Regret

Regret: a feeling of sorrow or remorse for a fault, act, loss, disappointment, etc.

I remember in junior high telling a friend that I didn't believe in regrets. Life was too short to have regrets. To me, a regret is something that I would do differently if I could go back in time and make a different decision. I've made plenty of bad decisions in life, but I only have 2 regrets.

I arrived home from work yesterday morning, and with good intentions had planned on having lots of coffee and making my way to Jo'burg Pride. But I made the fatal mistake of lying down "for a minute" and woke up 3 hours later. And I woke up with the strangest dream. I had a dream that I was at a party. I was not the host. And the party was only men I had dated, or men with whom there had been some kind of connection. Kind of a messed up dream, but it was interesting to see how well they all got along. It was spooky. Very spooky.

And on that background, I headed off to the Pride Rally. It was a perfect Saturday afternoon yesterday. Walking around the rally, I could have been in any city in the world. The crowd watching was superb, and the party seemed to still be going pretty strong at 3pm. I walked around with flashbacks to Denver and Dublin Prides, thinking of how great it was to show up in one place and run into so many friends, in such a festive, loving environment. I half expected to run into one of the guys from the party in my dreams. Though, I did run into 2 people I knew, which was a surprise given that I've been in Jo'burg for such a short time.

I went over to S&S's and showed up to a patio crowd sipping wine as dusk began, and hearing tales of the parade and talking of plans for going out last night. The wine was finished, and the group split up to head out for the night, with likely plans to rendezvous randomly at some point. Siza and I (Scott is out of town) headed to meet up with David in Parkhurst. We sat outside and had dinner for over 2 hours, enjoying the people watching and talking. We headed out to a club to see RuPaul perform, managed to get VIP access, and after the show ended (past midnight) we then went bar/club hopping. At 6am this morning, we walked out into the crisp air of dawn, a nice change from the smoky staleness of the club we had been in. After a couple hours of sleep, we went for breakfast, and were eating brekky at the same spot we had had dinner, less than 12 hours before.

Arriving home in a mental fog, having gotten 6 hours of sleep since Thursday, I should have gone directly to bed. But curiosity got the best of me and I googled the web for a coffee shop I heard about last night. And then I had a fleeting thought back to my party dream, and googled a name.

I either still talk to, or hear about many of the guys from that dream. But there was one I hadn't heard from in a while, so I googled him. Why google, it's complicated.

In the summer of 2002, I stayed in Dublin during break from medical school. One day I received an email from a stranger saying he was coming to Dublin to write a portion of a travel book (Frommers Gay and Lesbian Europe) and would I show him around. We swapped emails, turned out he had lived in Colorado for a while as well. So a month or so later, on a Wednesday night we met up at the Front Lounge in Dublin. And in he walked, with a baseball cap and cargo pants, and a t-shirt. Very American looking. We made a desperate gay pub crawl through Dublin, hitting many establishments which are likely now closed, and parted ways hours later at one of the bridges going over the Liffey. We agreed to keep in contact. He would be leaving Dublin Friday morning.

Walking home that night, I was in awe. Haas was smart. Funny. A world traveler. A foodie. Genuine. Athletic. And lived in Port Townsend. Thinking of him that night, I realized that he was who I thought I would become in the years after I finish residency.

The next morning while I was at the hospital (doing an extra summer elective), I missed a call and then got a message form him. I wish I still had that message. The genuine context, and honesty endeared me to him even more. He said what he felt, something that isn't done often enough. There was no "between the line message," not that day in the phone message, or the years that followed.

He called to also ask if I would join him for dinner. He had heard of a restaurant that he wanted to check out. And so that night, we ate at what became my favorite restaurant in Dublin. The restaurant where I went for brunch on my 29th birthday, and where I had my final post-graduation dinner meal before moving back to America in 2005. That was the night I got tipped over into realizing that paying for a good meal was worth it in more ways than just satiety. The pleasure of sitting down for a nice meal, in an enjoyable environment, with meaningful conversation was worth the expense; a concept which was foreign to me as pricey meals had never really been in my budget. What stands out from that night is a mixture of excitement and confusion. I couldn't recall ever having hit it off that well so quick, but confused because he was leaving the following morning, and there was no certainty our paths would cross again.

As it happened, our paths did cross; not coincidentally, but out of his travels for work and also his frequent trips/stops to London. My few days spent with him in Paris, the following spring, were remarkable. He was writing Frommer's Paris on $95 a Day, and ducking in and out of museums, restaurants, hotels, neighborhoods, and enjoying many great meals are cherished memories. I still remember the conversation we had one night where I tried to convince him that, while Port Townsend was great (I had been there in 1993), there were no residency programs for me in that part of the US. He was settled, I wasn't. When the book was written, he sent me a copy, with a note to check out the first few pages, and there was my name, in the acknowledgements. Before I left Dublin, we'd met up in London and Dublin a few more times.

