Cold Winter's Night

Yikes, it is freezing out.

 

It's actually felt like a cold Dublin day today. Had that grey hanging cloud cover that never left, a bone-chilling cold, and some mist in the air. It was really, really slow so I actually left at about 5pm. (We're on-call tonight). There were 4 SHOs on, now that one of the others is back from vacation. So not much to do. We'd only had 4 admission by the time I left..

 

Anyway, we're rounding at 6:30 AM on the old patients (SIX THIRTY AM) and then 7:30 on the admissions from call. This seems a bit cruel, but it means we'll get out earlier tomorrow.

 

I'm going to pour another glass of wine and read a bit more of Eat, Pray, Love. Which, I must add, is turning out to be a fantastic book. Let me add one last thing. Today it dawned on my that I paid 148 ZAR for the paperback version of this book. At about 7 Rand to the dollar, it works out to be a bit ridiculous for the price of a paperback. I'll add, that the reason to read more was to find something to occupy me so I wouldn't be wasting so much money elsewhere.. Hmmm. I may have to search for a used book store, or one of those places where you go and get books and then give them back.. What're they called again? Libraries?

 

g'night

EBM is bullshit, part 2

I've called this EBM is bullshit part 2, because I've lamented both personally and via email to many about how much I have come to hate EBM. Evidence-Based Medicine.

 

I find it tedious when rounding back home to discuss which drug, if used in 1.5 billion people is likely to save an additional 3 lives, and was the study well designed, blah blah blah. Let me puke. This doesn't mean I don't practice EBM. I want to be a good doc, so I'll look up the most recent study to see which drug/treatment/witch-doctor potion is best for "X" condition. But I'll also adapt a herd mentality, and do what my colleagues do, and more importantly, what the insurance will pay for... (No use prescribing a novel drug is it cost too much for people to afford).

 

There is nothing sexy about the mental masturbation of EBM... There isn't really much sex in medicine, contrary to what the TV shows portray. What is sexy though, is when on rounds, the pathophysiology of a condition is explained, when parallels are drawn to other diseases, then the lab results etc are correlated with what's happening at a cellular/tissue level. We're talking medicine in a bikini or thong sexy here. (Aside: Medicine seems to have a lower population of people who would look great in a bikini or thong. There's some irony to that).

 

I have visions of rounding back in the US were we all pull out our tools (palm pilots!), somebody gets on-line and we debate if 1 or 2 mg/kilogram of prednisone is best for the treatment of a pedi asthma exacerbation (who fucking cares cause the kid will likely spit out part of it, part of it will spill when the jar is opened, and it'll be forgotten on 2 days)...

 

Rounding here, there's no debate on this crap, there's discussion of why thy kid with nephrotic syndrome has an elevated ESR... (GROAN-what's the evidence behind the usefulness of ESR in the diagnosis of Nephrotic Syndrome-I can HEAR that question being asked by EBM Fans)... There's a 20 minute discussion of using the history to help figure out if an infant with jaundice has a pre-hepatic, intra-hepatic, or post-hepatic problem, and a conversation of what on the clinical exam will rule-in, or rule-out which congenital infection!

 

Don't get me totally wrong, I am fully aware of the utility of EBM in advancing medicine, but sometimes I just have to think that it's at the expense of the sexy part of medicine...

3 Deaths.

This morning as I made a run for coffee, I saw the Cuban surgeon who evaluated the child who I thought may have had intussusception. And I asked him about how's the child was doing.

Dead.

Sadly, he did prove to have an intussusception, and in to the operating room, they found dead bowel. The child made it to the ICU, but they were unable to maintain a blood pressure for long. This is the third child to die, or we seem to be averaging about one a call.

I also realized that the child who was in liver failure from suspected Reye's syndrome, had also died.

A couple of days ago, I overheard they few of the pediatric residents talking about the number of deaths from last month, and I don't recall the exact number, but I do recall one of the residents saying "well, you're under 10%." As if 10% were of the upper limits of acceptability. And I hope to point out that this reflects not only to the limitations of services, but also the severity of illness that is seen at the hospital. I highly doubt that the child with intussusception would have survived back home, and he came to the hospital so late.

On Fridays, the head Professor of the pediatric department rounds with the team that is on call on Saturday. Which means that the prof rounded with us today. We made a run through the ward and reviewed some of the unique admissions. It was phenomenal teaching. I was slightly apprehensive that this was going to be another pimping session, and was afraid of coming up with blank answers, but instead it was more of a guided tutorial at the bedside. This is how teaching should be. So we rounded on about six or seven patients with the prof, and there was much to discuss. The depth of knowledge of the prof was fairly impressive.

I diuresed my patient list today.... both Baby S and baby T. were discharged. Fingers crossed, and that we continue to get some adequate nutrition and gain weight. Baby T. is moving out of the area, and I am actually a little afraid that his mom won't follow through on getting him care for his HIV status.

As for follow up, our boy to was admitted with bilharzia continues to have bloody urine, and has failed his first treatment course of which apparently is not usual.

A, my 2 1/2 year old who has right-sided heart failure from an obstructed airway... I spoke to the ENT doctor today and explain the story, and apparently they will see the child in clinic on Monday. He was at least interested in seeing the kid, and his initial thought was that he will have to schedule the child to have his tonsils and adenoids removed.

And the and shocker this morning was going through results and finding out that baby M is actually HIV negative. He is the child who is six months old and has failed to meet most of his developmental milestones, and came in with failure to thrive. It was assumed that his neurological status was due to his HIV disease. His mom was tested on admission, and she tested positive so he preliminarily was considered positive as well based on his clinical picture. (He had other stigmata of HIV disease). Ironically, when I admitted him, his hypertonia and overall condition let me to think that he probably had cerebral palsy. And now that he has ruled out for HIV with a negative PCR, he probably does have cerebral palsy. Thankfully, the occupational and physical and speech therapists have had time to work with the mom and have made a little bit of progress, as well as to get him set up for outpatient care.

.

Sex and the City

I've mentioned a bit, that I feel like I'm living in a monastic life. I go to work, pop by the gym, then come home and read. Aside from chanting and eating by candle light (and no brown robe), I feel a bit monkish.

 

That's not really a bad thing. But I have been feeling a bit stir crazy.

