said I'd be back at 2pm.

It's 3pm, and I'm walking the drizzling rain. It's about a block between the ID offices where we'd wrapped up a lecture, and the HIV clinic. Though on Monday and Tuesdays, it's not the HIV clinic, it is the hematology/oncology clinic. When I get about 100 meters from the clinic, my phone goes off, it is a text message from the clinic. There are no pagers here, the hospital sends out a text/sms with a call back number, and I recognize the number. I quicken my pace, as I'm sure they're annoyed that I am not back yet.

I walk into the room, and wouldn't you know it, there sitting in a chair is Lucky.

Without even asking a question I tell him, "I'm admitting you to the hospital." Retrospectively I realize that this wasn't the ideal way to great a patient, who must feel like shit being as ill as he is. I remember one of the Pedi ER docs back home basically saying that if somebody shows up for a third time in too short of a span, at that point you basically need to admit. I would have been happy to admit Lucky on the first visit, and tried to persuade him to get admitted yesterday... We'll see what happens.

I admitted 4 of the 10 patients who came to clinic the past 2 days. Remember that these are days that we're not in clinic, except that we'll pop over to see people who are too ill to wait until Wednesday. I groan slightly, as my consult list swells..

I'm coming to the completion of 2 months in the HIV clinic. Aside from my 2 months on Ward 18 when I first arrived at Bara, this is only the second time during residency when I've done the same thing for more than a month. We have a one-month rotation block back home. I'm not sure if one month is really ideal. But here, the blocks are generally 4 months, which I don't think is ideal either. But 2 months has been enjoyable. I have learned a lot in these two months. Things that I never knew about before such as MAC (basically a brother of TB)-which I'm comfortable starting treatment even when I can't conclusively prove it's there (which may be rather taboo back in the US), and cryptococcal meningitis, as well as how to go about starting HIV treatment, following the treatment, and making changes. There is so much more to learn. There are frustrations, and all is not perfect. But I don't feel ready to leave. I'm having a hard time thinking about my rotations in the coming months, though I have a tentative schedule for the remainder of my time here, and I reviewed it with the Prof of Peds, who thinks it is a wise plan, part of me really thinks about staying where I am.

Recently, after a grueling Wednesday clinic session (286 patients), Dr K and I were chatting about the project I am working on, and then we just chatted for a while about what I may do down the road, post-residency. It is tough to know where I am headed, but as I was walking away from clinic today, I thought that if they were able to offer me a job in the department (after residency-as finishing my last year of residency is the only absolute/definite plan I have in life at this time), I would be hard-pressed to not take it. I could easily see myself working in this capacity (with finding a way to do some pedi work) at Bara for a few years. As I have mentioned to some, I will not be ready to leave in 4 months....

Lucky and Friday

2009-02-23T12:38:00.001-05:00

On Friday, 3 of the patients, who I had admitted the previous week/weeks went home. I'm seeing them in clinic this week. Was nice to see them going home, as opposed to the other type of discharge...

Today was a bit of a whirlwind. Phew. I had the usual six suspect who were still in the hospital, and had to round on them by 11. I tried to sneak through the ward and escape new consults, which didn't happen, and I picked up to more consults. Good consults though, so I didn't mind. One was a 28 year old who is newly diagnosed, admitted a week ago with pretty profound respiratory distress, and pretty impressive leg/groin/abdomen swelling. He's been there a week, and still on oxygen. The other was a patient we were asked to see for infective endocarditis, who was on a less than ideal antibiotic regimen. So, they were nice consults.

I'm on-call this week to see new consults in the surgical and ICU wards, but also get to cover the clinic on Mondays and Tuesdays, when we're in the wards. The somewhat disappointing thing about this is that, Monday and Tuesday are generally the days we get to sneak away a bit early (which still usually doesn't make up for how late we are there on Wednesdays). I got nailed in clinic, with 8 patients to see. Normal would be 2 or 3.

One of those patients was Lucky. I wrote about him a few days ago. He's the one who looked very ill, and had a CD4 count of two. I was actually glad to see him today, mainly because that meant he was still alive, and that resisting my gut feeling of admitting him 3 days ago was ok. He is still quite unwell, and this time I gave into my gut feeling and decided that I was going to admit him. The HIV medicines were making him vomit, and he looked even more dehydrated that a few days ago. But, he didn't really want to be admitted, and so I relented. Gave him a bunch of scripts and will see him (hopefully) again in a few days.

The evening finally ended when, I admitted one of the other patients who I'd sent to have labs and an xray done. Again, we teetered on admission versus sending the guy home and seeing him in clinic in the coming days, but it was 5pm, the pharmacy at the hospital is long closed by then, and there is no way for this guy to get antibiotics (aside from paying for them himself). So we admitted him, that and the one crucial lab result that we were waiting for, had seemed to go missing in the lab. Go figure.

That's about it.

Cheers

ps-I'm avoiding the obvious irony with the name Lucky. On a similar note, I was reviewing a chart for a study I am working on, and the name of this patient was Happy. He's dead.

"If I'm still alive"

2009-02-19T16:04:00.003-05:00

"I was just about to call you:" is how JC answers the phone. The plan, as it stood this morning, was that he was going to be discharged, and that he would walk to clinic and I'd give him a ride home, as he's definitely too weak to deal with walking to the minibus-taxi rank and taking a taxi home. "Well, I beat you to it. What's up?"
"Doc, I'm going to go home tomorrow eh?
"Oh-ok," I'm not sure why the plan has changed, but I can only surmise, that for the second time in as many days, the lymph notes that are swollen in his neck, and those in his abdomen, haven't been pierced by a needle, which is what we're waiting for.
"Can you do me a favor?"
"Yeah, sure."
"Doc," there is a pause on the other end, "can you go get me a loaf of bread?"
"No problem. I'll head to the bridge and grab you some bread. I'll see you in a while."

I need to head to the bridge that crosses over the busy street, and joins Bara to the outside world. It is the only real pedestrian entrance into Bara. I've never seen another white person on the bridge, when I've had to take taxi's to work and come in with those who don't drive to Bara-being most of the nursing staff, patients, visitors, construction men, radiographers, and just about everybody else who works at Bara I have patient files in my bag, and wonder if I'll get checked by security as I walk past them. I have my stethoscope right on top, which often serves as my immunity card to bypass security hassles in the hospital (and so far once for being pulled over as well).

I see some scones and buns for sale, but not any bread loaves. So I go all the way over to the other side, to where some stores line the street by the taxi rank. There is a tour group of white haired older folks. I try to hear their accents, not sure by their dress if they are European, or American, Or Australia. They are all homogenized. I feel slightly righteous. I may not venture into Soweto to hang out with the locals, but after 8 months I feel at home and at ease walking through the crowd. I cringe as I see one of the group take a photo of a woman selling corn.

I enter the mini supermarket.
"Eh, bubba, your bag." The security guard wants me to leave my bag at the door, where other bags are set into cubby holes, much like those found in kindergarten classes. No way, I think to myself. Not with the patient files in there, and also the sentimental value my stethoscope has...
"Eish, I just need a loaf of bread, where are they?" He points, and conveniently they are right by where the queue for the checkout stand starts. "Fine, I'll just walk there, grab one and get in the queue. I'll keep my bag with me." He nods in approval.

I get the bread, and head back out. The white tourist group has moved a bit further down the way, they are still all in a large bunch. Clinic finished on time, and so I'm taking advantage of what I feel is an extra hour to go see some of the patient that I'm following on the wards. I stop on the bridge, over the road, and just stare. To my left is Bara. To my right is part of the heart of Soweto. Actually, Bara is probably THE heart of Soweto I recognize faces walking past me, those of the nursing staff from various wards. Some of the HIV counselors are leaving as well, and they stop to say hi.

I chat with one of the counselors briefly about a patient I started on HIV treatment today. One of the consultants had see this guy last week and had scheduled him to come back and start medicines today, and as I was having a slowish day, he asked if I would see this patient. Dr T called the patient from the waiting room, and a cachetic (wasted appearance), guy stood up, and walked toward us. He was unsteady on his feet, and stood before us with labored breathing. He looked like somebody I would have admitted just based on how he looked. How ill and distressed he looked. Dr T shook his hand and explained that he was behind schedule and was it ok that I saw him and started his hopefully life-saving) medications.

"He's ready to start 1a." 1a is the starting HIV regimen for adults in SA. d4T, 3TC, and Efavirenz. I knew to start him on 1a. Dr T doesn't say this as if I don't know which medication to start him on, but rather to gently let me know that he is aware of how dire this patient looks, and that I just need to start treatment, and not admit him, nor go fishing for more problems-and in fact the patient is already on prophylactic TB treatment.

We walk to the end of the hallway, and I lead him into my room. I review his chart, and examine him. He's failed, twice now, to go register at the TB clinic. I get slightly irritated that this hasn't happened. But realizing that the TB clinic is equidistant in the opposite direction from the Bridge, and where the taxi stand is, it's no wonder the guy hasn't gone to register. It's likely he doesn't have the physical, and maybe even emotional strength to walk that far.

I examine him. The thrush is still growing in his mouth, at the base of his tongue. I look up at his palate and see a Kaposi Sarcoma lesion. I glance and see that it hasn't been noted before, and I feel oddly proud that I have found it. This is a worry, though, because with the HIV treatment, if there are lesions in his lungs, they could swell when the medications are started and worsen his already fragile respiratory system. There are other scattered KS lesions on his body. I listen to his heart beating away at 140 times a minute, double the rate of what a normal adult heart rate should be, and beating at the rate of a newborns heart. It's beating regularly, and I'm fairly certain that the significant dehydration, plus the lung disease is what is making his heart work at twice a normal rate.

I look over the labs. His kidneys work. His liver studies are normal. He has 2 CD4 cells. 2 lonely CD4 cells to fight infection. I imagine his CD4 cells hanging out, circulating in the body.
"Hey Bob! look, down there," as he points down the blood vessel.
"Oh shit, is that a colony of bacteria growing?"
"Yeppers. We're not going to be able to take out all of them."
"Lets just surrender."

I take out the sheet that we use to give information to all of those who start 1a. It has the medicines, a diagram of how to take them, as well as the side effects. It actually almost feels pointless to talk about the risks and benefits of starting the medicines. For without them... I go through the sheet. I make an appointment for him to come back in 2 weeks, and stress stress stress that he must come back if he feels worse.