So, this morning, with my laptop open out of nowhere he popped into my mind. So I put his name into Google, and with complete disbelief I couldn't believe I came across his obituary
Already in a sleep-deprived mental daze, I couldn't fucking believe that he had died. How could Haas die? Of a heart attack? The man who told me 3 years ago in Dublin, how he had just decided to run one day and ran 8 miles! The man who was so knowledge about eating healthy and being healthy? He had died, of a heart attack? The disbelief. Dead. Heart Attack. I can rationalize the heart attack, my medical knowledge gives me insight into that, but I absolutely have no way to process the information that he is dead. Dead.

And the profuse embarrassment that the anniversary of his death is a year from tomorrow. He has been dead a year from tomorrow. And here I am sitting in Johannesburg, having spent last night out clubbing-thinking about men and relationships, and this amazing man is dead? You've GOT to be fucking kidding me.

And closure. There had been a silence between us before he died. I had the feeling that he was giving me space and time. I had always felt like I had met him too early, that I needed a few more years to age and mature to his level. I had always assumed that in time, we would re-connect. That at some point we would find ourselves in a great restaurant (in some completely random city), enjoying catching up as if no time had passed, and picking up our friendship, (or more?) where we left off. I think back to the times when I thought about him, and made a mental note to drop him an email, but never did. I remember packing up my photos back in April, sitting on the floor of my apartment, and looking at a picture of us taken with the Eiffel tower in the background, and wondering how he was. But he was already gone.

Regret #3. Rereading the emails we swapped over the years makes me realize how much I didn't appreciate what a great guy Haas was, and how I assumed that time was on our side, and that gave me liberty to postpone crossing the bridge... I regret many things about this situation. And given the chance to go back in life, I would make different decisions, and I would have reciprocated the level of honest communication which had made him stand out that day in Dublin.

This is my definition of regret.

Rest in Peace Haas,

and thanks,

and sorry.

http://www.haasmroue.net/

Friday was the second most miserable experience thus far in residency. Admitting 20 newborns to NICU-Transition NICU & newborn wards, attending 10 deliveries, getting called about other newborns on other wards... (all between 5pm and 7:30am).

 

Did I make it through the night. Of Course.

Do I think I made any bad judgments. No

Did I get the IVs. Almost all

Did I get the blood draws. Some of them (poor average, disappointing)

Was I as thorough as I would have been back home. No way. 

 

I had a post partially written out, but decided to delete it.

 

After spending the day thinking about things after learning about the death of Haas, I felt a bit ridulous having written a post which largely complained about my experience on Friday night. It seemed ridiculous to complain about the duty of ensuring the safe passage of children into this world, in the context of the early and terrible tragic exit of Haas. So I deleted it. And now, as it approaches 10pm, I'm too tired to write a post describing, in a more factual aspect what call was like on Friday.

Well Shit...

Courtesy of freewillastrology.com

 

Aquarius Horoscope for week of October 2, 2008

Once upon a time, Brave Aquarius wandered out to the edge of the known universe in search of mind-blowing sensations and foreign titillations and clues to the future. So imagine Brave Aquarius's amazement when the rather attractive ogre who was guarding the rope bridge that crossed over the abyss said, "Stop! You're headed the wrong way! The mind-blowing sensations and foreign titillations and clues to the future you crave are back in the direction you came from. In fact, they are all the way back where you started." What to do? The ogre's advice was counter-intuitive and downright confounding. But Brave Aquarius, being foremost an experimental adventurer, thought, "Hmmm. I guess maybe I'll try what the ogre suggested. What could be more experimental and adventurous than changing my mind?"

 

According my horoscope, I'm suppose to leave SA and head to CO. (Via MA for a year).

 

Not going to happen, obviously, but this horoscope comes at an interesting time.

 

Off to get ice-cream, then going to chill out and get a really, really good night sleep before the onslaught of call tomorrow.

And now I understand

And I think I agree, horrible is likely to be the correct description...

 

I had a mini-orientation to being on call tonight. Call will be covering the LW. The Labor Ward. Solely responsible for assessing sick newborns, covering the c-section calls, and any infants who get sick in the outlying wards.

 

It's like newborn M*A*S*H. The babies just kept coming in... The LW is essentially a triage unit and an observation unit, and holds babies until the level 2 NICU can get beds open to take kids, or until the level 1 NICU has beds.

 

I think there is space for 8 kids. Well, beds for 8 kids. we had 7 kids, 2 of whom hadn't really been assessed when they brought in a premature baby who needed some minor resuscitation (just needed to be bagged). He went onto the last open bed, which was conveniently, the resuscitation bed. The glorious moment, or surprise, was when they brought in his TWIN SISTER (which they neglected to mention) who likewise needed some bagging. It's really all manageable, except  that the person covering LW also does all the bloods and IVs. That to me pushes me a wee bit closer to insanity. I was sorely out of practice today, and am hoping for a small miracle in reviving IV and phlebotomy skills before my first call in Saturday.

 

And again, I had flashbacks to being an intern, when a very wise colleague mentioned a saying: "they can hurt you, but they can't make the clock stop."

 

I mulled that saying over as I drove home. How the fuck would I manage if I were on call the rest of the night, tonight. I would count down until 8 am. I would literally see that there was an end point to this shift. That all I would have to do is keep kids alive until I get them sorted and into their respective units for further care. And so I thought a bit about the level of medical care, and came to think that when working in extremis, it is not feasibly possible to be the thorough type of practitioner that I expect of myself. That it is not going to be possible to really examine these kids in the level of detail I want to, nor to really review the maternal history and write the detailed notes that I come to expect as being standard.