 

I went to Pretoria today to haggle with the medicine board to give me my damn license, which finally happened (after being up there for 4 hours) and decided to avoid the rush hour traffic and stopped off in town to see Sex and the City. FINALLY. Of course I loved it. Sadly there were only 4 of us in the theatre. It was a nice escape, and for a while I completely forgot about the day-to-day stuff that has been occupying my mind. And I realized that I've settled into this different pattern here. I'm kind of enjoying the simplicity of the day-to-day life. There is also something else different about knowing that I'm here for just a year. Before coming here, a year seemed soooo LONG. But really, I think the time is going to fly by. When I moved to Dublin and Western Mass, I had remember having goals of having a great social life, creating a great group of friends, etc etc etc. But this time, there that drive isn't so strong... I suspect I will make a few good friends in the year, but I'll leave it up to fate, not going to go out looking for these things.

Before the movie, I walked around the mall (which is boring when one doesn't have an income and every expense is calculated), and decided that I was going to get caught up on some pleasure reading. I need some balance, and can already feel a bit of medical fatigue with the amount of medical reading I've been doing each night. Also, I've burned through a lot of internet time (300MB a month) and when I logged off this morning realized that I had already spent 16 hours on-line since June 23. There are so many more productive things to have done w/ those 16 hours.  So I picked up "Eat, Pray, Love," which was recommended by Randall back in February...

 

I'm not sure where this post is headed, but I'm going to try and close the loop.

 

I read a few pages while waiting for the movie to start. The introduction got me excited, thinking that I'm doing a similar task... Taking a year off and learning. Learning more medicine. But learning about what makes me tick. Feeling much different with this move, than moves in the past. [Aside: some people object to me calling this a year off, given that I'm working quite a bit, but to me it is a year off for many reasons]. Part of me wonders if I really am as mobile as I think. Am I really cut out for traveling and working? Or am I more a homebody and looking to settle in Denver? The answers that I thought I knew a few weeks ago are blurred now. Last night I was thinking about applying for a post-residency spot working w/ a pediatric HIV/AIDS program run out of Baylor which places pediatricians in Lesotho, Swaziland, and a few other countries, and what an amazing year that would be (and that is a paid job).

 

And then I find myself watching Sex and the City. Clips from New York, and thinking of the great trips I've had there over the past year, the friends who drove me there 3 weeks ago [and saw me off at the airport], and then the pendulum swings.

 

This is what I know. It's late, and I'm going to bed. Tomorrow I may strike off at night and head into town to check out the Craic (google it, it's an Irish word), or I may come home and bounce between reading about travels, or traveler's diarrhea and other infections.

 

 

 

In Another World

It started off as one of those days... We're post-intake (call) and so I got to work early so I could round on my old patients, before we did the post-call round and saw all of the new patients.

There were 25 admissions yesterday.

 

Kiddo A: my 2 and a half year old who has cor pulmonale (heart failure from a non-cardiac cause) has gotten better w/ diuresis, but it is now PAINFULLY obvious that the problem is that the kid needs his tonsils and adenoids out. The cardiologists signed off after they did their echo. Apparently the kid needs a neck xray before the ENT docs will see him. And I fucked up and wrote his name on the wrong list so it didn't get done yesterday!! Argh, wasn't too thrilled to figure that one out this am. Hospital day # 10 for this kid. So, he finally got the xray this am, and I asked about getting the ENT docs consulted. To which I hear I need to get the radiologist to read the xray. Well, at 3pm when all the other urgent stuff has been done, I enquire about getting the xray read, to find out that it has to be read earlier in the day, that they are gone by this time. And, then my coworker guestimates that it could be months before he goes to surgery...

 

Kiddo K: Day of life #70, born with transposition of the great vessels, with NO shunt who was admitted with sats in the 30s (who knew that was compatible with life), and eventually had an atrial septostomy, and I've been caring for him for almost a week now. We're waiting to make sure the kid gains some weight and to get the cardiologists final blessings before sending him back to his home hospital. Yesterday, we tried a trial off oxygen. He failed. Back to a sat of 30. (his goal is >70). So back on oxygen he went. This am, the oxygen mask is (no nasal prongs his size) hanging close to his air passages, and sats are 60...  

 

Kiddo K: a cool 3.5 y/o who has some congenital renal/bladder issues (history of posterior urethral valves) who has been in the hospital for a week. Reasons not worth going into. Who I couldn't FIND this am. Don't get me wrong, this happens back home often w/ medicine patients, but not w/ kids. He'd been in isolation on another ward, but we were taking care of him, and he was due to be transferred back to our ward... So, after walking between the wards twice, and looking for the familiar face (and he's a cutie!), I gave up and decided to ask the nursing staff... but, and this is a great part of the day: It was the time of the day where the nurses start their shift with singing. There is no interrupting the am ritual of morning song, and no interrupting morning report (which lasts for an hour). I figure that at some point, the kid will appear (I don't even think the kid should be in the hospital, and I make a mental note to see him before I leave).

 

So, needless to say, it was a bit frustrating this morning.

 

But,  there were some really good things about this morning as well. Some of the kids that I have been taking care of for the past week are starting to look much better. Baby S and baby T are both starting to put on a little bit of weight, and are even starting to show a bit of personality. They look much different than when they were admitted a week ago. Instead of examining them from head to toe each morning and a looking for new problems, instead I enjoy picking them up and examining them while I carry them around. In some ways, it feels like a leap of faith to let them leave the ward, which will hopefully happen in a few days.

 

We eventually got around to starting our post-intake ward around, and again, we hit almost every chapter of a peds  textbook (there was no cardiology stuff today). Some notes I made during rounds.

 

1-We're taking care of an infant who is in acute liver failure. The reason is not entirely clear. The best working etiology is that we are seeing another possible case of Reye's Syndrome. There was debate on the ward round as to whether this kid was a candidate for intubation and for the intensive care unit. After some lengthy debate, the child was intubated after discussing w/ the ICU if there would be room for him.

 

2-We admitted two children with diabetic ketoacidosis, both are new onset. It was oddly refreshing to see a medical condition which I feel fairly comfortable with. However, I realized that my usual management was a bit different. Whereas, one of the new onset kids was in mild DKA, and could have been managed with subcutaneous insulin, both were managed with IV insulin coverage. I was also curious to see what kind of insulin regimen these children would to go out on. It looks like we will be covered on three times daily regular insulin and then intermediate insulin at 10 p.m.