I'm turn to head down the ramp of the bridge, and run into another counselor She served as the interpreter today. After we'd finished tying to figure out whether a young woman was really taking her pills or not, I asked if she would help me interpret over the phone. When I arrived to work this morning, I pulled out DM's file to get a phone number. I needed to give him a stern warning/lecture to get his ass back to the hospital immediately. Mourning was over. I was sorry his brother had died, but he had been let out for a weekend pass only. And the weekend pass had now gone on for 10 days. I was annoyed to see that the only phone number was for his sister-in-law. That could make it tricky to get a message to him, without letting it be known what was really going on. I had talked to the sister-in-law for all of 30 seconds this morning when she said, "Sesotho."
"Ok, I will call back.:

I explained the situation to the counselor. She grabbed my phone and made the call. They exchanged polite introductions. And then I head all I needed to hear.
"Dead. On Sunday. Ohhhhhhh, so sooorry," and then the phone was abruptly handed to me, as if I needed to hear for myself.
"HI again..." I expressed my condolences and then said goodbye. There was really nothing else to say. "Shit!" I said out loud. DM had to make one of the toughest decisions, and he made the one he thought he needed to make, as much as we were opposed to his choice.

As I headed off the bridge, and started walking toward the wards, I ran into AW. AW is a patient who we were asked to evaluate on Monday. He is a man, in his 30s, who has Non-Hodgkin's lymphoma, which is what the found when they biopsied the mass that had been growing for months under his jaw. And at the same time, tested him for HIV, and found him to be HIV positive (which wasn't a surprise). He is escorting a woman to the bridge.
"Are you his doctor" she asks.
"No. Well yes, I am one of the doctors taking care of him."
"Well, tell me what's going on with him."
"What do you mean?" I ask this to buy time, and to see what she knows. I've been here long enough now to know that HIV is a secret, often times. People don't mention it. It's like RD's wife finding out he was HIV positive. She found out a few hours before he died, when he asked her to pass him his HIV medicines.
"I mean, when is he leaving the hospital?"
"I'm not sure, they need to finish evaluating his cancer. Why?"
"We have a funeral to go to on Saturday."
"Well, I bet he can probably get a weekend pass, as he's just waiting for CT scans and other tests for next week." AW, himself, has kept quiet the whole time. I look at him, "I'll come see you in the ward and we'll chat. I have one other patient to see before you."
"OK doc, I'll be there in 5 minutes."
"Take your time, it'll take me longer."

VM was suppose to get her abdominal ultrasound today. She's been in the hospital 6 days now. And she was actually looking better this morning. The swelling in her legs and abdomen had gone done, the pains in her stomach were better, and she was eating. I told her to make sure she went for her ultrasound today, and that I'd see her in the late afternoon. He bed is at the end of the corridor, and as I walk down, she has a grin on her face.
"I walked to the ultrasound department" she informs me.
I grab the chart and look at the report. Normal liver. Normal kidneys. Normal gallbladder. Minimal amount of ascites (fluid in the abdominal cavity). But the sleen is enlarged, has microabscesses (small collections of what is likely infectious material) as well as enlarged lymph nodes in her abdomen. All suggesting TB. She did, in fact, have an abdominal TB IRIS. And she's improving. We chat, and she's doing her best to convince me as to why she should be able to leave the hospital, and go home. Little does she know that I am already in complete agreement, but it's nice to see her have some energy in her, so I let her go on. Last week, when she came into the office, swollen from the abdomen downwards, looking miserable and in pain, and having gained 8.6 kilograms, (the equivalent of 8 litres of water, or 2 gallons) and looking depressed, I wondered if I would be wrong. First time I met her, I wasn't sure she'd make it. Then starting TB treatment she looked great. Then crappy again. And now great again.
"Ok, I think you can go tomorrow, you have an appointment to come back and see me on the 27th anyways." She smiles, looking thrilled to be able to leave. "You're going to do great, ok. You are going to get well, and stay well." I say this, perhaps, to also convince myself.

I make my way to ward 22. Before I get to AW, I see SM. He's walking down the hallway.
"Sorry doc, I was in the shower." He thinks I was looking for him.
"You're looking good, how's the breathing." I guestimate his respiratory rate has settled from the 40s when I saw him in the office, to the low 20s. And he's talking more comfortably.
"Much better."
"Ok, I'll come back and see you tomorrow."
He's still waiting for a test result to see if he has PCP pneumonia...

I find AW sitting on his bead. And I draw the curtains closed, which only gives a false sense of privacy.
"Does she know?"
He shakes his head no.
"Why not?"
"We're not really married anymore, we don't live together."
I assume, or hope, that implies that either they are not sexually active, or that they are using protection.
The hematology team have asked us to start HIV treatment ASAP, while he is in the hospital. Starting the treatment in the hospital isn't really ideal, as there seems to be better compliance when it is started in the clinic. Also, AW lives close to a clinic that can give him HIV treatment, but there may be a delay in him getting an appointment there. So we've been debating what is the best option. The hematology team is impatient, and they wanted the treatment started Monday. Fair enough. AW and I talk about the logistics, and have to plan it around a possible weekend pass out.
"I guess I have to tell them?"
"Well, what do you think?"
"They aren't going to be happy. My mom is going to cry and be sad."
"Why do you say that?"
"My brother died of HIV. But he didn't take his pills right. He missed a lot of doses. In the end he got real sick and died. My family is going to be mad, but I guess I got to tell them. I just got to tell them. If they get mad, they get mad. Nothing I can do about it. I just got to tell them."
The way he keep repeating about telling them, makes me think he is trying to convince himself, more than explain to me.
"It is probably best if you tell them, but I can have the counselors talk to you about telling them." I just stand there for a minute. It's the stigma of HIV that will continue to make HIV/AIDS such an insurmountable disease in South Africa "It's not easy to tell people these things, but it will be best to be honest." I empathize I can think of many times, year ago when I was coming out, how I kept repeating the same mantra to myself: I just need to tell them. Just need to get it over with. We finalize our plan. He'll be away this weekend on a weekend pass, then will collect his medications on Monday. We've decided to postpone starting until Tuesday. That way he doesn't have to take his pills bottles home, which may release his secret before he wants to. Unlike RD, AW wants to be frank about his disease.

I finally make my way to JC, to drop off the loaf of bread.
He laughs. "What am I doing to do with a whole load of bread?"
"That's what you asked for, a loaf. Share it with the others?
I flip through his chart. He's basically wasted this week in hospital. The lymph node excision that the surgeons were to do on Tuesday never happened. The ultrasound-guided lymph node biopsy/aspiration (in his abdomen) that was suppose to be done today never happened. He stated TB treatment this morning. I think it should have been started a week ago. I've watched him lose weight this week. And get weaker.
"How's the ensure?"
"It's sweet."
"Well, you can dilute it, just use 3 scoops, not the full 6."
"Dr T was surprised to see a can of it here. She didn't think the dieticians had any for the patients."
"What did you tell her?"
"I just let her believe it came from them, not from you."
"Thanks."
We talk a bit. He's worried that if he has to do DOTs (directly observed therapy-where he will have to go to clinic each morning and swallow his TB pills in front of a nurse) that it will be very exhausting, as he doesn't think he has the strength to make the daily pilgrimage. I think that the extra calories he'll burn each day walking to the clinic would be better saved... He'll be discharged tomorrow, and will come back in early March for the biopsy, and for review in the ID/HIV clinic.
"I'll see you then?" he asks.
"Nah, you'll see Dr T. I'll be out of the clinic for a bit," he seems disappointed. "but don't worry, I'll be in the clinic again in April. I'll give you a shout in a few weeks to check up on you, and make sure you're doing well. We'll meet up in April."

His reply: "If I'm still alive."

And it is the first time, in the almost 2 months of taking care of the sickest overall population I have ever encountered, with such high mortality, that somebody has actually verbalized insight into their own mortality...

-

New Pics Up

2009-02-16T09:21:00.001-05:00

Check out: http://picasaweb.google.com/BackToBara for updated pics from the last 2 weekends away.

Weekend Warrior

2009-02-15T13:58:00.001-05:00

When I threw on my pack this morning, the pain in my shoulders and hips reminded me of the 14 miles we had hiked the day before, and the 4,500 foot elevation gain we had made in the 8 hours that we hiked yesterday. With the pain, I also had an immediate flashback to being in Nepal, and the second day of my trek. I tried to console my sore spots this morning by remembering by the 3rd day or 4th day, my body had gotten use to the pack, and I wasn't sore. But sadly, this was only an overnight trip.

Friday night Cecile and I drove down arriving past dark, to find that Thomas had set up a tent and had a fire going. The stars were out in full force, the moon hadn't yet arisen, so as the fire died down, we decided to just thrown the sleeping bags outside and sleep under the stars. The only danger was the possibility of rain (it had been raining all week) and the almost softball size pinecones. But risking head injuries from falling pine cones and rushing into a tent were well worth it, as in the end it turned out to remain cloudless, and only one pine cone came close to hitting one of us, and we were greeted with a sunrise and a perfect day.

The goal, was Mount-Aux-Sources. Many months ago, David and I did some hiking in the Berg, and we hiked to the base of a waterfall, which was DRY! Well, this hike that we had planned was a 14 mile hike, gaining 4,500 ft in elevation, which included 2 chain ladders going up a few stories of a mountain face, to the plateau at the top of the Drakensberg Amphitheatre. It was a cloudless day, and a perfect hike. The views were incredible.

It was great being away, and having periods on the trail to just think about what's been going on lately.

I thought about how I'm still pissed that GT died. I wondered why DM hasn't returned from his weekend pass, which he got the weekend before. I keep thinking I should find his file in the clinic and see if we have a working telephone number for him, and call him and tell him to get back ASAP. I worried about VM-the patient I wrote about recently who looked so great after finally starting TB treatment, who I saw in the clinic and is all of a sudden not doing well, and had been mismanaged a few days ago, and was sent home instead of being admitted. I thought about JC, and how Saturday was his birthday, and was glad that he was home on a weekend pass, to celebrate with his wife and daughter--I am learning JC's story, and it is inspiring. While thinking of these patients, and many others whom I have not written about I vented multiple times to Cecile (who is in medicine as well) about my frustrations.

I reflected on what it has been like to be so far removed from the lives of family and friends, and colleagues, and to have missed special occasions etc. And what it will be like to return. I find myself bringing this up more and more with a few friends who are perpetual transplants in this world.

I felt guilty for enjoying the weekend. I know my consultant does an incredible amount of work on the weekends, part of it has been on a project I am involved with. And I envision him sitting at the computer doing some work, and there I was watching hawks fly overhead, making false goals to come home on Sunday (tonight) and to complete the 20 chart audits I have brought home for the weekend, as well as the database which I had hope to have revised by tomorrow.

I didn't enjoy wondering if we would encounter "Bandits" who are known to roam these parts and "steal hiking boots" and other things at night while people sleep in their tents. But it made me think how dire things must be if people who live in the surrounding areas can only survive by occasionally borrowing from persons who can afford the luxery to have fancy outdoor equipment and come invite themselves into their backyard. I had taken what I had hoped would be plenty of bribery money so that if I was awoken by strangers at night, I could give plenty of money so I could keep my boots. Hiking back today, I was glad to have my hiking boots.