 

If I had to guess, I would say that in the 5 hours I was there for orientation tonight, we probably had 12 kids filter though, plus getting called about problems on outlying wards, and reviewing 2 stillbirths. I'm not really sure how one person is suppose to do all of that work, but I guess I'll figure it out on Friday night.

 

Slow Learner

I may be a slow learner...

I had too much on my mind, so I went for a nice run, hoping to repeat the run I had sunday night where I caught the perfect sunset and dusk. But I was too late, and was running in the dark. I miss running at night, and have been a bit hesitant to run at night, but I am finding that it's actually pretty safe and running at dusk is fine.

I finished my run, and opened the gate to the house. There is an electrical fence surrounding the house. And where the gate opens, the electrical fence is within reach. I had this very odd temptation to reach out and touch it. I know this doesn't make sense, but just the thought of doing this made me think of my family back in Denver, and I had to laugh, out loud.

I didn't have thoughts of them in the sense that I expected if I touched the electrical fence I would fry, and I'd have visions of them as I went into burning convulsions. But rather, I had visions of you meeting my brothers and dad, and heaven forbid they let out all the family secrets (what family doesn't have them), and they decide to tell you about the time, when I was young, when I stuck a key in an electrical outlet.

There you have it. Yes, I did that. All I recall is lots of excitement and some spanking (it was the 70s, that was ok then). And, I have, on occasion, been humiliated by hearing this story told, often time in the company of somebody I would rather not know this about me.

So, as I was tempted to reach out and grab the electric fence, I was pleasantly shocked to relive these memories, and decided I didn't need to do it again.

--yes, the pun was intended--

Anticipation

"It's horrible."

 

That has been the response from more than one person, well in fact, just about everybody when I tell them I am doing neonates next month.

 

Neonates, for clarification, I found out today means NICU, a transition unit , and then a combination of kids not sick enough to get in the NICU or transition unit, but still sick-ish, and covering deliveries, c-sections, etc etc etc

 

I've had some theories as to why people don't favorable enjoy NICU. And in fact, back at home home institution, it's not the favorite amongst everybody either. But I don't think I've heard NICU, or even any rotation described as horrible. I suspect that since Neonates is a required rotation of all doctors in SA, that if you don't like kids, then Neonates is bound to be a bit painful...

 

I also suspect that part of the reason it's not too terrible enjoyable, is that it is a busy month. Honestly, we all like a little downtime in our day, and I hear that it's constantly running and being behind. But, at least it's just for a month.

 

So, I kind of figure that I've done a fair bit of neonates, and I'm looking forward to seeing the differences here, and a more practical approach. And then I heard this figure today.

 

24,253 births last year in Bara.

 

Wow. That's a helluva lot of babies.

 

461 babies weighing less than 1kg

584 babies weighing between 1kg and 1.5 kg

942 between 1.5 and 2kgs

 

(1kg=2.2lbs)

 

Funny how anticipation can melt into anxiety...

 

Neonates starts on wed, first call on saturday...

 

 

Brief Hiatus...

Hello-

 

It was a holiday here today. Things were closed. Not much going on. Moritz (my German housemate) and I headed into town, where much to my extreme sadness Bean There was closed, so I couldn't get fresh roasted coffee beans. I can hear the hecklers already, but I think of the Kenyan farmer who they are buying the beans from, and the positive impact that these guys are making with their business. My coffee "habits" are bettering the lives of others. That and I'm really keen to try the Rwandan beans that they have been working on...

 

So, after the failed coffee expedition we headed to Newtown to explore a bit. This is the area that I decided to not explore back in June before I started work, as I wasn't so sure this was an area I should be out walking around in. But upon further enquiry, I have found that it is safe(ish) enough to walk around in the vicinity of a few blocks. We checked out a rather mediocre museum, and then we were directed to the Oriental Market. Which was a nice find, and was hopping. We had some curry for lunch and enjoyed fun people watching. Then we picked up a med student that Moritz knows from the hospital, and made our way to the Soweto Festival.

 

The Soweto Festival was a mix of music and vendor stalls, and some really great people watching. There was a 46664 sponsored stage which produced an absolutely shocking/inspiring/motivating 3 actor play about breaking the stigma of HIV/AIDS, and encouraging open discussion of HIV/AIDS in SA (As is becoming my soapbox: People just don't talk about it). One of the things they did was ask for a show of hands of who had been tested for HIV among those in the audience. Just this simple act of raising ones hand in front of complete strangers conveyed a powerful message. I, of course, have been tested. But I was very self conscious of having others know that, as if by them knowing that I have been tested, it means I am open to be judged for my actions. 

 

I heard more facts which I had tried to commit to memory to share, but am beginning to think that writing about facts and figures is such a poor method to convey the level of seriousness which this miserable virus/pandemic deserves. Sitting there, among the patients I treat, being keenly aware that I was an outsider, but feeling welcomed, again made me realize how lucky I am to have been able to make this year happen. Though, as is becoming the norm, there was a sense of being powerless to bring about change to this crisis, and wondering what my part will be down the road, and how to make this part of the world a little better.