 

3-We had another organic phosphate poisoning. We seem to be averaging about one on each call.

 

4-I admitted a three-month old who has been jaundiced since birth. This is the first admission for this condition for this child. I can't quite piece together all the details, but apparently when the child went for immunizations yesterday, the general practitioner noticed the jaundiced and referred the child to us. I am not sure how the jaundice was not noticed during the previous immunization visits. The working diagnosis is some form of biliary atresia. However, just before leaving, the CMV came back w/ positive IgG and IgM... perhaps this is fallout from congenital CMV?? I need to read up on that tonight.

 

5-Mumps: We admitted a child with mumps as well last night. However this is not just simple mumps. This child also has bilateral ear infections, is malnourished, and likely has HIV +/- TB.

 

6-Congenital Myopathy?? We rounded on a new three-month old who is admitted for hypotonia. We're talking flaccid like a rag doll. And she's been this way since birth.

 

7-Pneumococcal pneumonia...

 

8-Hep A: were seeing a three-year-old who was diagnosed with hepatitis A a few weeks ago. However she is having worsening jaundiced and appears to be going into liver failure.

 

So, it is quite a busy service....

 

I kept a list of things to read up on tonight, but it is too extensive to hit all the topics.

 

 

Intake

We were on intake (aka call) Friday night. Basically 24 hour admissions, and it was a light call with only 16 admission or so. The process goes something like this: Kids with medical problems are seen in POPD (Pedi Outpatient Department-AKA pedi ER) unless they are a trauma, in which case they are seen in the trauma unit (flashbacks to 2003). They docs in POPD do their stuff, and it seems like kids can be there for a while.. initial hydration attempts, maybe x-rays (not usually labs). If it looks like they are going to need admission, they are shipped over to the Admission Ward (Ward 36). This to me is brilliant!

 

Once we'd finished most of the days chores, the team essentially splits up. Some in our ward, and then the others headed to the admission ward. The ward is half admission, and half "High Care" Like a step down Pedi ICU. Though, that being said kids in high care may be vented, and waiting to get in the combined adult-pedi ICU. Admissions are split up, histories taken, x-rays done, labs done, etc etc etc. 

 

[reflections back home: I've often thought this is how our medicine service should be run. If they obviously looks sick, and are stable, the IM residents should do the bulk of the work up and initial management. ED decisions seem to often function at the brain stem level, not the cortical level. Sick lefts just pick 2 random antibiotics and give them, who cares about cultures before abx etc.. I digress]

 

Random pts from intake (not mine, but since admissions are a team sport you basically see all the kids).

 

An 8 month old sent in for question of gastro. The strikingly obvious thing was that his belly was HUGELY distended. You could almost make out the loops of bowel pressing on the skin. Shit, this is not gastro... Someone asks-Ileus? Maybe. We're doing IVs and blood on the kid, and he doesn't even flinch. The red flags are literally dropping from the ceiling that there is something really, really wrong here. I'm having a slight bit of anxiety at this stage cause I'm banking that this kid has intussusception! (Some know my intussusception stories from back home, so I always hesitate to bring up the I-word). This kid is not an ileus, he's gotta be full on obstruction. We get the abd x-ray, sure enough huge fluid levels, totally obstructed. Incidentally, the kid did have a CXR in POPD, which we saw after the abd x-ray, and even on the CXR you could see fluid levels. Pedi Surgeon (super guy from Cuba) comes over, he's pretty sure it's intussusception, and likely bowel necrosis by this point, and is going to get an  ultrasound. Now, even during normal business hours, getting an urgent ultrasound is a bit of a challenge... All I know is the kid went to surgery for likely intussusception. No idea how he did.

 

4 month old comes in with a sat in the 70s.... Blue. Supplemental oxygen and admit to the ward.

 

11 y/o boy admitted with Bilharzia. (Google or wiki it). Bilharzia! Looked at his urine under the microscope and boom-diagnosis made. That's good stuff.

 

I like the team sport feel to admissions. Nice to have everybody there, a procedure room-do bloods, lumbar puncture (spinal tap), and IV in one swoop.

 

When the kids are transferred to the ward. The sisters (nurses) wait until there are 3 or 4 who are ready to go, and regardless of the age they are placed on one of the famous red gurneys and covered with a blanket. A strap is placed across them to keep them from rolling off. I saw 3 infants and an 8 yr old on the same gurney.

 

Compare...

Two babies. Infants really, but they are so tiny I think of them am newborns. I've been taking care of them all week.

 

Baby S. Is 8 months old. He weighs 5 kilograms (11 Lbs). Pathetic is the word that best describes him.  He came in with vomiting, diarrhea, having been given some muti (spelling?)- or traditional meds. He is the definition of a marasmic kwash. He is wasted in size, and also edematous. He has strep viridians growing in his blood culture, and e coli in his urine culture. His lips are cracked and peeling, his perineum (the part that sits in a bike seat) is also excoriated, and raw. It's painful to look at. He usually stares off into space. He makes an attempts at a cry when examined. Again, he is 8 months old. He doesn't sit up. He doesn't roll over.  His mom is HIV +.

 

Baby T is 4 months old. He weighs 5 kilograms (11 Lbs). He came in with one week of gastro (vomiting, diarrhea). He was acidotic and ill appearing on admission, required aggressive fluids. He doesn't have anything growing in his cultures. He isn't marasmic, or kwashiorkor. His mom is HIV +

 

Baby S should weight 8 kg/17 lbs

Baby T should weight 6.5 kg/15 lbs

 

Both have gotten better as the week has gone on, both are off of IV fluids, taking in formula, and even have gained some weights. Both have been tested for HIV. It's been tough to think of HIV status as another label for all of these kids. I sometimes just think that all of the kids are HIV positive, they look so small and sick, it's hard for me to grasp that this can be the sole result of not getting enough nutrition.

 

Enough nutrition. This hasn't really been a problem in my training thus far. And, in fact, we deal with TOO much nutrition. We have a "chunky" baby who looks like a normal baby to me. But this kid looks chunky here. The other day as we were doing bloods and IVs, I tried to explain how we have to counsel parents on LIMITING junk food, eating veggies etc.