As we approached the car, I couldn't help but think about how hectic tomorrow will be. Yet, I didn't find myself dreading work tomorrow, I found that I was actually eager to get to the wards, and see that my patients are doing ok.

Time to wrap this up. There'll be no weekend warrior next weekend, as it will be a frantic weekend getting caught up from the two previous weekends spent away.

I must add, though, that I was very distressed to learn that ibuprofen (aka wonder drug) is only sold by prescription here. I can consume ibuprofen like tic-tacs at times, and could really use some tonight, seeing as how I depleted by ibuprofen stock months ago. I actually had to ration them in Nepal. And had I know, I would have stocked up there for the return trip.

Cheers.

PS: photos coming up soon.

Mixed Bag

2009-02-12T14:40:00.002-05:00

It's kind of been a mixed bag week.

Almost feels like I'm on the hematology/oncology service, as most of the consults I'm covering in the hospital seems to have blood or lymphoma problems, too little of one, too much of the other.

I admitted a patient from the clinic yesterday. Who, I felt was quite ill. Wrote his admission orders and left a fairly good laundry list of stuff that needed to be done when he was admitted. Went to see him this evening, and was a bit annoyed to see that they hadn't even bothered to do most of the things that he needed done on admission, and to annoy me even further, they admitting registrar seems to have completely minimized his symptoms and level of illness. I had the luxury of having plenty of time to take his history and examine him in the clinic. I am almost willing to bet that that the admitting resident spoke to him for less than 5 minutes, and probably only listened to his lungs, then copied my admission note. Which would be fine, had the lame-ass bothered to copy what needed to be done for the patient. This guy may not live; this is based on my recent experiences. JC's story is unravelling.

That's gotta be it. It is almost 10 pm, must quickly pack for a weekend backpacking trip, have about 10 charts to review, and some other things to get done.

Cheers.
-

JC

2009-02-09T13:39:00.001-05:00

My phone rings this morning at 8:30. It's one of the ID attendings, asking if I know where JC is. The radiology department had just called her to try and track down JC, and they couldn't locate him (doubtful they even tried, but I wouldn't want to be the one spending an hour searching wards for a patient, just rather call the person who ordered the test). So she asks me if I have seen him. And wouldn't you know it, I get to be the one to try and track him down...

So I head to the most likely place. The ward he was originally admitted to last week. That was ward 38. Though he was never technically in ward 38. He was admitted to ward H1. And then on Thursday he was bumped to ward 22. It took me half an hour to find him on Thursday. So I show up at 38, no sign of him. Perhaps he just hasn't returned from his weekend pass yet. But I'm slightly paranoid about what radiology wants, and I'm a bit worried that they have bumped him from a CT scan which has been arranged for tomorrow, to a study today. And if they want to do it now, and we can't find him, it's possible he will lose his spot, and then god knows when it will happen.

I depart ward 38 and decide to head off to ward 22. As I'm stepping into the ward, the attending calls me again to explain that what radiology wants is to confirm, again, the details for tomorrow. The CT scans are so backed up at Bara (do keep in mind there are 2 CT scanners, for 2,000 plus beds) that on Tuesdays they send patients to a nearish by hospital do have scans done there. They depart in the morning, and return in the afternoon. Everything has to be arranged for the trip. A functioning IV has to be working, the consent has to be signed, and food has to be arranged.

As I walk into the ward, verifying the details with the attending, I hear my name called out, "Doctor Brian." My surname is too confusing to pronounce, and in fact, I've grown to prefer Dr Brian.

JC is back. We chat about the weekend. He had a nice time home with his wife and daughter (who I keep referring to as his son, and only half the time does he correct me, so I am perpetually confused if he has a son or a daughter). I write a brief note in his chart for the ward team, again laying out what needs to happen for him to get his CT scan tomorrow. While this may not give all the answers, it'll hopefully shed some insight into the mass that is easily palpable in his abdomen. I finish my note, and tell him later I'll see him on rounds.

A few hours later the attending and I go visit him. It really is more if a visit than to evaluate him.

"Here, I'm done reading these," he says as he hands me back some magazines I left him.

"Pass them around, I've already read them." It's a bit of a lie. Last week when he was admitted, he forgot to bring something to read, so when I was at the bookstore I picked up some magazines. As an aside, I actually found it quite tough to figure out what he would want to read, and I didn't want to pick something insensitive, like Home and Garden or Men's Health. I figured current affairs are always safe, so I grabbed a Time and some other local current affairs type magazine. I honestly can't recall what was on the cover of time, but on the cover of the other one was an anti-genetically modified article. This cover is showing as he hands it back.

"GM foods are evil. More attempts by the US to make profit on the hungry in the developing world."

I love it. Just love it. The comment is from one of the ward docs who passes and sees the magazine.

"Actually, we're just trying to save the world from starvation," I add.

"But don't you think that modifying the genome of foods will possibly have some consequences that we don't know about," asks JC.

I confess to him, "I don't know anything about GM foods, I just like to play devil's advocate when US affairs are mentioned in a negative context."

JC goes on to tell me his concerns with GM foods. I will never be able to explain how bizarre this is. I don't have these conversations with patients here at Bara. In fact, as he is talking it dawns on me that he have such little interaction on a personal level here. I have a flashback to talking about Moby with a 50 year old patient when I was on the CCU service as an intern.

But there is more to it than just having a conversation, it is the fact that we are having a fairly cerebral conversation. I am not sure how to word this in the most appropriate context, so let me preface by saying that if what I write seems offensive, or insensitive, then it reflect my desire to type this out quickly so I can get back to the hours of work I still have to get done tonight. The population that accesses health care in Bara are not persons who are employed in careers which have required higher education. Which is not to say that the people aren't in-tune with current affairs etc, but to be discussing the science of GM foods is a rare at Bara.

"So, you're calling my bluff."

"Eh doc, it's no problem. I studied biochemistry before."

Before. Before he ended up as a refugee in South Africa. There is more to his story, but I don't know it, yet.

BPB

Champagne Castle

2009-02-08T13:36:00.001-05:00

We orchestrated a weekend retreat this past weekend. 5 of us rented a Chalet in the central Drakensberg. I'll get the pics up in the coming days. We got off to a delayed start, and the initial mood was slightly less than festive as the traffic in Jo'burg was horrendous, and what should have been a 4 hour drive took 6 hours. So we finally arrived at 10:30 to the chalet. And in true form, we unpacked, cooked dinner, and sat outside drinking wine til 3:30 in the morning. Waking up Saturday we just enjoyed the amazing view from the porch and had a lazy brunch, walked a bit, then had an evening horse ride, and returned to the chalet to cook up another storm. Sadly the weekend flew by, but it was a great weekend. We keep talking about "doing this again soon," but I fear that realistically "again soon" is sometime after my departure at the end of June.

Dead Wrong

2009-02-05T15:56:00.001-05:00

Ok, I was dead wrong.

GT is dead. Made an afternoon round after clinic wrapped up, headed into one of the wards, and the curtain was closed around his bed, and when I peeked in saw the defib machine. That's the surprise. He's the one I thought would live, at least for a longer while (talking years).

So I walked to find JC and see how he was getting on. I calcuated that 60% of the patients I have admitted from the HIV clinic had died. So I was worried about JC. Finally tracked him down to another ward. He is status quo. He'll head out this weekend on a weekend pass, and has lots of investigations lined up for next week.

I left him, and then as I was walking I saw PM, who is the guy who had infective endocarditis, from previous injection use. He was in clinic to follow up and to start HIV treatment, but has a fever, and so is being re-admitted. He was, in fact, discharged by the ward team earlier than we thought may be best. (Reasons-bed space?). I walk up to him as he is standing outside of Ward 20, the admission ward. He starts to talk, as his tears start to form, and he is explaining how frustrated he is, has been there all day, and hasn't gone to a ward yet, he isn't feeling well (and he's in mild respiratory distress as I watch him talk). He tells me how painful it was as the medical student kept stabbing and stabbing to get the IV and take bloods. And they want to poke him again. I'm afraid he'll just leave, he looks like he is at breaking point. But I am fearful that if he leaves, he won't be back, and he'll go home to die. I try to convince him to stay. He says he will, and I head off, wondering if he really will.

Bara is a place like no other...

Secrets

2009-02-05T15:50:00.002-05:00

For those not on the major time wasting activity and impersonal posting forum known as FaceBook, this is currently going around. You're suppose to post a list of 25 secrets, so for those who wouldn't see, I submit:

1. The best accomplishment, thus far, in my life was not my graduation from medical school.
2. In high school we talked about running away to Alaska, to create a life based on Northern Exposure. Secretly, I think we all hoped somebody would have had the balls to say we’d leave the next day and drive to Alaska. I still have a Northern Exposure Fantasy.
3. I wear bow-ties because it reminds me of one of the last conversations I had with my closest friend during internship, and the agreement we made before she died.
4. Every time I post something personal on my blog, I have to pretend nobody will ever read it, I don’t like to share. (Ironic, I know).
5. I gave away my 3 favorite shirts (2 in Zimbabwe, 1 in Nepal) and now it feels ridiculous to have ever been attached to a shirt.
6. My brothers and dad have married amazing women. How we ever went from dysfunctional bachelors to a real family is something Oprah and Dr Phil couldn’t figure out in an hour on their talk shows.
7. [ ] This one is going to the grave.
8. I am definitely not who I thought I would become, and it makes it easier to not have any clue about who I will be in 10 years, in 20 years etc.
9. Watching my friends and brothers become parents has been such a joy.
10. Up until recently, I supported the death penalty. (Shhh on that one).
11. I waste entirely too much time thinking about what to do after I finish residency.
12. In college, I drank Irish Crème coffee. As a coffee purist, I’m embarrassed to admit this. But if I had a cup now, I would have such incredible flashbacks…
13. I have a very close group of friends, some of whom have been friends for almost 20 years (jesus, is that right??), some of whom I’ve known less than a year, and it’s crazy that they now span 6 continents. They inspire me to be a better person. Thanks.
14. But, being without contact from the world while in Nepal was incredibly liberating; some days I think back to being on the trek in Nepal and think about smashing my computer and mobile phone and going back to the simplicity of life.
15. I secretly hate face book. I wish that people sent emails again and made phone calls.
16. I love watching the sunset.
17. I get really annoyed when people ask me which I like taking care of better, kids or adults. I don’t choose, I enjoy taking care of both.
18. If I could be re-incarnated as a type of fish that can only survive by swimming in coffee or whiskey, I would do it.
19. About 2 years ago I had a dream of opening my own coffee roasting company. I still think of it often, and still have the slogans and labels that I made (along with a small coffee roaster and green beans). Hanging out at my favorite coffee roasters here in Jo’burg makes think that at some point coffee roaster will be my next profession.
20. My first crush on a boy was in second grade. Actually my first few crushes were in second grade. I don’t think second graders can choose their sexuality. (see #4 above).
21. I have boxes of books in the basement of my brother’s house in Littleton. I never intend to unpack them, or give them away. I suspect he knows. I may ship books to him from SA. It’s my book grave. He doesn’t know that.
22. I plan on trying heroin, but am waiting until I am on my death bed so I don’t become addicted, well or so I don’t become addicted for long.
23. I keep enough foreign currency from everywhere I travel to afford cab fare to a hotel, and enough to get a bite to eat.
24. I tend to keep most emails that I received. I never knew why. But over the past few months I’ve gone back and reread hundreds (no seriously, many, many hundreds) of emails, and it’s been wonderful.
25. I will be up most the night to get stuff done so that I can go away this weekend and next. I’m reminded how fucking lucky I am to be doing what I am doing. And if I had some, I'd brew Irish Creme just for the sake of it.