 

The holiday ended with a trip to the Westcliffe Hotel for a drink. I'll get the pics up in the coming days, but the rewarding view from the hotel was a nice way to wind down the day.

 

As for the brief hiatus, I've got a few things that really need some attention in the coming days, and while it may only take a few minutes to read these entries, I spend a fair amount of time thinking of what I want to write about, and even more time actually writing them. (Which is why I don't proof read them, cause that would take even more time).

 

So, I'll catch up with y'all in a few days.

 

 

Lesotho

The Kingdom in the Sky.

 

I'm not sure where to start. Let me start at the border of Lesotho and SA. It's dark. We're a wee bit behind schedule. The cars are barely creeping along the border post. I'm travelling with my housemate, Moritz, who is a German medical student who is do the trauma elective at Bara. It's a little confusing going across the border, through check points, and then getting out and going into immigration. It all goes smoothly. Except that is is DARK out.

 

Why does this matter? Because we decided to stay at a lodge recommended by some of my coworkers, which is a ways away from the border. Originally we were going to stay in the capital of Maseru, but have decided to make our way to Malealea, which has a lodge in a more mountainous part, and has some hikes etc.

 

I got the directions off the internet of how to get there. We didn't really get a map of Lesotho, but I trust Lonely planet, and a keen sense of direction. But, let me explain that the directions from the internet of how to get to this lodge do require a slight leap of faith.

 

"At the taxi corner, turn right only the newly tarred road." Reading this before hand, I had hoped that no other roads had been newly tarred. You see where I'm coming from.

 

Getting past Maseru, I can see Moritz may not be as up for the challenge of driving in a foreign country, with shotty directions, and barely any road atlas at all. On, and did I mention it is PITCH DARK out? Oh, did I mention also that there are no street lights.

 

I figure we can make it, and if we don't we'll backtrack to Maseru and stay there for the night, or stay elsewhere. I've done a bit of homework before leaving, and Lesotho is NOT Jo'burg. People aren't plotting to carjack or rob us..  I try to recall the line from Blues Brothers about having a full tank of gas and cigarettes..

 

So, we head out of town, and are making our way to the highway. Did I mention how dark it was. No moon. No Street lights. People walking in the road, on the side of the road. Did I mention the bus that didn't have tail lights? I thought this all the norm, and really no big deal, I mean all we had to do was find a newly tarred road...

 

More to the point, we arrived at the lodge at 9:30pm. We didn't make a single navigational mistake. The final road was rocky and a little challenging to navigate in the dark, but I had flashbacks to driving on dirt roads late at night while in high school, specifically some of the camping trips taken while during our senior year in HS.

 

 

As for Lesotho... Poverty And Beauty.

 

Partners in Health.

 Medecins Sans Frontieres (Doctors Without Borders).

Baylor International Pediatric AIDS Initiative.

 

All 3 work in Lesotho, and likely other organizations as well, though I'd be happy to work with any of these three. The reason. Poverty. And 30% prevalence of HIV/AIDS. And increasing deaths from TB. And a life expectancy that is extremely low. It is a country that defines poverty. 

 

The Lesotho people were very welcoming and friendly. Something I didn't expect to find. While off the beaten track, (or while taking the Bakkie out for a drive on some almost 4x4 quality roads), people, of all ages, actually asked that we take their pictures. I haven't found adults before asking to have their photos taken (for free). The Lesotho, warmly wrapped in their Aranda Basuto Blankets proudly smiled for photos...

 

Part of the highlight was heading to Mafeteng, a town about 80 or 90 Km from Maseru. We were the only white people we saw. We walked the town, searched out for the best priced blankets, haggled with shop owners, people watched. Having learned a slight lesson in Peru, I didn't eat there. Though was tempted. I wasn't really tempted to buy a blanket, but after seeing them worn by people all day long, and then seeing the amazing quality, I decided to pick one up. Check this out to read a bit about the blankets: http://www.malealea.co.ls/basotho-culture/basotho-blankets.html 

 

Anyway, it was a quick 48 hours in Lesotho. I was caught off guard by the striking beauty of the country as well as the welcoming hospitality of the people. I doubt it'll be long before I make my way back here.

 

PS-check out the link I have posted off to the right side, I have uploaded some pictures (finally) and will try to be a bit better out getting photos up regularly.

 

Cheers

Moo

Worth the read:

http://egan.blogs.nytimes.com/2008/09/17/moo/?ei=5070&emc=eta1

 

 

1900 & 20

1,900

 

One Thousand Nine Hundred is:

A-The amount in SA Rands that I paid for dinner last night.

B-The number of brain cells a certain potential VP has.

C-The number of times my blog has been viewed.

D-The number of children infected with HIV today.

 

Answer:

D.

 

ONE THOUSAND, NINE HUNDRED. Of course this is just a number. Numbers don't mean anything in this day and age. If every bed in the hospital, where I train back in the US, were filled with 3 kids, that would be 1900.  That's enough to fill FOUR 747 jumbo jets. That's more than 4 times the size of my graduating class at Columbine. Let me re-iterate, this is the number of CHILDREN who will be infected with HIV  T-O-D-A-Y. It happened yesterday. And guess what, it's going to happen tomorrow. And the day after.