 

So there are all these new factors to deal with. HIV status. Nutrition status. I've been trying to link HIV status with overall appearance. Like, if an infant has TB, then that kid must have HIV as well??

 

And this week I learned that you can't tell.

 

Baby S is HIV negative.

Baby T is HIV positive.

 

The only way to tell is to test.

Not For

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

 

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

 

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

 

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

 

The kid is no longer "not for."

 

 

 

 

Square One, and Hiearachy

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

First Day

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Cheers.

Driving "home" with Cat Stevens

Today has been a lighter studying day, after days of cramming, my brain was feeling saturated. So I headed off to one of the larger malls, with the goal of hitting larger book store to find a better Jo'burg guide. (no luck). What I did find, though, was that Sex and the City was playing, which is quite a relief, since I want to catch it in the theatre..

It was a beautiful day today, in fact quite a few people in shorts here. (Don't forget it's winter here, we're far south, and high in elevation-it gets cold). I started to make my way home, kind of thinking that this is the evening best suited for meeting with friends and laughing and enjoying a beer. Though, I don't know where I'd go for a beer, and I be going out solo. A moment to discuss the sunsets, which have been spectacular. I don't know if it's the winter sun, or what, but the way the light strikes the buidlings and surrouunding hills, the area lights up in this golden and then amber color, and it's beautiful.. I got home, thinking about the topics I have to review tonight, and deicded to pop on some Cat Stevens while eating dinner (thank god for itunes and having my entire music collection here-though that being said I have been listening to a lot of local talk radio-fascinating stuff w/ the SNAFU in Zimbabwe).

And Cat Stevens started to sing "On the Road to Find Out." A song I know word-for-word, as it's been very practical at other times in life. Fitting that it should come up now.

--On the Road to Find Out-- Cat Stevens
Well I left my happy home to see what I could find out
I left my folk and friends with the aim to clear my mind out

Well I hit the rowdy road and many kinds I met there
Many stories told me of the way to get there

So on and on I go, the seconds tick the time out
There's so much left to know, and I'm on the road to findout

Well in the end I'll know, but on the way I wonder
Through descending snow, and through the frost and thunder

I listen to the wind come howl, telling me I have to hurry
I listen to the robin's song saying not to worry

So on and on I go, the seconds tick the time out
There's so much left to know, and I'm on the road to findout

Then I found myself alone, hopin' someone would miss me
Thinking about my home, and the last woman to kiss me, kiss me

But sometimes you have to moan when nothing seems to suit ya
But nevertheless you know you're locked towards the future

So on and on you go, the seconds tick the time out
There's so much left to know, and I'm on the road to findout

Then I found my head one day when I wasn't even trying
And here I have to say, 'cause there is no use in lying, lying

Yes the answer lies within, so why not take a look now?
Kick out the devil's sin, pick up, pick up a good book now

I'd suggest listening to some Cat Stevens.. I'm way over my internet allotment for today (10MB daily). Tomorrow is Sunday, and it'll be the final day to get some preparation done. It's like before the first day of kindergarten all over again. I'm going to drive to work and make sure I know where to go. I'm going to lay out my clothes before bed. I'm going to make sure my stethoscope works (kidding).

Man, I feel damn lucky to be able to do this!

Cops vs Cops in Shootout

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

 

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

 

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

 

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

 

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

 

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

 

Cheers

 

 

Take your phone-in case you get mugged

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

I'm sure I'll be sore tomorrow.  

 

 

 

 

Hats off to Bank of America

Hats off to Bank of America, for shutting off my cards after only one day! Thanks for the hassle of trying to get them back on. Oh so thankful for having good enough credit to have 2 credit cards. And yes, I did call them and tell them I was MOVING to SA, but that doesn't seem to have helped the situation. Bastards.

 

Wasn't planning on using this credit card anyway. Capital One doesn't have a fee for foreign transactions, but that card never arrived in West Springfield, and is presently being shipped this way...

 

 

 

 

Mantra

The mantra for today: "Stay Left."

 

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

 

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

 

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

 

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

 

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

 

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

 

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

I'm in the airport at Abu Dhabi, and I'm TIRED! I managed to watch 3 movies. Etihad is a great airline. 74 movies to choose from. I have only slept in scattered 2-3 hours allotments the past few days..

 

Fri night was a nice round of sendoff drink w/ friends at my favorite restaurant:

http://picasaweb.google.com/brianpatrickbost/SendOffDrinks

 

Then Karin, Ted, Jackie, and Elsa drove me to NYC, where we crashed on Lucia's floor, arriving about 2:15 am. Lucia and I went for a nice morning stroll about 6am, and then it was off to the airport. It was nice to have the gang along for moral support.

 

I'm not sure the balance of this blog/website and my Bara blog/website (notesfrombara.blogspot.com), but I'd check both of them. I may at times post to both, and may at times just post the more personal stuff here.

 

Cheers,

 

 

 

 

Failure of Ownership

In adult medicine, we talk about ownership. Of patients. Ownership of patients. Who "owns" the patient. A term which we use to bring a sense of personal responsibility to taking care of our patients.

 

On Friday, as I was sitting at the pedi graduation party, there was a comment made about how taking care of children is a special privilege and that children are the most important thing in the world to their parents, so when we take care of kids, we should not go about our job lightly.

 

To me, these are the same issues-presented in different contexts. It's about realizing the significant role we play in the lives of others, and the responsibility we have to provide the best care to those whom we serve.

 

I strongly believe in taking full responsibility for patients.

 

Patients

in

the

hospital.

 

At 4:30pm I logged on to the computer, and a message popped up. In my mind I was already out the door, trying to figure out where I was going to go get my haircut. But I had 2 orders to enter, and when I logged on, I noticed I had an inbox message. I let out a groan, assuming this was yet another medication refill request, and debated leaving it til tomorrow.

 

But the Aquarian curiosity got the best of me and so I opened the message.

 

RT was in the ER. And then things ground to a halt.

 

Four hours earlier, I had gotten word that RT was going through hell. His mom had called because she was very concerned about him. I had never met RT, but I am his Primary Care Physician. For over a year, I have been his PCP. And I have never met him, and now he is in crisis, in the ER, and I am his doctor-but only for 4 more days and what the hell do I do???