Vitality in your 30s

2009-02-03T15:50:00.001-05:00

I'm tired. It's late. I have a good bit of work to finish before bed. But as I was driving home from my new late night bookstore (a SA B&N equivalent), I was thinking about today, and the guys who I am rounding on in the hospital.

They are all in their 30s. In fact, I am older than all of them. I though one of them was in his 40s, based on how aged he looked, but yesterday I realized he is 32. Right now I'm not really sure what their individual prognoses are. Only one of them seems to really have a diagnosis, and that's Doctor. He definitely has non-Hodgkin's lymphoma. The other one GT remains a bit of a mystery. I think I'm starting to favor a diagnosis of lymphoma in his brain. He's waiting for an MRI. And JC, is likely to be lymphoma or some other nasty cancer in this abdomen.

None of them look well. None of them could walk to the end of the corridor without having to stop and rest. IN fact, GT can't walk period. There is no sense of vitality, at all.

But, back to JC. I'm at the bedside, with two of the consultants. One is Dr JT, who saw JC on Jan 22nd, and did the initial work up. She's a little miffed that an ultrasound was done to, among other things, evaluate the mass that you can feel, and about which there is NO comment on the ultrasound report, and the other is the head of our unit, Dr AK. We review the notes, and the likely diagnoses, and what needs to happen, and happen fast. Dr AK takes some ownership, and decides that we'll go ahead and arrange for some of the work up, we'll book the CT scan that needs to get done, and we'll add one some labs. There isn't time to waste anymore, the clinic already wasted 6 months of this guys life, and the team who has admitted him are post-call and swamped today, so we'll help them in getting the ball rolling.

While the 2 consultants get into a discussion about something else, JC and I talk a bit. I'm slowly piecing his story together. He lives with his wife and 5 y/o child. He is from Zim, and is quick to point out that he has refugee status. I tell him what he plan is. He'll have a CT scan. A bone marrow biopsy. An scope down this esophagus into the stomach, as likely have one of those large lymph nodes taken out. It's going to be busy, and unpleasant. He wasn't to know what he'll get for pain control for the bone marrow. I hope they give him something, but I am unsure. He remarks how he is glad he ended up at Bara, and that something is finally being done to help him. He explains to me how after a while he thought maybe there wasn't anything wrong with him like the clinic doctors were telling him, and that maybe it was all "in his mind" like they said. And that he would get better with the HIV treatment. My attending catches a bit of this conversation and shakes his head.

We talk about it as we're walking to CT scan, to plead our case and hopefully get an urgent CT for JC. Dr AK re-iterates the reason why he doesn't like to down-refer patients to the outlying clinics. (Down referral-basically transferring care to the community clinics which can manage HIV treatment). Even though there are more than 4,000 patients on treatment in our clinic, and even though there are 3 vacant doctor posts at our clinic, and even though sometimes the clinic doesn't finish until 5 or even 6, and even though sometimes the clinic sees well in excess of 200 patients a day, it's still better to keep the patients where we can make sure they are getting the correct care. It's not about work load, it's about good patient care...

BPB

Failure and Success

2009-01-30T18:39:00.001-05:00

Failure:

JC is the third or fourth patient I see in clinic today. He sits down, shows me his ultrasounds report, asks me his CD4 count, wants to know what is the next step. I'm caught off guard, because I don't even know what step we're on. And I'm pleasantly surprised. I find his direct questioning a deviation from the usual patient encounters. It shows he is concerned about his health. I glance over his details, I realize his birthday is a year and a day after mine. I can't explain why, but I know I'm going to like him.

He's new to our clinic. Yet he has been on antiretroviral treatment for 6 months, which was started at an outside clinic. This is pretty unusual for persons who have been initiated at a clinic to be referred to us; mainly they end up here if they move closer to our clinic, or if there is a problem. And JC is here because there is a problem. Though, I think "problem" is a bit of an understatement.

I needed a minute to digest the note from his visit 2 weeks ago. He was seen by one of the attendings/consultants, and there is a detailed note. Something really isn't right. JC was started on treatment with a viral load of 60,000, and a CD4 count of 20. After the usual 8 weeks, his viral load plummeted, but his CD4 never picked up, and in fact, testing 2 weeks ago shows that his viral load is suppressed (less than 25), and his CD4 count is 24. He seems to have immunological failure (his CD4 count hasn't risen), but has a good virological response (his viral load is undetectable).

But there is more. Way more. He's lost a significant amount of weight. Actually, he's lost a shit load of weight in the past 6 months. He's gone from 63 Kg (138 lbs) to 49 Kg (108 lbs) in the past 6 months. He has lost 14 kg (or 30 lbs). No cough, no fevers, no sweats. TB would be the main culprit causing the weight loss in him. But his work up for pulmonary TB was negative.

When our doc saw him last week, she noted his complaints of stomach pains for the past 6 months, as well as back pains. These have been treated with pain medicines and anti-ulcer treatments, and they haven't gotten better-at all. And then she examined him.

I flipped back through his notes from the other clinic. Nobody has listened to this man. For months he has been saying he isn't well, and nobody has listened. For 6 months they watched his weight plummet. For 6 months they gave him antacids. For 6 months they continued to note that his CD4 wasn't picking up like it should.

And for 6 months, they didn't notice the mass in his abdomen. Which he has known about. Back in March, it was mobile. But for the past 3 months it has been fixed-- unable to be moved about. The doc last week noticed it. Unfortunately, the abdominal ultrasound shows lots of abnormalities, but didn't mention this mass.

I sympathize with this man. Sitting with him, I had flashback to where I was 5 years ago. In the GP office in Ireland, explaining how all of a sudden I couldn't run, how I was winded just trying to go up stairs, and how miserable I felt with a persistent cough. I told him there was something wrong. I was given a script for allupent (which is basically a placebo medicine-technically an expectorant), and sent out the door. It's the exact treatment that JC has been getting. A dose of failing to really care about the patient, and pacification with placebo medicines. There are so many red flags in his story, that I don't even know where to start explaining things to him, partly because I know the outcome isn't looking too good.

We talk, I tell him my frustration that he has been literally wasting away for 6 months and nothing has been done, and that I think it's best that I admit him to the hospital so that he can get a CT scan, a endoscopy, and more work up. I tell him that based on the ultrasound results, it looks like he may well have TB in the abdomen, but that the biggest concern is that he also has a lymphoma or other cancer in the abdomen as well. We negotiate. He'll spend the weekend with his wife and 2 year old child, and then will be admitted on Monday. I give him my mobile number so that he can call if anything changes. Initially I balked at handing out my number in clinic, but I'm realizing that negotiating/manipulating the system here is beyond the capability of many people (as it is in the US as well), and that most will likely be too embarrassed to actually call, but at least they will have the option.

Success:

It's mid-afternoon, and I scan the people sitting in the waiting room for VM. She has been sick since she came to the clinic three weeks ago. I'm relieved she made her appointment today. I call out her name, and watch as she walks toward me, and she smiles. She looks completely different. For a minute, I wonder if it was her I really saw at that initial visit.

It was late in the afternoon three weeks ago. She had decided to not start HIV treatment back in November, and then had changed her mind and came to the clinic. And she was ill. Chronic diarrhea. Losing weight. And she was coughing, with sweats. She had horrible thrush, and wasn't able to drink enough to make up for the lost fluid of the diarrhea. She really needed to be admitted. But she declined. (I almost said refused, but that's medico-legal speak, which means if something bad were to happen because she didn't go into the hospital, then it's her own fault, and the clinic/hospital/doctor aren't responsible). But she couldn't go into the hospital. If she did, and were away from her home at night, it would be likely that her home (shack) would be broken into and her stuff stolen. She needed to be home. It was too late in the day to do labs, or get medicines, or get xrays, so she would have to take 3 mini-bus taxis home, and return the next day to do the stuff, and then return the following week for results.

When I saw her 2 weeks ago, she looked even worse. And I feared that she wasn't going to make it. Her chest xray confirmed likely pulmonary TB, which would mean she would need to be on TB treatment for 2 weeks before starting her HIV treatment. And so that's what we did. Gave her the pills for TB, and said we'd see her again in 2 weeks to start her HIV treatment.

And today, after 2 weeks of TB treatment (as well as treatment for diarrhea) she finally feels a bit better. It was a huge relief to see how well she was feeling. Again, I found myself thinking back 5 years, and retrospectively realizing how lousy I felt when I had TB. Once the TB treatment kicked in, and breathing became less laborious, and I had energy, it was easy to smile. You literally feel like you get your livelihood back. And I completely understood why she was smiling.

Three weeks ago I wondered if she would really have the strength to take the 3 mini-bus taxis back to Bara. Or would she simply resign herself to what she saw as her fate, stay in bed as the TB continued to consume her, as the diarrhea wreaked havoc on her electrolytes, and at some point die at home. She's going to make it. And having the privilege of helping somebody like VM get healthy is the most rewarding aspect of this job.

Keeping Silent

2009-01-27T14:25:00.001-05:00

I sat at the computer this morning to review labs. And I don't know why, but the moment I saw that RD had a blood culture that was growing a gram negative organism, I knew he was dead. I can't explain why or how I knew. I just knew that the minute I saw his culture results. I knew I need not even bother walking to the ward. His bed would be empty.

I'm quite pissed about the whole event. And you can bet I am censoring my post. I know where I place the blame. I know to whom I would point my finger. And I know where in the system I point the blame. All I can say is that if you watch the Al Jazeera documentary, you'll get an insight into what goes on when a medical system cannot cope.

But of course, I needed to know for sure. So I walked to ward 16, praying that the antibiotics that we desperately recommended yesterday would have been started in time to give him a fighting chance to fight the sepsis that had started DAYS earlier. And as I was about to enter the ward, I met the person I would point a finger at, who informed me that he had died late in the evening. It sucks to be right sometimes.