 

By the end of this month, that means there will be 57,000 NEW HIV infections in children.

 

Shit. It's just staggering when you take a minute to think about these things. I know there are many important issues in the world. Financial troubles in the US. Fear of republicans getting elected again. Zuma in SA. Floods in Texas. Neglected patient populations in the US. But to enter this world and be a statistic on the day you are born...

 

And 20...

 

20 is the absolute CD4 count of one of the teens I saw today. Vente. The number of ounces in a large drink at starbucks. 20 Lonely CD4 cells hanging out, I imagine they are much like the UN troops trying to guard Darfur. Spread here and there, too thin to actually be effective in mounting any real defense. I started this kid on antiretrovirals today. And as I wrote the scripts, said a silent little prayer that in the coming weeks, months that he doesn't get sick with some minor infection which his body can't handle, and dies of some wimpy bacterial infection.

 

Oh, and that figure, ONE THOUSAND, NINE HUNDRED only applies to children in AFRICA.  That is more than one child every minute of every hour of every day.

Honestly, are we really doing all we can?

 

Doubt it.

Kilimanjaro In March

I'm organizing a trip to climb Kilimanjaro in March. Maybe spend Paddy's Day atop Kilimanjaro with friends (and some Guinness or Jameson)? If you're interested, please email me sooner rather than later so I can figure out which date seems to suit best. So far, there are 2 of us, the more the merrier

Expat..

I had two emails today, which had EXPAT in the subject line, one from my medical insurance and one from Jo'burg. I forget I'm part of the "expat" community. I kind of like it. In the list of labels I use to identify myself, I'll add Expat!

Check out my Bara blog for a post about last night.

 

http://notesfrombara.blogspot.com/

Running with...

[I have to type this fast so that I can get out the door and make it to the thing that I have been excited about for a week now-I'm literally jumping up and down inside I'm so excited for what I have planned for tonight]

 

I got out of work early again today, as like last Friday. So I went for an afternoon run in the local nature reserve. I was running along, concentrating hard on the trail. Readers will know I have a tendency to look around while trail running, and in essence this leads to scarification. So I was running, looking down, thinking about an ethical dilemma from today, which pisses me off and I'm actually not going to write about it at all. So I'm cruising along (the wind was at my back, I was making great time. Well, I don't know about time I didn't have a watch). So I was cruising, and I look up and see a horse. Which isn't unusual since there are often horses in a pasture at the end of the run.

 

Except that..

 

It wasn't a horse. It was a wildebeest. Yes, when I looked closer (again, I was deep in though) I noted it was an ugly looking horse. Or rather a wildebeest. then I noticed that there were half a dozen of then. Looking at me. And then I noted the dozen or so Zebras. How quickly I was reminded I live in South Africa.

 

I don't know much about wildebeest. I suspect they taste like Buffalo. But I wasn't about to go bite into one. I was more concerned about their name. I thought it was (WILDA-BEAST). Aka WILD BEAST. Which to me means that they eat humans. Or charge. Or hurt people. The Zebras didn't concern me, and I know the wildebeests eat grass, or at least they had been when I showed up, but who the hell knows, maybe that is a ploy. Hey Mr Human, come pet me, look I eat glass. And then when you pet them, the maul you to death!

 

So, I did what I remembered from living in the wilds of Colorado. Climb a tree? Play Dead? Back up? So I turned around and cursed them for not letting me finish my run (like less than half a kilometer). (Kilometer, it's metric. Look at your speedometer).

 

To compensate for not getting my full run in, I took this long loop back, which loops up the side of a big hill (I almost called it a mountain, but that would be SUCH an exaggeration). And ran much longer than I have been. I already feel the pain in my legs.

 

Ok, I am outta here.

Happy Friday.

 

Thanks, BOA and Capital One

It's getting difficult to lead an extravagant lifestyle. Jet setting across many countries. Charging random expenses to a credit card. Even having called TWICE to inform BOA that I was going to be doing all this crazy stuff, they were nice enough to shut off my credit card, again, again. It was really hard to pay for dinner with a non-functional credit card. Ok, so now I'm just being dramatic, when in fact I have started to keep cash on hand, and using the cards less and less.

 

Here's what's funny. For months how I have had standing charges on my card. Health Insurance (from the UK), Gym membership (SA) and car insurance (SA). The only new charges are a plane ticket and a US$ 14 concert ticket. And my card got shut off.

 

Bastards. If it weren't for the billion points I have accumulated on there, I would cancel that account. That, and also the fact that I have all these standing things which need to go through every month.

 

On a related note... I called Capital One last week. I initially applied for a card with them since they don't charge foreign transaction fees. A HUGE bonus for me cause I get nailed with these fees. That is until I found a bank I can use here which has a BOA agreement to not charge fees, hence I'm carrying around more cash than I use to. So anyway, the card never showed up to the the apt that I stayed in for a few weeks before I came here. After a long brew-ha-ha with the manager, they agreed to send me a card to SA. Which never showed up. I emailed then, but they wouldn't address this over email, and said I had to call to report the card missing. Well screw that, I didn't have skype then. I thought about the card here and there, but really wasn't too concerned. The mail here is sooo fraudulent that I figured somebody had stolen the card, and would hopefully be kind enough to buy a water well for a small village (or a villages) or warm clothes for homeless kids, hopefully not use all the money at once and buy a BMW...