 

I believe in ownership.

 

He came to the ED because when I heard what had happened that nauseated-gut-wrenching-ill-feeling hit me, and I I was bound and determined to help my patient. At some point, a paternalistic-physician mentality takes over, and there is an outreaching to help. It's the core value of my profession. I scrambled to figure out who would be able to track down RT and make sure he ok.

 

I found him in the ED. It was easy. His bloodshot eyes showed the strain of days of tears.

 

I introduced myself.

 

"You're my doctor." He looked surprised to see me. Which was fair.

"Yes, I am. We've never met. But I know who you are, and what's been going on, and I came to meet you personally, at last."

 

I'm here because of guilt. I don't take ownership of all my patients in clinic. There are ones I know well, and I think I take ownership of them. But there are many, many more I don't know well, who I may see once a year, or have maybe met once or twice in 3 years. And there are those who are "assigned to me," and quite frankly, I don't have any clue who they are. RT and his partner (JT) were assigned to me over a year ago, but I have never met them; their infectious disease doc managed most of their needs. Managed their ID needs. But as their PCP, I am responsible for managing their health, which includes their mental health. And knowing that JT committed suicide a few days ago leaves me feeling like I failed to live up to "ownership." RT and JT were assigned to me for a reason, and knowing that I did not live up to my own standard of taking special care of, and interest in my gay male peers compounds this feeling of failure.

 

And there I sit looking at a broken soul.

 

We talk. There is a total lack of privacy sitting in the hallway of the ER, but oddly the rest of the world seems to go silent as we talk. 

 

I have gone into denial about what will happen when I am gone from the clinic for a year. I don't ask what will happen to my patients. I have taken a leap of faith that somehow "The System" will work and that my patients-those who I own, and those who are assigned to me-will be provided for in the year to come. But sitting, talking to RT, I realize that blind faith is a lousy plan.

 

I tell RT how he can get in touch with me, day or night. Fuck the system.

 

Today is a failure of patient ownership.

 

I know full well that the events that have happened were going to occur regardless of if I had ever met JT, but today serves as a reminder that I have a cadre of patients, whom I can serve better than my co-residents, and that ownership should extend equally to the outpatient world.

 

Final Week

Hard to believe that this is the final week at work, and then flying out on Saturday.
 
It was a whirlwind weekend with Heather flying in from Tacoma on Friday.
 
The two big highlights from the weekend was going to Dave Matthews concert on Sat night (thanks to heather), and seeing a great show. I'm sold. And then yesterday was the baptism for Ian and Emily, followed by a great party at Karin's.
 
Am working on the final to-do list, and I think for every one thing that I cross off, two more go on the list. Have yet to find a converter for SA, but suspect I can get one at JFK or in Abu Dhabi... Having a packing fiesta tonight, have enlisted a fellow glove setter to help with the final prep.
 
Cheers!
 
 

Reality...

Has set it.

 

It is crunch time. And I feel it.

 

The 2 week mark is here, and all of a sudden there is this overwhelming desire to try and do about a hundred things at once.

 

I've had many great attempts recently to jot down a few thoughts, but when I sit down to write, I get distracted by other tasks that feel more pressing.

Northern Exposure

Last night was extraordinarily painful at work. Part of the pain is that the fun of doing night admissions is long gone. Scrap that previous post of thinking the life of a nocturist would be enjoyable. Working the night shift, doing admissions and cross-cover is not as fulfilling as it had seemed. On top of that, the night float team works with everybody. So part of the lack of joy is having to clean up other people's messes. Kind of scary really. ER doing half-ass work ups for people who need to be admitted (if I see one more patient to be admitted with a blood pressure in the 200s!!! I may go on a rampage). Medicine residents doing half-assed job of tucking in patients at night so they can get out right at sign out time. Attendings doing a half-assed job supervising residents. I do like the autonomy of working solo at night, but picking up the slack takes a toll.. .

 

There were a string of shitty events last night, so that when this morning rolled around, I couldn't wait to escape from the world. Sadly, the residents were 20 minutes late to relieve us this morning (it's becoming the norm), and then I had a dentist appt.

 

I needed mountain air and solitude.

 

I slept about 2 hours (post dentist, which was nice because then I could feel my mouth and suck on my platypus bag when hiking), and then made a break for the hills. I can't use the term mountains, they really are hills. That being said, the towns leading up to my usual trail head are really cool. The kind of remind me of Colorado Mtn Towns.

 

Had I had my daypack already packed when I got off of work, I would have just left after work and slept on the way when I got tired, or slept at the trailhead, or slept while hiking. It was a PERFECT hiking day. Cool, in the 60s, cloudless beautiful blue sky. Part of me wished that I had my overnight pack instead of the day pack, and I'd be out under the stars right now..

 

Lots of random thoughts came and went during the 5 hours I was hiking. I kept thinking it's a damn shame to not be getting out hiking more. I realized I was wishing that some day (maybe on return in a year) I just keep a day pack and overnight pack in the jeep, and make use of getting to the hills as much as possible. Which lead to the thought that I wished I lived somewhere that had lots of desirable hills to go hiking in.. which lead me to think about where I would want to work, which lead me to think about small mountain towns in Colorado (but obviously towns with hospitals) which made me think about this rural loan repayment program in Colorado, which after damn near tripping on a rock reminded me I was actually hiking not day-dreaming about my future life, and then thoughts of Northern Exposure popped into my head. And I thought back to the time when I thought I'd grow up to be Dr Joel Fleishman working in some small mountain community. 

 

So, I made a mental list of what I want to do once I'm out of residency. These are in no order.

-Himalayan Base camp doctor

-Colorado mountain town doc, in oh say Telluride (aside from the lack of hospital)

-Med-Peds hospitalist at DG

-Cruise Ship doctor

-Repeated stints w/ MSF (aka Doctors w/o Borders)

-Be employed by WHO/UNICEF

-Take a tropical medicine course

-Spend time doing locum tenems

-Work 6-9 months a year in the US, and 3-6 months a year abroad

 

Seriously, I have not a clue what the hell I'll be doing, or where I'll be doing it.

 

It's probably a good thing I have an extra year to think about it.