I'm seeing big disparities between medicine and pediatrics. I'm glad we're in clinic for the next 3 days.

PS: if you're a fan of Abraham Verghese, he has a new book coming out and a book tour as well. Not that I've heard him speak, but I bet it would be an inspiring event.

http://www.abrahamverghese.com/

Keeping Silent...

Real Live Bara

2009-01-25T02:28:00.001-05:00

A documentary series has been made about Bara. It has started showing. The old episodes can be found on YouTube.

Check out:

http://www.lefthandfilms.co.za/soweto/synopsis/

http://english.aljazeera.net/programmes/general/2009/01/200919143440701450.html

Also, the series is called "Saving Soweto" and if you google that you'll come up with some other articles.

Will I?

2009-01-22T16:49:00.001-05:00

Will I?

Will I lose my dignity?

Will someone care?

Will I wake tomorrow from this nightmare?
-RENT 1996

I'm at the gym, and listening to RENT. Which isn't ideal gym music, but I was lacking inspiration as I walked into the gym. I've listened to RENT countless times, I know the lyrics, and yet often when listening to it, what ever message I need to hear at that moment seems to ring louder during that time when I listen. It is a profound musical. And when "Will I?" started, I had to stop doing chest presses, and listen.

Will I lose my dignity.

Will someone care.

Will I wake tomorrow from this nightmare.

Written in 1996, reflecting the emotions of a group of people who were embattled in the fight against HIV/AIDS, poverty, and social ills, it is about the lives of Bohemians in New York city. 1996. Now 13 years ago. I remember I went through a phase where I read a lot of AIDS literature. And what was striking about the stories then-was the stigma, and the lack of compassion, and the lack dignity during the decline to death. The decline to death.

I'm walking down the back corridor of the waiting room today, and I see a familiar face. I see EM. I am slightly confused as to why she is back in the clinic. I saw her yesterday. In fact, I saw her in the evening. She was the last patient of the day, and came into my room at 5:30 pm. To start antiretroviral treatment. When I grabbed her chart, I had a slight sinking feeling. It was late. I was tired. It had been a hectic day, the now usual story of seeing lots of patients, some well, some sick. But to start somebody on treatment that late in the day was slightly irksome. So I called them from the waiting room, and this smallish woman was pushed in a wheelchair by another woman and we headed to the end of the hallway to my exam room. I glance through her notes, she was diagnosed a few months when she was found to have TB in her lungs. Typically, she has something like 60 CD4 cells probably working overtime to try and keep her from succumbing to pathetic opportunistic infections. We talk about the treatment, and I go into my now familiar spiel about how she'll need to, in all likelihood, be on these medications for the rest of her life. It's a way to help me see if a person understands how important it will be to take these medications.

"I just want to live."

I don't suspect she's at death's door, she may not even be on the right block, but she has this determination in her that strikes me. Did I mention she is 62. Short. And spry. And she just wants to live. She is 62, but looks years past that. She's passed the first hurdle of this visit, which is to indicate that she understands the importance of the medications, and will be ready to start taking the pills. I flip through her past labs on the computer. There is some mild anemia, which is so mild I barely consider it anemia for this population. Everything else looks good. She tells me she is feeling well, except that she has noticed she gets full really easily when eating. If she were a routine clinic patient, I'd likely do the bare minimum examination-look in her mouth for thrush, listen to her lungs if she had a cough, check for sign of anemia. But since she's about to start treatment, I have a sense of responsibility to at least do a bit more on a baseline examination. I help her get onto the examination table, and when she lies flat, I notice her protuberant abdomen-which was masked as she sat in the wheelchair (which she got at the entrance to the hospital because she was too tired to walk the block to clinic). When I get to examining her abdomen, it's rather distended, is full of fluid, and has some dilated veins. Her legs are also swollen. There's a problem. She almost looks like she should have cirrhosis, but nothing to suggest it by her history, and what labs I do have. Does she have TB hiding in her abdomen? Could it be ovarian cancer?

EM is in clinic with her sister. It's approaching 6pm. Nothing will get done at that hour. No labs. No pharmacy. No xray. Nothing. They have taken a mini-bus taxi to get here, and now I'll have to send them home, only to return tomorrow to get new blood tests done, go to the pharmacy, as well as book an abdominal ultrasound, which won't be done for two, or three, possibly even four weeks. They have been waiting since the morning to be seen. They will have to slowly make their way out of the Bara complex, over the bridge to the mini-bus taxi rank, take a taxi home, and return tomorrow to complete these tasks. Don't forget the costs of the taxis.

So I see her in the waiting room today.

"EM-are you ok?" I'm worried that somehow she feels worse today.

"Oh doctor, I am good."

"Why are you in the clinic?"

"I just wanted to see if there was anything else I needed to do."

I ask about the labs, pharmacy, and ultrasound. Check, check, check. Done.

"Nope, you've done all the things you needed to do."

I review, again, how she'll start her medications tomorrow. I remind her to start taking her bactrim prophylaxis today-almost out of anxiety on my part hoping that ward off any infection before her immune system recovers.

And she reminds me, "I just want to live."

I see a very pleasant 30 year old woman today who has been on treatment for 215 weeks. A long time. She is on the starting regimen. There are only 2 regimens. I glance briefly at her last few notes. They have been uncomplicated visits. She is a pro. She does well with her treatment. It'll be a routine visit. I go through the standard questions. I ask how she is feeling, if there are any new problems. I consider not even asking if she has missed any pills, I mean, she's been taking these pills for longer than I have been a doctor, and her CD4 and viral load are where they should be. But I ask.

"Doctor, I don't always take my efavirenz at night."

And admittedly, this catches me a bit off guard. People who have compliance/adherence issues, or who have defaulted treatment in the past carries these labels with them on their charts, and I glance again at her last note to review compliance. This woman is bright, and articulate, and has volunteered this openly and honestly. It turns out, this isn't new, and in fact she has been skipping efavirenz doses at night for more than a year now. I wonder why it is, that this is the moment she has chosen to disclose, not that I ask, because I want to encourage her to feel she can disclose these things in the clinic. It turns out she can no longer tolerate the nightmares she has from taking the efavirenz. This is a known side effect of the medication. She has reached a point where she knows that not taking it regularly is going to have consequences for developing resistance. I ask a little to clarify, if these are dreams, or nightmares. It's purely out of my own curiosity. Some antimalarials give dreams, as I experienced in Zimbabwe, and I loved the 6 months of vivid, colorful dreams I had when I was on treatment for TB. But had they been nightmares, I likely wouldn't have been as keen to keep taking the pills for 6 months. And she's been taking them for years. Perhaps she has been worried about how we, the clinic, would react to this disclosure, and that is why she has kept this to herself. Her options are tough... But we come up with possible plans to deal with this issue, and she'll come back to us with her choice...

Clinic finishes at a decent time today-and I have 3 consults to do, and I also want to check up on the other patients I'm seeing on the wards. I decided to pop in and see the guy with infective endocarditis, who is doing great and should be heading out of the hospital soon. As I walk down the ward, I look at the patients lying in bed. I look at the faces. Confused men, lying naked in bed. A man trying to get a cup to his lips, struggling, and spilling water over him. I head to see my patient. After 3 plus weeks, he's bored, we chat for a bit. I write a brief note in his chart. When I look up, I recognize the guy in the bed next to him. It's the guy I admitted this morning.

"Doctor" is the patient's first name. Not an all too uncommon name. He showed up at 8am this morning, I handed him his admission papers, and sent him to get an xray and then head over to the admission ward. I checked a few hours later to see if there were any labs on the computer, as a surrogate measure of if he had maybe been seen yet. No results. I hoped that he wouldn't sit for hours waiting to bed admitted. And here he was. He smiled, and we talked a bit. I looked over the admissions orders that the registrar had written. Doctor had a biopsy of an abdominal mass weeks ago, was told he had non-Hodgkin's lymphoma, and needed to follow up with the hematologists. When I saw him yesterday, I wasn't even sure if he knew he had cancer. I imagined the conversation when he got his results went something like this.

"Well, your biopsy results show you have non-Hodgkin's lymphoma, we'll send you to the hematologists good luck and take care."

Yesterday, after weeks, he hadn't been to the hematologists, and the work up that should have been started wasn't anywhere close to being done, or even started. Doctor is about my age. But looks at least 10 years older, though I have more grey hair. The striking thing is how wasted his face is. You can literally imagine what his skull bones look like, because he basically has a thin shell of skin covering them. He was in the office yesterday, with his girlfriend, and their infant (maybe 6 or 7 months old). You can see the fear in this guy's eyes. He has no immune system. He has cancer. He knows this. Yet, like EM, you can see he desperately wants to live.

Will I lose my dignity?

Will someone care?

Will I wake tomorrow from this nightmare?

As I'm lost in a moment of vanity at the gym, I hear these lyrics, and these are the faces and stories that immediately came to mind. Dignity. Care. Nightmare (both literal and figurative). How is it that lyrics written about this damn disease 13 years ago in America still perfectly capture what is going on today in other parts of the world.

Inauguration and ID

2009-01-21T13:04:00.001-05:00

I went to an inauguration party last night. Must have been close to 75 people there. A mini UN of people. And it was wonderful. You could feel the excitement that the world shares in this change of leadership of the country. Seeing non-Americans get sentimental at the swearing of President Obama was very moving.

As for ID-

Whoa. Man these Wednesday clinic are killer. Non-stop from 8am to 6:30pm. I'm quite frankly exhausted. There are things I want to say, but honestly it's so late that I think about all I can do is pop into the gym, have dinner, read up on one topic briefly, and then crash. I've never seen people so ill. Today I could have admitted 3 patients, but instead will admit one tomorrow (so he could take his wife and infant home, get his HIV medications from home, and will return tomorrow to be admitted for the rest of his lymphoma work up), and am going to try and work up the other as outpatients. What I do kind of enjoy, is that I'm also working up pretty significant hypertension in a young woman, as well as abdominal swellings in 53 year old woman whom I started on HIV treatment today. I also tried to convince a 66 year old man with schizophrenia (well controlled on meds, you'd never know he had schizophrenia if you met him on the street) to start treatment, especially since his CD4 count is hovering at 41. He's thinking about it for a week or so.

I find myself telling people to hang in there, that they are going to get stronger and feel better. And every time I say this, I have flashback to KR (the child who died after telling his family he would get better), I scold myself to not say these things again. And because, quite frankly, I don't know if they will get stronger or feel better. That's what I certainly hope will happen, but those who are already emaciated, have no immune system, and barely have faith themselves, are already behind the 8-ball...

That's it. For now.