 

So I called them, and they kindly informed me that the card was carrying a US$ 10,000 balance, which included significant amounts of pornography, and trips to Aruba. OF course, my first question was if the porn was bought here, or in Aruba? Maybe there is money to be made taking porn to Aruba. I'm kidding. There is no money to be made in porn. And the card wasn't stolen (kind of a shock). It had been mailed back to the US. Since I had figured out a way to avoid fees, by getting cash regularly, I decided to just cancel the card. I really had assumed that this would be a much more convenient card to carry than this damn BOA (which has now been shut off a total of 5 times, in 3 countries).

 

After a heated conversation, BOA has agreed to call me next time (I'm optimistic, I know it will happen again) they plan to shut off the card. I've also given them the name of somebody else to call before shutting it off, in case I'm unreachable (like in 2 weeks when I'm in Lesotho). Jason- if they call, keep the card on. I have vision of the bakkie (my car) being out of petrol (gas) and my card having been long shut off, and me giving impromptu English classes, or medical care for cash..

 

 

D, Part 2

This morning I was seeing Xolani. He's 7. Has HIV. Has been on ARV/HAART for 2 years. When I called his name, he jumped up, and grabbed his grandma's arm. He's a smiling, happy 7 year old boy. Wearing a smart button down blue shirt with a white long sleeve shirt underneath. The look I try and pull off when I want to look like I am still in my 20s. His granny is likewise delightful, greeting me with a generous smile and a firm handshake.

 

We enter the room. Before calling them, I had grabbed the chart and read through the note that the counselor had written.

 

"Xolani knows why he takes his medicines. He is doing good taking them [sic]. He feels good. His granny knows the names of his medicines, and how to give them. Granny is the only provider. Parents are dead..."

 

I talk to Xolani and granny, examine him, he's doing great on his meds, virus is suppressed, his immune system is strong. He's happy, talkative. Singing a song which I don't recognize, mainly because it is in Zulu. He's a well adjusted boy, especially given his life circumstances, thus far.

 

Granny: His mom died on Saturday.

 

Mental Halt. Saturday. As in 2 days ago. So I enquire a bit, she was living in a nearby house. I had assumed that she had died long ago, there is no sign of grief in this child. There is a cultural element in play here as well. My friend S (of S&S) has been explaining his relationship to his mom, and how culturally it is the norm/expectation of children to be raised by the grandparents, even before AIDS created an orphan culture. When parents had to go off and work in the city, grandmothers were the providers, and essentially had a mother role as well. But still.... Saturday?

 

And so this shock, and somewhat discomfort lead me to question some thoughts. And I decide to take a formal poll today of what parents are alive.

 

XN: both dead

KM: both dead

SM: both dead

AM: mom dead

ZM: mom dead

SM: both dead (not a duplicate)

PM: both alive.

 

Either ZM or AM's mom died 2 weeks ago.

 

We saw about a 120 kids today in clinic. All united by HIV/AIDS. During the busiest portion of the day, I looked around in the waiting room, and for once, the extreme of ages really hit me. Young kids, there with grandparents. Maybe I've been in a bit of denial about how absolutely destructive this fucking virus is. Today I forced myself to really look, and tabulate the consequence.

 

Me: Grandma, is he doing ok?

Granny: Oh Doctor, he's very healthy.

 

I know he is healthy, I know his CD4 and his viral load, and I've looked in his mouth, felt his lymph nodes, his spleen tip, and his liver. I know his body is healthy.

 

Me: (beating around the bush) If you think he needs to see the counselor with his mom passing, let me know

Granny: He's a strong boy, he'll be ok.

 

And I hope, optimistically, that he will be ok. I hope that granny lives another 15, 20, 30 years, as she is his only family.

 

 

 

 

Vitamin D

Vitamin D for me:

I'm sitting outside on a perfect afternoon typing away. Reason #12 why I love Jo'burg is the incredible amount of sun that the place gets. It reminds me so much of sunny days in Colorado. I think that moving from CO to Dublin made me realize how great sunlight is, and sadly gave me pasty white skin. I'm thinking that after a year here, I'll be back to pre-Dublin day. So I've been making it a point to be outside as much as possible and get some vitamin D for me.  Friday I left clinic early, as there was really nothing going on, all the patients had been seen, and I wasn't really all that motivated to stay indoors and read. So I took off and headed out to the nature park (where I go running) and had a nice afternoon hike. In fact, maximizing sun exposure has been the theme this weekend. Saturday S&S I went for breakfast/lunch, and sat outside of this incredible café for hours. (I'll add a plug for coming across a new favorite SA coffee roaster, but there is more to this, and I'll comment next weekend). We then went back to their house where we sat outside for the rest of the afternoon and read, chatted etc. (I finished reading the new David Sedaris book-good stuff). I've got a fair bit of stuff to do today, but it requires me to be indoor, and honestly, it can wait until after sunset.