 

So, back to the hike. I stopped in one of the small towns, picked up a bagel sandwich and a cold beer, and found myself enjoying dinner sitting on a rock, in the middle of a large stream, staring up at a waterfall. And all of a sudden, the bullshit of work was the furthest thing from my mind... 

 

Maybe I should keep the packs in my car...

 

[And for the record, in 1993 on a road trip, we went through the town of Roslyn's, WA where Northern Exposure was filmed, and watched then film part of an episode, as well as walk in the gift shop where you could buy, among other things, part of the piano which was flung!). Oh yeah, I was addicted to that show..

Party Antics..

Just keep this in mind while you view the following.. I was S-O-B-E-R when these were taken.. One of the pedi attendings had an annual party, and it was kind of fizzing, so "The Other Brian" and I tried to liven up the place...

Full Circle

Friday night I went to NY to hang out with Lucia. Sitting in the back of Queen of Sheeba, an excellent Ethiopian restaurant in the city, we discussed my impending departure.

 

It was 11 months ago, and we were sitting outside another restaurant when I first proposed this idea to go to Bara for a year. And now, it is a reality, and in 4 weeks I'll be arriving in Jo'burg. With some minor pre-departure jitters (or due to voluminous coffee required to stay up post-call) we discussed what a great opportunity this is going to be. It was also helpful to ask some last minute technical details, related to where I'm going to live and getting around the city. When Lucia went to Bara, she actually stayed where I'll be staying...

 

In some ways, it seems like there is still a lot to get done in the next few weeks. A few boxes of stuff to go through. Trying to read up on some pedi topics. Lots of people to see. I suspect that what'll happen is stuff to sort through will simply end up in storage, unsorted, pedi topics won't get reviewed, and I'll be on the plane thinking of the people that I didn't really get to hang out with before departing..

 

It's all good.

Getting Sued

This afternoon, in clinic, a patient handed me a crumpled business card of a lawyer, and he said he was suing me.

 

Ironically, this was the highlight of my afternoon.

 

I hesitate to write here how much I loathe clinic. I fear that there is some eager medical student who wants to go into med-peds and will Google and somehow come across my blog, read about how much I loathe clinic, feel it is a reflection of our program, word gets back to my boss, and then it gets all weird. If you're that person reading here, email me and we'll talk in private. Suffice to say I highly doubt I will ever practice outpatient adult primary care. Pediatric primary care, sure. Adult urgent care, sure. Pedi urgent care, sure. Free inner city walk-in clinic, sure. But adult primary care, not a snowball chance in hell. Med-Peds hospitalist, definitely. I've actually volunteered to cover some Cardiac ICU shifts this week to get out of clinic!

 

Anyway, I had just wrapped up seeing a patient brand-new to our clinic, who has some SERIOUS medical conditions (including possible new heart failure) who I was seeing without ANY medical records and trying to triage her medical issues, debating admitting her to the hospital so I can get a work up done that will take me 3-4 weeks in the outpatient world, and was suppose to do this all in 5 minutes. Well, I mean I should have had 30 minutes for the visit, but essentially since clinic was already behind schedule, I really had 5 minutes from when I entered the room, until I was scheduled to see my next patient (who wants to sue me-I didn't know that then), and the 4 patients after him. In reality, this new patient is complex enough that she should have had an hour or two to be seen...

 

So, I walk into GVs room. I'm seeing him for follow up. I saw him 2 months ago, referred him to a specialist to be seen, and gave him some meds to try and control his issue until he could be seen by the specialist. In talking to GV, he decided against taking the pills as I prescribed, and he is on the wait list for the specialist. So, essentially today's appt is a waste. Except, that I really like GV. I wanted to strangle him when I first met him since he was out of control (that'd be good ammo for the lawyer- You're Honor, He tried to STRANGLE my client), but over the 3 years I've seen him change and I no longer fear seeing his name on my schedule. So, he hands me a crumpled business card. I was hoping he hadn't crumpled my business card.. and I read it. LAW FIRM. Oh shit. Are you kidding me. I look to his family, and his relative says "He wants to sue you." Honestly, I wasn't too worried. I mean look, he hasn't even taken a handful's worth of the pills I prescribed 2 months ago.

 

I look GV square in the eye:

 

Me: You want to sue me

GV: Yes

Me: Oh really. What for?

GV: You had them put those sticky things on my chest last time.

 

We had to do an EKG to monitor for possible medication side effects, and he can't articulate that the sticky things were the EKG electrode patches.

 

I look to his family, as if to say is he outta his mind?

 

Me: Yeah, so?

GV: I had 4 chest hairs, and now they are gone, so I'm going to sue you!

Me: FOUR? I examined your chest when I listened to your heart, I didn't see them. How much money do you want?

 

I'm sure the hospital legal counsel wouldn't want me to bargain in the room, but I'm pressed for time..

 

GV: Five thousand dollars.

Me: Tough, I have 20 dollars til pay day.

GV: Holding out his hand.. Ok, give it to me.

 

Instead, I grab his head and give him a nuggie. Again, I am sure the hospital lawyers wouldn't think this is an acceptable solution to a pending lawsuit. But given that GV is 9 years old, I think it's appropriate that I use my bruit strength to remind him that I am in charge. His grandma laughs. I ask her to please give him his meds, tell them that I'll miss them for the year I'm gone, and look forward to seeing them in a year.

 

It's a small reprieve.

 

 

Websites

Here's a collection of websites that I've been following...

 

http://multimedia.thetimes.co.za/photos/2008/05/flames-of-hate/

 

http://news.bbc.co.uk/2/hi/africa/7407055.stm

 

http://www.nytimes.com/2008/05/19/world/africa/19safrica.html?hp

 

http://news.bbc.co.uk/2/hi/africa/7396868.stm
 
http://www.cbsnews.com/stories/2008/05/01/60minutes/main4063191.shtml
 
http://msf.org.za/PR/PR_SouthAfrica_MethodistChurchZimbabwe_050208.html

 

http://www.guidepostsmag.com/personal-change/positive-people-archive/?i=730&page=1

 

 

BPB

Nocturist

I spoke to one of the nocturist last night at work. He works 3 nights, a week, in a row. Admitting patients to the hospital, and providing cross cover on the already admitted patients. Sometimes, I really think this would be a great job. You get the challenge of creating the admission differential, you get to start the initial work up. Plus, the added benefit of having free time during the day. Hmmm

 

Pushing through

I am literally pushing through today. No thoughts of crashing. I was the night float/medicine admission resident last night, managed to not have any admissions from 2:30 am til 5:30 (slept poorly on a couch) and this am when I saw that it was going to be a beautiful day, the only think I could think of was getting into the mountains. Some needed trail time!

