March Madness

[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.

 

I.

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

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

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

 

 

March Blogging Hiatus & Experiment.

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

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

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"

"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

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

 

 

Weekend Warrior

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

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

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

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

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

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

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

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.

 

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Keeping Silent

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

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?

 

         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.

 

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