 

Vitamin D for kids:

Ricketts. I took care of a kids the last week on Ward 18 who was a textbook case of Rickets. Not something seen very often in developed countries, but we see quite a bit here. This kid had it all: craniotabies, frontal bossing, rachitic rosary, Harrison's sulcus, wrist enlargement etc.

Vitamin D for Adults:

As is Denial. I was seeing a 3 year old girl in clinic. One of the things that we do is see if the primary care giver knows their HIV status, and also see if they are on treatment etc. This mostly applies to when the primary care giver is a parent, but with so many orphaned children, the caregiver is often the grandmother, or occasionally an Aunt. So we ask the primary caregiver if they know they status etc.. I noticed on the notes from the last visit, that the status of the primary caregiver was unknown, but it didn't' say who the primary care giver was.

 

Me: Is this your daughter

Mama: yes

Me: Mama, have you been tested for the HIV?

Mama: no

Me: They didn't test you when you were pregnant

Mama: They did

Me: And?

Mama: blank stare

Me: What was the result?

Mama: I never got the results

Me: Oh, I see. Did they give you the pill to take or medicine for the baby when she was born

Mama: No

 

Or this exchange which happened the same day, again with a mom and her 2 year old daughter.

 

Me: Mama have you been tested.

Mama: Yes when I gave birth.

Me: Are you on treatment?

Mama: No, I'm negative.

Me: Really?

Mama: Yebo, I tested negative when I was pregnant.

Me: have you been tested again?

Mama: No

Me: why not?

Mama: I don't want to know my status

Me: Oh.

 

So on Friday afternoon, while enjoying my own vitamin D I thought a lot about these two exchanges. Both moms are clearly in Denial. Well, actually I think mom #2 has some insight and knows in fact that she is positive. Is it complete denial? These kids congenitally acquired HIV. From their mothers. These two women. Is there denial in thinking that they don't also harbor HIV? Is there guilt which keeps them from wanting to get tested? It's very complex. Discussing this at dinner last night, somebody asked what about ignorance on HIV transmission in general? I don't honestly know. This is SOUTH AFRICA. 30% of the population has HIV. HIV has been around for a long, long time. HIV is everywhere. HIV is a fact of daily life. HIV is on the radio. HIV posters are up in the clinics. Everybody knows somebody who has HIV. HIV is rumor and gossip...
 
I didn't see it as my role to address the denial of these moms. I think I felt less inclined to bring it up because there are counselors who address these issues at regular clinic visits, and I don't think I have the cultural understanding to effectively address this issue with these moms...

 

 

A Day Off

I have this overwhelming desire to call in sick (though, I don't know what number I call to call I sick), and take the day off. I actually feel well, but think that spending the day outdoors, drinking coffee, reading seems much more exciting right now that going to work. Maybe even drive off to a game park for the day and hang out and wait to see animals. Yes, that sounds nice...

 

But instead, I'm headed to work.

 

Maybe I just need more coffee...

New Month

Mentally engaged. In foreign territory. I can honestly say that I know very little about pediatric HIV/AIDS. And every patient I saw today (which is kind of a lie, because I sat in with another doctor and observed), was there for one reason. The child with either infected with HIV, or has AIDS. Today was a bit of a crash course in learning how the clinic operates, and getting a basic primer in the drugs that are used on the SA scheme. The drugs have been available since 2004, and it is a nice, simple regimen of drugs.

 

There were a few interesting things today. One of them being a woman who brought her niece if for her doctor's appointment, and when she entered the building that we work in, Harriet Shezi, Pediatric HIV service, that's the moment she realized that her sister's daughter, who lives with them (many families in one house) was HIV positive. This was a very intelligent woman, who had time to process a few things in the waiting room, including, concerns of disease exposure (But doctor, she had a cut that was bleeding and my daughter got blood on her, do I need to worry)...

 

Other themes.. orphaned children. Both parents dead from HIV. Or looking at parents who are ill themselves, and not on treatment, who are struggling to provide for these kids.

 

I'll say, that many times the past few months I have felt a bit torn about my dual med-peds training, and have felt this angst to spend more time treating these children, in the long term, and today I sat and caught myself thinking that these children have so many strike against them, why wouldn't I dedicate more time to helping them? The kids are in this state because of circumstances beyond their control... But, for balance, the other day I found myself running through adult treatment algorithms for cardiac events, and slightly looking forward to treating some adult conditions.. I guess at the end of the day, I'll be happy that I'm dually trained..

 

As for now, I should turn of the computer and spend some time educating myself, will start seeing patients on my own in clinic tomorrow (will discuss them with the attending)..

 

 

Brief note:

Only 2 months...

 

And I got sick while at work Friday, just achy, ill feeling, nothing more to write home about. Though am proud to say that it took 2 months, and that I didn't pick up something quicker. One of the other docs was sick too, as was Satkile, our abandoned kid. I think he was spreading nasty germs, and since we pick him up every free chance, I'm sure he's the culprit for spreading nasty disease...

 

Thankfully, I rebounded today, as this is moving day. I'll get pics out soon, but this room is HUGE, and I look out onto a garden.