I have this secret fantasy of some day always having a day pack and an overnight pack (w/ 2-3 days of stuff) in my car at all times so that as soon as I leave work I can make a break for the hills and escape for a few hours, or a day or two.

Today was that day. I called Karin (who is on vacation) and we went to SW Mass and hiked for a few hours, then met up with Elsa for a divine lunch. I ended the evening by reading bedtime stories to Ian and Emily, then coming home and having a few glasses of wine w/ my flatmate. Such a great day.

I can't explain the mental fog that has settled on my brain. I am exhausted. Period. My bed is a few feet away, and I know the minute I lie down I will be out for the count.

Work Hard, Play Hard. There really is no other philosophy in life...

Off to bed.

Just Hanging

I haven't really mustered up the energy to post in a while..
 
Random things:
-stopped a drug seeking patient from getting more narcotics from the clinic yesterday, got to call security to the clinic to escort him out of the building, -THAT- was a fun time
-ran again along the trail I've been running a few weeks now. The leaves are finally out and the trail looks totally different
-no medical license for SA. And honestly, am thinking it won't happen until I get down there
-avoided going to Pride last weekend, kind of over the small town bullshit that goes on here. Think this is the first time ever I've intentionally skipped Pride
-Have found a vehicle to purchase in Jo'burg. A 1999 Ford Bantam. A UK doctor (friend of a friend) is leaving so it's convenient to buy his car
-Am really really really trying to find time for one last overnight backpack trip before I leave
 
That's about it really. All is just kind of status quo.
 


 

Denver Pics

Real Life Scrubs

I moved in with JW, who is a medicine resident in the same hospital. She is on-call tonight in the CCU (we worked together in the CCU in October) and I'm on night float, so it'll kind of me like Scrubs when Turk and JD.. 

 

I'm spending today, finally unpacking in the new room. Basically taking clothes out of trash bags, and separating out books and papers.

 

Wrapping up

 

I flew to Colorado on Saturday, and am flying home tomorrow. It's been a quick trip, that's for sure. Have kept it pretty quiet this time so that I can maximize time with family. It's hard to believe that I won't be seeing the family for a year. 8 weeks and counting.

 

I have some great pics, but they will have to wait until I get back to Massachusetts-I forgot to bring the cable to connect my camera to the computer.

 

 

The Flask

It's weird the things you pack when you're headed away.

I'm half way through packing up the kitchen. And I came across my flask.

Ironically, somebody had a flask at dinner last night. (I'll just let you use your imagination on that one). And I kind of wondered where my flask had migrated off to. I hadn't used it in a while. Oh wait, the last time I used it was backpacking... Whiskey (Jameson) on the Appalachian Trail with Johhny K. Ah yes...

So, there it was, hiding in the cupboard.

Before Johnny K, the last time I had used the flask had been in Ireland. It was in my suit pocket at a med school function. I am almost too embarrassed to admit that the flask was used to add whiskey to coke. Those were the poor years. Mixed drinks were expensive.

Why did it even make it to Ireland? Because it was a gift, from a very dear friend, whose wedding I participated in 2 days before moving to Ireland. I basically flew back from that wedding, spend a day in Denver and then flew to Ireland. The flask was just part of the luggage at that point.

Over the past few days of packing, I've been setting things that need to go to SA in a box. Books. Certain photos (most photos are now on the computer). My extra phone. Foreign money. My passport.

And tonight, I put that flask in the box. It seems silly to take the flask to SA...

I can only hope that at some point in the coming year, I find myself in the Drakensberg Mountains, sharing my flask with new friends, while remembering the great friends who have supported me for many years.

Running

I'm on the run.

I'm making a real effort to start running regularly again, and not to just codes in the hospital. I forced myself onto the treadmill, once, and on rare occasion twice a week during the winter. That's a total lie, I can think of one week where I was on the treadmill twice.

Anyway, this past Tuesday was beautiful. I was done at a decent time, and decided to escape away and go for a nice trail run. I picked a gentler path than normal, and ran for about an hour, covering just over 4 miles. And paid the price. Oye pain on Thursday. But, no pain, no gain.. right?

I'm hitting the wall today.

In my post-call-mental-slumber, concentration seems to be lacking. I only have 2 goals today. Get some packing done, and finish a presentation I'm giving tomorrow morning. Packing has been a minor failure. I can't quite part with some books that I haven't opened from med school. The books are all packed. The storage closet has been emptied. Basically all that remains is sorting through clothes. Moving day will be Friday.

I can't resist the pull of the beautiful sunny afternoon.

I'm going to have to give in and make a break for trail run #2. Surely it will hurt less than earlier in the week!

Wild Things

Yesterday was a tease. Offering what the summer will bring, but also what I will have to give up for a while.

Temperature in the 70s. Blue sky. Off of work by 4. As was KZ. So we met up, she picked up the kids and we went to the park. Got to hang out, playing on the swings, going down the slide. And then going for a stroll on dirt paths around the park, in a very cool wooded area. Darn, forgot the camera.

Bedtime rolls around, and the priceless moment was getting to read Ian and Emily their bedtime story. Emily was in my lap, Ian was propped up hanging off my side, and both were grabbing and turning pages. Growling. Showing fangs. Hoping that I get many more nights like this before I leave, and hoping that there is a day when I get to read bedtime stories to Ryan, Jordan and Haley too. Wishing that all the kids in my clinic had parents who would actually read to them at night...

Have Visa, Will Travel

Well, much to my delight and surprise, I got my passport back today. Have stamp allowing multiple entries as a temporary resident for the next year!

I am headed back to SA!

SHIT!

I have microwave popcorn..... AND NO MICROWAVE!

Let me think about this for a minute...