Parallels

2009-01-15T16:47:00.001-05:00

I walk into the clinic at 7:45 this morning. The waiting room is full. It is already warm in the room as well. And muggy. I know that within a few hours it will be hot in this room, yet the people will continue waiting until they are seen. I left at 6pm Wednesday night. There were 250 patients registered to be seen. There were 5 of us working all day, with one or two others popping in when they could, to help out. When I left yesterday, I went home, walked down the street to have a beer and dinner, and had to just sit and watch the sunset to let my mind unwind.

But it is a new day, and I'm ready. I've set a goal to be more efficient today. I call the first patient to be seen. Mr. AN.

A man stands up. He looks no different than many in the room. Aged. He looks fifty plus, but looking at his date of birth, I see he is actually 40. We walk to the end of the corridor, and enter my exam room. I glance over his details.

Week # 48 of ARV (anti-retrovirals, aka HIV treatment). Doing well. His viral load was not detected 3 months ago, and his CD4 count is around 300. No other real medical issues that will have to be dealt with. I look over his clinic note from 3 months ago, and he's compliant with meds (as expected given his undetectable viral load, and decent CD4 count). I breathe a mini sigh of relief, first patient of the day will be out of my office in 5 minutes. I go through the standard questions. Have you been hospitalized? Have you been started on TB treatment? Have you missed any of your medicines? No, No, No. Is anything wrong? No. Perfect.

I look at his vital signs. No Problem.

I look at his weight. Problem.

We're using a simple bathroom scale, the kind that you may buy at Target, or any store. It's not all that accurate. But AN's weight is down 5 Kgs since his last visit. About 11 pounds. Where is the problem??

I worry about hyperlactateaemia. A complication of HIV treatment. Asymptomatic elevation of blood lactate levels. The only sign may be weight loss. Possibly some abdominal pain as well. He is feeling fine though. I can only really rule this out by doing a blood lactate level. I tick the box on the lab form.

I worry about TB. He doesn't have a cough, or fever, or night sweats. He had TB in the past, but that was years ago, and he's far out of the risk of IRIS. And he has a decent CD4. He shouldn't have TB. A chest xray would likely be pointless (but I'll get one anyway), and no chance of getting sputum because he isn't coughing.

I worry that maybe he's too embarrassed to admit to having chronic diarrhea. So I reword my questioning, but he's consistent. "Doctor, the caca is fine."

I worry that his liver has taken a hit from the HIV medications. But he tells me he has a good appetite. He's already denied abdominal pain. He hasn't been jaundiced.

I wonder if he has hyperthyroidism. But his heart rate is normal, and no other real stigmata of thyroid disease.

There is a problem. He has lost a significant amount of weight, and I can't forgo finding out why. I'll throw out some target screening labs, in addition to the lactate, I'll check his thyroid, his liver, his blood count as well as his renal function. Maybe he needs an ultrasound of his abdomen too?

We talk about these possibilities. I write up his note, and his lab forms, and his xray form.

"Doctor, I take my pills on an empty stomach."

"Well, that's fine," I say, "but luckily the pills you are taking can be taken on an empty stomach, or with food."

I go back to writing. As I'm writing, he grabs some papers out of his bag, and I recognize the familiar disability grant paperwork. And the light bulb goes off. I've made such a gross assumption, that I'm quite embarrassed

"Is there a reason you take your pills on an empty stomach?"

"Doctor, I'm not working, I don't have food."

Is it possible that the reason he's lost weight is because he doesn't have food. Is the simplest explanation the most likely?

I take the disability paperwork. All of a sudden I have a flashback to the resident clinic back home, and the sinking feeling of getting those fat envelopes in the mailbox when somebody wants disability, when in fact, there is no disability, but rather poverty and poor social circumstances. Today, I filled out 5 disability forms. For 5 people who all are unemployed, some supporting 3 kids, but none of them qualifying for disability. I didn't know what to do in these circumstances, so I filled out the forms, and told the patients that they wouldn't qualify. Perhaps I (grudgingly) filled out the forms to make me feel better, but knowing that they were only going to waste time and effort for these patients, as well as "the system."

After clinic, talked to the clinic attending, Dr K, and asked about what to do in these situations, when somebody wants disability, but won't quality... We talked about the breakdown in "the system" and what to do...

I see AN in 2 weeks.

Cholera (aka: The world is f*cked up)

2009-01-13T15:49:00.001-05:00

We had our grand round today-both the infectious disease team and the microbiology staff. We went to see a patient, who may well be the first cholera case at Bara, related to the outbreak in Zimbabwe. There have been plenty of cases up in the northern region of South Africa-the Limpopo area which borders Zimbabwe. And there have been a smattering of cases at Jo'burg hospitals (JHB General and HJH), but none at Bara. Which seems a bit unusual... But the cases at the Gen and HJH have been patients who were seen in the MSF (Doctors w/o Borders) clinic in the heart of Jo'burg, and they refer patients to the Gen.

So, it was a great bedside (well, not at the bedside, since the voluminous diarrhea makes it somewhat distracting to talk at the bedside) tutorial on Cholera. In addition to all the stuff that would bore most people (pathogenesis, treatments etc) we also looked at the Zim statistics.

Consider this:

-only 10% of people with Cholera are symptomatic. There are a reported 30,000 cases of cholera. Which means that that the actual number of cases, based on the reported 30,000 is therefore 300,000 cases. Take into consideration that Zim is falling apart, that there is poor disease reporting, and that people are likely not accessing health care, and the figure of 30,000 reported cases is likely a GROSS under-reporting.

-that the expected death rate of cholera is 1%. It doesn't take any special, drastic measures to treat. Simply rehydration alone, and antibiotics for those severely ill. But, the overall death rate in Zim right now is 5%. BUT the death rate in the community (i.e., those not in treatment centers) is estimated to be 55%, of those who have been diagnosed.

I say that this is "aka the world is f*cked up," because there is plenty of bad news in the media these days. (Though I have to admit that I spend less time on my favorite news sources-the BBC and NY Times, and simply look at major headlines to see what new f*cked up problems there are). The Economy. That guy who stole all the money. Gaza. Iraq. Pakistan. Iran. The US. Unemployment. Somali Pirates. Jacob Zuma. The Denver Broncos.

But this is f*cked up:

"healthcare" in Zimbabwe-as per BBC

Cholera: 2,204 died since August

Anthrax: Eight deaths since November

HIV/Aids: Estimated 400 deaths a day

TB: Brain-drain has practically closed the national testing laboratory which now has only one staff member

Maternal mortality: Risen from 168 per 100,000 in 1990 to 1,100 in 2005

(Please read the full article at http://news.bbc.co.uk/2/hi/africa/7826304.stm and also check out http://physiciansforhumanrights.org ).

So, our one patient with probable cholera will have an uneventful course at Bara. He'll get his hydration, and antibiotics, and he'll head home in a few days. But had he been in Zimbabwe, there's a good chance he could have been #2,205...

Ward 15, Bed 14

2009-01-12T10:34:00.001-05:00

I got to work an hour early today. I knew it would take me some extra time to get use to the system, the system of actually finding patients. I'm not too sure how many medical wards there really are, but there are quite a few, and they are scattered about.

I think there are about 10 general medicine wards, each holding 65 patients. As best as I understand it, each general medicine team has 2 wards, a male and a female ward. Teams are on call every 5 days, and take all the admissions for 24 hours. The day of call, some patients from that team will be sent to wards with free beds to make space for the admissions. And then when the new admits have filled all the beds on the ward, the overflow admissions will go to other wards.

The average number of admissions seems to be well above 100 -ONE-HUNDRED, and probably closer to 130+

So, I admitted 3 patients last week. One on Thursday, and two on Friday. And it was my goal to locate them all by 8:30 am, and to have hopefully rounded on at least one, or two of them before meeting the consultant at 8:30. I started with what I thought would be the easy way of finding the patients. I looked in the lab results of the computer, hoping that they had labs done over the weekend, and that the lab results would say which doctor (in which ward) had ordered the recent labs. And, so I randomly picked a medical ward to go use the computer. (I had to fight the urge to go back to the pedi admission ward, or even ward 18 to use the computer). As luck would have it, I ran into a resident there who I knew from my time in pediatrics. (She doing her mandatory community service at Bara). And she was kind enough to inform me that the computer in her ward didn't work. So I did the next logical thing, or so I thought, I headed to the next ward, and searched for the computer. Same story, not working. But, while I was there, I skimmed the book to see if the patient was on the ward.

The bloody books. The manual record of who is on the ward, or who has been transferred to another ward. The is no computer system to indicate where patients move, but rather one relies on multiple log books of patients. And no success in that ward. So I moved on to a third ward, as I looked at my watch and realized that it would be less likely to see 2 patients before 8:30. Strike 3.

Somewhat getting desperate, I decided I would head to pedi land and use the computer there. And as I was walking to pedi, I passed the same resident from earlier, who told me to pop into the medical admission ward and use the computers there. Which I did.

Patient #1- no labs since admission. Not helpful.

Patient #2 and #3-no ward indicated on the lab computer.

Shit. Now I don't know where they are. But at least I have some lab results.

I run into the resident again, and try to figure out how to find these patients. And it's simple. Knowing what day they were admitted, means they were allocated to either the male or the female ward of that team that was on call that day, and then all I need to do is head down there and look in the books to see where they are. And here I've spent the better part of half an hour to learn this.

I head to the male ward (16), to see Patient #3. I saw him in the clinic on Wednesday. Nice guy, 52 y/o male. On HIV treatment for 3 months now, and on TB treatment for 2 months. But he's lost 7Kgs (about 15 pounds) in a month, has a horrible cough, and just has that unwell appearance which made me think that something bad is going on, or something is being missed. So, since I saw him late on Wednesday, and they were done drawing bloods in the clinic, I send him out with a lab form and instructions to come find me in the clinic the following day to review his results. To make a long story short, his results were all out of whack, new kidney failure, worsening liver function tests, and he didn't come find me on Thursday. So I called him back and saw him on Friday and admitted him to the hospital. Since his admission, there really hadn't been much progress in his work-up. I find him in the ward, don't really have time to write a note on him, since I haven't even found the other 2 patients yet, but we chat briefly, and I glance through his notes. It'll be nice to come back and see him later and leave better instructions about which tests I'd like done. He likely has either MAC, or MDR-TB, or Non-Hodgkin's Lymphoma, plus his renal and liver issues.

Patient #2 was admitted the same day as patient #3-so she must be in the female ward (15) of the team that was on call on Friday.

So, on Friday, as I was writing the admission letter for #3, there is a knock at the door, and the sister opens the door.

"Doctor, the next patient is sick, can you see her?"

Of course I think "no" let her see a consultant. But I'm here to learn... "Sure, let her stand outside the door while I finish writing this note."

I send off patient #3, and then patient #2 is wheeled into the room by her aunt and uncle. And she looks like crap. She will have to be admitted. Turns out she's 26, was seen in the HIV clinic back in October, but then never came back for any visits. And today is brought it to our clinic by her aunt and uncle who are worried about her, rightfully so. Her CD4 count is 60. She has a weeks worth of a horrible headache, as well as she can't swallow anymore because of the pain. She also has Kaposi lesions all over the face and her arms. She's unwell. She's going to need a lumbar puncture (spinal tap), lots of labs, and empiric treatment for a bunch of stuff. I check her vitals (I know-it's a universal... I don't even ask ancillary staff anymore to check vitals.. I just do them myself). Heart rate of 160, BP of 82/54, RR of at least 30. (Ok I didn't formally count the RR, it was at least 30, and I didn't want to know if it was 40, or 50). So I ask the consultant to see her when I'm done with my note, and he agrees, book her for admission.

I'm walking into the ward, and I look over her results. Her lumbar puncture is actually bland. Will have to see what grows out on the cultures. I hope they've started her on antibiotics. Her other labs show bad acidosis on admission, which improved a bit as of yesterday. There are blood and urine cultures pending. I'm thinking what my plan will be for her. She's unwell, and needs to get on HIV treatment, fast. But she may need TB treatment for 2 weeks first...

I look in the book, and she's in bed 14. So I walk down the ward. Curtains are closed at pts are getting bathed. And I peek behind curtain 14, and the sheet is pulled up over her head. For a minute I wonder if she's been having chills with fever, but then I realize that it's also tucked in around her body, and she's not really moving.

She's dead. Too little. Too late.

home

2009-01-11T06:34:00.001-05:00

I am home.

Yesterday when I woke up at S&S's place, I was longing for home. Don't get me wrong, it was a great week staying with them, I just longed for home. I was, albeit, slightly confused about where home was. I was certainly eager to get back into my own space, in the Mondeor house, but also had a bit of longing for home. But which home?

My definition of home is changing. When I was travelling last month, and people asked where I was from, or where home was, I went into the lengthy explanation. I had to make it clear that I grew up in Colorado (which arguable is the best place in the world to grow up), but that I currently live in Johannesburg, and that I'd be returning to Massachusetts in July. And often times somehow it would come up that I'd lived in Dublin as well.

For a while, I defined Home as where my dog lives. Not that she's really "my" dog anymore. After 9 neglectful years of not paying alimony for her care, I'm pretty sure I've lost the right to call her my dog. (I am a deadbeat dad). And then I had this complicated definition of where home was. I'd thought that Colorado was really Home. But Dublin had been a home, just like Massachusetts had been a home. But Colorado remained Home, with the big "H."

But waking up yesterday, and longing for home, I wasn't sure where that was. Or rather, felt an equal pull to Colorado, Massachusetts, and even a pull to Dublin. I wasn't able to exactly figure out what I was missing. With the ability to access internet anywhere in the world, I've been able to keep in touch with people easily via email (and facebook); and skype has made it possible to have regular phone conversations with people-a true luxury. I found myself longing for random things yesterday. Seeing the Rocky Mountains. Seeing how big my nieces and nephews and godchildren are getting. Going out to dinner with the work crowd after a busy week in the hospital. Sitting with J&A having way too much coffee, having breakfast, and letting their daughter entertain us. Having a study afternoon with GK at Barnes and Noble. Meeting up randomly at Metro Café, or a drink at The Front Lounge. Ironically, I'm sure that 12 months from now I'll be able to add waking up at S&S's house after a night out having a late dinner (and lots of wine) and then heading out to breakfast at Espresso and watching the crowd.

I loaded up the Bakkie with all my worldly possessions in Jo'burg, and drove down to Mondeor. As I pulled down the driveway, I realized I was home. I was excited to be back in this house. I am excited to be back here in Mondeor.

As I unpacked yesterday, I realized that I'm fortunate enough to have many places which I could call home, but for the next 5 and a half months, this is Home.

200

2009-01-08T12:21:00.001-05:00

Wow. Flooded is the proper term. Waiting rooms overflowing, people sitting out on the lawn outside.

230 patients in clinic yesterday.
210 patients in clinic today.

There are many things I want to jot down, but am a bit short of time right now. And I'm also very sweaty and smelly, and we're going out to dinner soon, so I neet to make myself presentable. I'm sweaty and smelly, by the way, because there is no air conditioning, and when that many people are waiting in a building to be seen, the place gets hot.

I'm going to skip patient stories for now, because they are party composed in my brain, and I'd rather save them for later..

The clinic, has been incredible. Absolutely incredible. Seeing simple clinic visits which can be done in 10-15 minutes, to seeing sick, sick people. Admitted 1 person with an acute-ish abdomen today, but also saw a sick guy yesterday (who I should have just admitted for his work up) but instead did labs on him, and he failed to show up for results today, and based on his labs alone needs to be admitted to work up his multiple abnormalities.. That's on tomorrow's TO DO list, somehow find the sick guy who didn't show up today and get his *ss in the hospital.

I saw my last patient at 5:30 tonight. She arrived at the hospital at about 9 this morning, waited in a queue for a long time to register, and then waited in our clinic for a long time. When it looked like patients weren't going to be seen in time to go get their HIV medicines filled from the HIV pharmacy, they were sent from the clinic with new scripts (and likely waited in line there for well over an hour, maybe 2-3 hours when it was at it's busiest-as there is also pedi HIV clinic so those kids are going for meds today as well) and then back to wait to be seen. But, there were no complaints. Patients were kind and thankful. These docs work incredibly hard, and they just keep picking up charts and seeing patients. It's very rewarding.

As for life...
Sadly will be leaving S&S and moving back into my old place on Saturday. Will be nice to be close to work again, but has been great to stay with them.

Cheers!

BPB

Back to Adult Land, and more..

2009-01-06T10:18:00.001-05:00

It's nice to be back in the land of adult medicine. I feel like part of the team this month. In fact, last friday the clinic director specifically mentioned if I had any ideas on changes that may help their clinic, to please let him know. And then rounding today, when we were at the bedside of the guy with infective endocarditis, (and we were rounding with the microbiologists as well the other ID attendings/consultants) it turns out that just two of them have seen right sided endocarditis from IV drug use before. Now, a couple things to mention. The were still able to quote the current treatment guidelines, discuss the common pathogens, etc etc etc. I point this out because I find it impressive that these guys have seen a case in the past, long ago, but still know current treatment stuff. And secondly, it was odd because I've seen more of this than them. I was slightly jittery when they turned towards me. I had flashbacks to pedi land and was getting ready to brace myself for defending US practices... but rather it was such a pleasant adult conversation about what we do back home in these situations. There were also soooo interested in heroin use, methadone, and these patients back home. They just don't see these patients here. Kind of a cool experience.

I like my ID attending. I think we share a similar practical philosophy. Case in point. We were reviewing bacterial meningitis treatment and outcomes in journal club this afternoon. The attending pulled the articles on the use of steroids in treating bacterial meningitis, and outcomes. The mortality rate at Bara is about 55%. I just throw that out as an aside. So we're reviewing all data, which is somewhat mixed, and tough to interpret. You have to factor in HIV/AIDS. Delayed diagnosis and treatment. Etc etc etc. And whereas the literature may be indicating that the use of steroids does not reduce morbidity/mortality (and there are no harmful effects) my attending says:

". . .when you know that more than half the people are going to die it's tough to follow the advice of these articles and hold off on the steroids, I'l still give them. . ."

Ahhhh. Yes. Thank you. If I have bacterial meningitis (heaven forbid) I'll take the steroids too! We're on the same wave-length. He's a practical clinician.

And typhoid: There is a 14 y/o boy on the adult ward (which is what happens here), how has ben diagnosed w/ typhoid. Which isn't all that common. Was absolutely superb to be at the bedside and hear the ID and Micro attendings give a lecture, at the bedside, about typhoid. It was just superb teaching. And kind of a lucky event since they don't see that much typhoid..

Other stuff of note: One of our attending was the on-call attending yesterday, and did post-call rounds with his ward today. They admitted 135 (ONE HUNDRED AND THIRTY) patients yesterday. Their ward holds 130. It's not worth explaining the logistics. Interns are covering 35 patients.

That's it for now. I'm off to read about Typhoid.
Cheers

ID Rounds

2009-01-05T12:00:00.001-05:00

Keeping this brief (still a bit under the weather-which is perfect for being on the infectious disease rotation)..

I roudned w/ another reg today. We say 20ish patients before meeting w/ the consultan, and then re-rounded on the patients.

TB.
HIV/AIDS.
MAC.
HIV/AIDS.
TB.
HIV/AIDS.
HIV/AIDS.
Possible cholera.
MAC.
IV herion user with right sided endocarditits.

Well of couse all the patients were interesting, but the team was most fascinated with that last one... Here is something they don't see. Infective endocarditits (infection of the valves of the heart) from shooting heroin. In fact, the consultant couldn't really remember the last time he'd seen a case, and the other reg had never seen a case. So it was nice to have a little basis to discuss, and discuss what we did for treatment back in MA.

CD4 counts today:
16, 43, 92, 23, 197...

More soon.

BPB

Shifting Gears

2009-01-02T11:38:00.001-05:00

I asked one silly question today (in the adult ID/HIV clinic), just to prove that I've been in pediatrics for the past 6 months...

"Do we give them written appointment cards?"

I'm so use to the hand-holding of pediatrics... Do everything to ensure that the parent's fully understand treatment plans, and when the next appointments is, checking if they'll be able to afford to make it to the clinic/hospital etc etc etc.. So the prof looked at me with a small smile.

"Nope, their responsibility to keep their appointments."

It was a "light" day in clinic today. Jo'burg is still in holiday mode, and the streets are empty of traffic, and most people have been away from work since mid-december, to return sometime between the 5th, and 15th. A light day... we still saw 100 patients today in the clinic. A light day. I didn't ask what a busy day was going to be like.. but I peeked at the patient list from the 30th, and they saw 160 patients that day. Wow, it's going to be busy. And it's going to be a great month..

Aside from work, have been fighting off germs that I nicely acquired on my last day in Kathmandu. Am on the mend. Am staying with S&S, and then headed back to my old house a week from tomorrow.

Will hopefully have pics up from Nepal over the weekend-need to get somewhere with wifi to upload form my computer. I took about 1140 pics, but have managed to get that number down to 1000. Don't worry, they are not all going up, but you can rest assured that when I see you next I will make you see all 1000!

Hope your 2009 is off to a great start.

BPB

Nepal: Cleaning Up

2008-12-26T04:03:00.001-05:00

I have some time to kill until a friend arrives from Pokhara...

With the lack of hot water (due to no electricity, mostly), I've become quite comfortable not showering every day. I've tossed aside western standards of cleanliness, and don't mind not showering daily, and when active (trekking or bike trip) if I smell, I smell. And since I'm not working, the dirt under my nails doesn't really bother me either.