How did this happen. When I bought microwave popcorn, I had a microwave. Oh, that's right, I'm giving away what I can, and I freaking gave away my microwave! MORON! I don't use it all that much, but now, dammit, it's 1am I am wide awake (for reasons that are unclear to even me), I have the munchies (and a lack of food). I have no chocolate stash. I have no ice-cream stash. I don't want health food at 1am, that doesn't satisfy a craving for badness. Popcorn would have done it..

I'm going to go experiment in the kitchen.. certainly the kernels don't know they are suppose to only pop in a microwave, I'm going to try and pop them in a skillet with oil...

Wish me luck.

My Rorschach Inkblot Test

"An Iraqi army soldier looks on as a woman picks up rice at a checkpoint in Sadr City, Baghdad. The Shia suburb is suffering food shortages as troops clash with the Mehdi Army militia."

-BBC-

What's your reaction???

My Verdict on Pike Place Roast

I understand why they did it. Getting back to the purity of coffee. Getting back to the fundamentals of what makes a good coffee, or coffee good.

Fresh roasted is best. Blue Bottle knows this. That guy built a coffee company with fresh being the core concept. Coffee older than 48 hours is not fresh, and he gives it away. Starbucks started out small, with fresh roasted coffee, then exploded into a coffee empire, offering pure roasts, exotic blends, and a confusing array of lingo and ordering styles. You're average Joe gets his cuppa and likely ruins the taste with splenda and soy. Wait, I mean the average Joe uses milk and white sugar, carbo queens go for the splenda and soy..

Joe likes the whoosh of a can, not the whirl of a grinder. Joe doesn't care if the coffee is from Latin America, or if it's a Yemen. (Yemen, being my all-time favorite coffee).

Starbucks proved that they can master blends and roasts. They are good, but mass production of blends can't be best, because by the time you get those coffees to a consumer, they are no long have freshness. Local coffee roasters offer freshness.

The idea is great. Mass roast one blend, and bring back freshness. The Starbucks I visited yesterday had coffee roasted on 3/29. That's pretty decent.

That one blend is Pike Place Roast. I think it is very mediocre. But that's what they needed to do. Find one blend that east coast coffee wimps would drink, but not too dilute that hardened west coasts fanatics would avoid. I think Pike Place Roast accomplishes this...

That's my opinion.

Random Thoughts

1) This morning, I packed up my book shelf, and dismantled the kitchen table. I have to be out of the apartment in 2 weeks. Reality bit me in the ass. 3 boxes of books. Sadly, there are about 5 books to be read still, and I kept those ones out. I'm not sure these boxes will be unpacked. When I moved to Ireland (almost 8 years ago), I packed up 4 or 5 (maybe more) boxes of books, thinking someday I would be back and unpack those books and display them in my home. I'm not sure when I'll ever really settle down long enough to unpack all these books. And maybe I should just learn how to part with books...Or *gasp* use the library.. Maybe I should just ship these boxes to Colorado to join the other boxes of books.

2) VISA. Applying for my South African Visa tomorrow. To me, this is the real final step. There are some small things like getting an international drivers license, applying for medical indemnity coverage etc, but this makes it real.

3) I would drink Animal Dung Coffee.

4) My hair. I am growing it out. And right now it is in that frizzy annoying short-long phase. If I hear one more person tell me that the grey makes me look "distinguished," I am going to develop even more of a complex and may consider getting my hair darkened, which is a total waste of money, but I don't want to look distinguished. Actually, if I want to look distinguished, I'll wear my glasses. Shit, maybe I am more vain than I realize.

I am going to bed now.

Sundays

Heather, my old flatmate from Dublin came for a visit this weekend. It's been over 2 years since we've hung out (when I went to see her in Pittsburgh). It was like old times. We reminisced about the simplicity of life in Dublin, and the things we took for granted there. We had dinner at The Blue Heron (one of my favorite places) Friday night, and then a drink at the Montague Book Mill, and then made our way home and watched episodes of Sex and the City. Saturday we went to Brattleboro and Shelburne Falls, the two places here I would move to in a heart beat, except they are too far from the hospital. This morning we went to Karin's for brunch, and had a great time hanging with her and the kids. And like that, the weekend is mostly over. Weekends are going fast these days...

JR

Last week the ER resident called me to admit a patient. "I have an eight-year-old boy with pyelonephritis. And he has rash." Interesting, I remember thinking, you don't really get a rash with pyelonephritis.

I made my way down to see JR. As I knew I was already going to get out of work late, I decided to take my time and make some small talk with JR and his mom before I asked them all the medical questions.

So, I asked him about what he liked to do. And he told me he liked to knit. I was taken aback. What 8 year-old boy likes to knit?? He told me how he has knitted scarves and also a hat. This was no normal 8 year-old boy. We talked a bit more, and the more we talked, the more inferior I felt.

"So, JR, can you drive a car?"

"No, I can't reach the pedals." Well, I was glad to know that there was one thing I could do that JR couldn't!

Even before asking him or his mom any questions, it was very obvious that he did not have pyelonephritis. As we talked, I was looking at the rash on his hands, looking at the injection of his conjunctiva, and looking at his red cracked lips. It was time to stop the chitchat and get down to figuring out what was going on...

After taking a history, examining JR, and looking over the labs, I suspected that he had something more serious than just pyelonephritis.

I talked to JR's mom and told her that I was concerned about what was going on. She asked me to call her partner, who worked in health care, and discuss what I thought was going on. And I told them I suspected that this was Kawasaki's. But it was too early to make a diagnosis.

I explained to mom #1 that they would have a new residents taking care of them in the morning.

"But, we like you. Will you please be our resident?"

Our team size was alread a little unruly, but how could I turn down taking care of this cool kid, with two moms, and an interesting/complex medical condition.

JR had a rough course. There was disagreement about whether he had Kawasaki's or some infectious cause. He failed initial treatments. And on day three, he was looking worse. We had multiple family meetings daily discussing his care, and what more we could/should do. We called the Kawasaki specialists in Boston, and were on the verge of transferring him. Thankfully though, he responded to the second course of treatment, and went home a week after coming into the hospital.

When I went back to work on Monday, they have left me a card with their number, and an invitation to come over for knitting lessons...

They were the coolest family that I have taking care of, and if I ever have a family, they would be one of my role models.