But for some reason, the unruly hair around the back of my neck was just nagging me. The downfall of having closely shaved hair. [Oh, I shaved my head again in November, which is perfect for traveling]. You can't really shave back there, not without taking a chance and really making a really bad mistake and an erratic mess of a good hair line.

So, after lunch I decided to go get my neck shaved. I figured it would take all of 5 minutes and maybe 100 or 200 rupees... My only hesitation was making sure the blade would be soaking in some cleaning solution... flashbacks to the hepatitis C outbreak among uncleaned razors years ago.

So I popped into a HOLE in the WALL place, for a neck shave. Oh, and just to clarify, it is POURING rain outside. And I've been told all month that it never rains in Nepal in December. So if you think it sounds like an assinine waste of vacation time to get a neck shave, there really isn't much else to do beside drink coffee/tea, read, do email, and get a neck shave.

With bits of gesturing I think I get the point across that I need my neck shaved. So I sit down, and out come the clippers. And while I wouldn't mind a bit taken off the everywhere, I don't want to hassle with that now, I can do that in a week when I am back home in Jo'burg.

So he puts away the clippers, and moistens the hair around my neck and ears. Perfect, I think. I'll back to the coffee shop in 10 minutes, reading, and waiting for Dilip.

But I leave an hour and a half later.

Wow.

So, after a meticulous neck shave (with a new blade on an old style shaver), I got a scalp/head massage. Wow. And I factor in a few more rupees for the bill. And then the power goes out, and a candle is lit. And as the power went out, the rain went from a drizzle to buckets. And I'm dreading heading out in the rain. And I'm really enjoying the scalp massage, and I wonder if I have time to get a real massage (and more rupees flash before my eyes). As I think this, I'm now getting a neck massage, and then find myself leaning over the counter as I get a shoulder and back massage. And the paranoia in me wonders if this guy can read my thoughts (which would be embarrassing, because I'm thinking I wished this massage was coming from somebody younger and cuter). But I digress.

Wow. More rupees flash before my eyes.

It is still pissing rain.

And now I get a facial-massage. This is a bit different, but I'm seriously taking this all in, and can't believe all I thought I would get in this TINY barber shop is a neck shave. Since the moment I arrived (and we made small talk about my trip to nepal and trek etc) he asks if I want my face shaved. Might as well. Though I am afraid, slightly, that he'll shave off the mole on my face and I'll bleed to death here. And of course I freak out forgetting that this guy can read my mind. I go to my buddhist mantra which I've been using since I learned it a month ago. He can read that all he wants.

My face is as smooth as a baby's ass after the shave. I notice he grabs another bottle. And then he paint (literally paints) something on my face, and he shows me and all I recognize is the word sandalwood. I'm cool with that. But I don't know what it is. And I'm unsure if this is some kind of thick aftershave. But he hasn't undraped me, which I know is a universal sign that the business of salon stuff is over.

But now he is cleaning up. And don't forget, there is only a candle lighting the place. So I sit. What the hell, it is STILL raining out.

And that's when I realize I am getting a FACIAL. Whoa! [Bonus points for 'the card']. And now I'm really hoping that I get a manicure as well. The face mask dries, which is a bit of a weird feeling as well. I could get use to this, maybe wake up on saturdays, have porridge, apply face mask, read the paper, then shower?

The face mask is cleaned off. And I get aftershave on the lower portion of my face, and face cream on the upper portion.

And I'm sooo confused. How is it that I have thoroughly enjoyed this long pampering process (and now seem to have radiant skin), but also thoroughly enjoyed being smelly after a day of trekking, or getting to my hotel last night with mud covering various bits after the 40 mile bike ride back to Kathmandu???

I suspect, that in a nice salon, that would have been fifty dollars, maybe more...

Nepal

2008-12-22T00:26:00.002-05:00

I find myself:

-kneeling in front of the Tibetan monk, who gives me a blessing "om mani padne hum" (which roughly implies long life and good luck), while he drapes a special cloth around my neck. He adds in a blessing for good health, every day. It's the every day part which I find touching, and secretly hope that it means I'll have healthy knees.. We finish our conversation about life, politics, and then head out. I still have the cloth.

-In the main part of Pokhara, asking my Nepali friend Dilip to please take me away from the tourist trap of Pokhara. We're eating dinner at a local place. I suspect I'm the only westerner that has been here in a long, long time. But am treated with great service, and a great meal. Dilip kindly leads me. We've ordered a variation of Daal Baat (the normal Nepali rice/lentil/curry meal) and are having Dhido, which is a soft polenta-like mash which is dipped in sauces. I know I'm off the tourist path when I don't automatically get offered silverware. So, I eat with my hands. Which is oddly gratifying. And I'm thinking back to the meal LR and I had at a superb Ethiopian restaurant in NY back in the spring, and thinking that silverware is slightly over-rated.

-Having breakfast with Dilip, watching Pokhara wake up. Shop keepers sweeping the stoops of their doorway. It seems odd that more shops aren't opening. We watch a mob trying to attack a taxi driver, as about 20 police officers show up to recue the taxi driver. It will be the last taxi we see that day... We're planning to head a bit out of town to the Tibetan Refugee center, I want to meet these people. We're also planning on seeing a bit more of the real city. But there are no busses. It's oddly quiet. It takes half an hour to figure out what's going on, and as it turns out, there is a one day strike, called by the students, in protest of something??? We spend the day walking up and down, up and down, up and down, the main tourist road. Having tea. Having coffee. Me trying to learn a bit of Nepalese. Learning about growing up here. Difficulties of daily living. We run into 4 or 5 people I met while trekking. We have dinner with a Danish friend I met, and her guide and her guide's wife and child.

-On the bus. Which is typical of what you expect if you think of the stereotype of what you've heard about if you think of buses in India. Except there are no chickens. I could write a whole blog entry alone on the bus. I marveled at the insanity of how the bus was packed with people, mixed with slight waves of anxiety thinking that if the bus crashed, it would be damn near impossible to get out easily. (and buses crash regularly). The bus ride is 17 hours, overnight to Bardia National Park.

-On a stopped bus, at 10pm. On the middle of the major east-west highway. I don't know why we stopped. I kind of don't mind, since it's likely more safe to be stopped at night. A fight breaks out on the bus (while we sit idle) at about 1am. I wonder why we're still stopped. The older women pray. But most people don't seem to care. The police show up. It's dark outside, and I can't see much. It's 8am, we're still not moving. I get out of the bus and se buses lined up and down the road. Seems odd, so finally I enquire. An unannounced strike has been called. the 17 hour bus ride has now been delayed 10 hours. We leave an hour later.

-On a Jungle Safari with Santa. I kid you not. Christmas is the furthest thing from my mind, given that I'm in a hindu/buddhist country, no signs of xmas, and no snow. It could be July for all I know. but meeting my guide, and learning his name is Santa (I asked twice) makes me realize that is is towards the end of December, and xmas is getting close. The Jungle is wet this am from all the dew. I get soaked. It's great fun, just me and Santa, tracking a rhino. I'm informed: If a rhino charges, climb a tree, if an elephant charges, run in a zig-zag. Santa doesn't mention what to do if bengal tiger charges. I'm putting all my faith that Santa will be able to beat the tiger with his walking stick. He has no gun. I think back to having been blessed recently for long life, and good luck. That must count for something. We do end up finding a rhino and an elephant. The tiger remains elusive.

-Riding an elephant through the jungle. Crashing through the underbrush. On the elephant as it pushes over trees in the way. That's impressive.

-On a raft trip. Ok, more like a float trip. But we are on a raft. It's fucking cold. cold cold cold.

-Sitting at dinner, drinking beer with Santa, and the other guides in the lodge. I'm hearing stories of what it was like when the Maoists troubles were going on. Bomb attacks. Constant harassment by the police, the army, the Maoists. Not knowing if the lodge would be bombed. Bad times. I read in the paper that 170 people are still missing from the area, all suspected to be dead, but nobody telling where the bodies are located.

-At the "Exact Spot" where Gautama Siddharta Buddha was born. Before he became enlightened and started buddhism. Being the skeptic, I look for signs of this. Maybe some amniotic fluid splash marks? Maybe the placenta? I was annoyed so I didn't pay the dollar equivalent to take photos there, and not it seems stupid to have balked over a dollar. Lumbini is the birthplace of Buddha. And it's not at all inspiring or peaceful. I've already booked to leave the following morning.

-Back in Kathmandu. 3 days earlier than planned. My hotel costs US$ 4 a night. You get what you pay for. :)

-Shocked that the price of a life is 17,000 Nepali Rupees. With is about US$ 250. This is the price a taxi driver has to pay to the family if he kills somebody.

I am booking a bike trip for the next 3 days, so will head out tomorrow on a bike trip for a few days. Then will be back here to finish exploring Kathmandu for a few days before heading back to warm Jo'burg.

From Nepal, I wish you a very happy and healthy holiday season, and a great 2009.

Brian

Nepal: More Random

2008-12-13T22:14:00.001-05:00

Ok-maybe I've been a bit harsh.. I know why there are so many westerners camped out here.. It's freaking cheap. My hotel is about US$ 4 a night, and it is entirely possible to eat for as little as US$ 5 a day. And it's beautiful. So the chance to sit, sleep, eat, and read and meditate, do yoga, walk around is pretty alluring. Could you imagine if Aspen, or Vail, or Breck were this cheap.. the same crown would flock there. What I'm not that travel crowd.. I want to be somewhere with authentic culture, not a cheap tourist trap... Thankfully, a Nepali friend is going to take me off the tourist track for this afternoon, and tomorrow. Really interesting guy who grew up in a village 100 miles away but moved away from home and has lived here for many years. We're going to hit up the main part of Pokara, see a Tibetan refugee centre, and some other local stuff not in the Lonely Planet guide...

Power Cuts: The power is off from 6-9 am and 6-9 pm. So I'm in an internet cafe this am which is power by generator. I ate dinner last night by a fire, and breakfast this am in the cold. Having gotten up at 6am for the past week +, I woke up at my normal trail time and headed out to watch the city wake up. It's peaceful walking down a street where the shops are open, there are no lights except for the natural light...

Supporting the Locals... It is really tempting to BUY BUY BUY. stuff is sooo cheap. The main tourist season is in Oct and Nov, and you can feel the slowness in the shops, and the eagerness of the shopowners to sell. I'm on a bit of a mission today to find a better way to support the local economy than to buy buy buy..

This was my schedule for 8 days.
6:00 wake up
6:30 get the courage to get out of my warm sleeping bag
7:00 Breakfast/page
8:00 On the trail
2-4 pm: arrive at lodge, shower (ideally), wash clothes
6pm eat
6-9 Chat with other trekkers in the lodge
9pm get into sleeping bag, read or listen to ipod
9:15 asleep.

Anyway.. This will be the last blog post for a bit.

BPB