Also, now that there is internet in the house, as well as a landline, I am looking at options to be more in phone contact with people. Am looking to set up a Skype acct where people can call me via a local number, and so that I can make calls out... More on this later.

 

Time to finish unpacking, and then head out and get some sun, and make up for part of the lost weekend..

 

 

 

 

 

 

DNC

I wish I could be in Denver for the DNC. Not nearly as much fun to read about it on-line, and watch small clips. Denver is getting fantastic international coverage, have been catching bits of the BBC news, Euro News (flashbacks to watching euronews while eating breakfast in Dublin), and the local SA news. People have stopped me to comment of how wonderful Denver seems to be.. and I just nod and say "yep, it don't get much better than Denver..." Though, Jo'burg has the same fantastic climate as Denver, sans mountains.. and a bit more crime..

 

No word from the little brother who is working in Denver during the convention, but am looking forward to hearing his stories.

 

Absurd

Absurd. Throughout the day, this seems to be the word that kept coming to mind when thinking about how the past 24, 30 hours had been. Our call yesterday was just absurd.

 

For the record, I came home from work, and went right to bed. That was at 5pm. I don't think I have ever gone to bed, by choice, at 5pm. When I woke up an hour ago, I decided I should take out my contacts and try to be slightly productive...

 

I don't even know where to start..

 

5 pediatric resuscitations. I know there were 5, because I counted them.

 

Let me tell you about #3 and #2.

 

#3: I'm walking past the bench that kids sit on when they are waiting to get admitted. The bench had been empty ALL morning long (the ominous sign), and then we got nailed, and moms kept walking in with relatively sick children. Resus kiddo #2 was stabilized, I'd just finished admission paperwork, and had grabbed the next kid to admit, and was walking into a room to grab an admission packet when I happened to look at this child being held by mom. And this child looked dead. He had that unnatural waxy skin look to him. So, I did the right thing, I kept walking pretending I had never seen the sick kiddo, let him be somebody else's problem! Kidding. So I stopped, and quickly listed for a heart beat, which was there, and was less than 60. 60 kind of being the magical number for if this kid was going to get chest compressions or not... I grabbed the kid from mom and headed to the resus room, and grabbed the other senior resident at the same time. Time for ABCs. She started to bag, I started compressions, and others arrived. One of the medical students started bagging, she prepared to intubate, and I grabbed the first needle I saw I and miraculously got the inter-osseous IV on the first attempt (slightly pissed this kid was sent for admission without IV access from the ED-but this anger was retrospective). After a fluid bolus and some bagging, the heart rate picked up, but kid refused to breathe effectively on his own so he got intubated and went on the last available ventilator. This is an issue... Not having vents, but having more sick babies means it's time to make decisions about who else will get vented, and also means it is time to start calling around and find out what hospitals in Jo'burg have vents and will accept kids..

 

#2: Somewhere around 8pm, I went to do an arterial gas on my kid who had been the second resus of the night. This child had been treated for meningococcal meningitis and discharged the week before, and came in severely acidotic and dehydrated. She got the full resus, but managed to escape the vent. So, I arrive at the bedside, and before jabbing her, glance at the monitor. And her hear rate is in the mid-70s, and her sat seems to be in the mid 70s as well. These are both bad numbers, being sick, her heart rate should be more than 110, even 120, and her sat should be well above 90.. What the hell is going on. I send for the other resident as I poke the kid for blood. As she arrives, the kid drops her hear rate to 20, and then NADA. Zip. Zero. Zilch. We momentarily stare in disbelief at the monitor thinking that this is a cruel joke, but as she listens, and I feel, the child really is not breathing and no heart beat. We start coding the kid. And here, I honestly wish I were back home where there are code teams so somebody else could do chest compressions while we tend to the other details. It really sucks to be powerless. We run the whole algorithm, debate all the possible causes and are pushing meds, I get the kid intubated and as I bag, bloody secretions are aerosolizing and covering the child face. The absurd thing, at one point there is a 3 or 4 year old child behind the glass window of the room behind us who smiles and waves as I glanced in his direction. The medical student wants to throw I the towel at the 10 minute mark ("But we've been doing this for 10 minutes" she tells us). We watched this kid code, he was bagged immediately, and has had effective chest compressions, I try to explain to her why we will continue-(but really I'm half tempted to jump over the bed and strangle her, though I know the other senior resident has first dibs). It's futile. And we call the code after almost 40 minutes. It's really frustrating. This is a child, whom we admitted hours previously (after a vigorous resuscitation correcting fluid and electrolyte abnormalities) who was being followed closely, and who fucking still died with us watching. Literally, with us watching.

 

It's approaching 10pm. The bench is still full. I'm hoping to head home soon, so have stopped admitting new patients and am drawing bloods, doing IVs, spinal taps, etc on the kids who will be admitted. I'm in the procedure room when I hear the door open, and immediately I hear really sick breathing coming from the infant being carried by the senior resident. I pass of the kid I was taking blood from, and we watch as this kid goes into a horrendous coughing fit. This is an easy diagnosis. This child has pertussis. I have a 4 week old with pertussis on the ward, who looks exactly like this kid. Well that's not true, this kid in front of us is in quite a bit more distressed. This night sucks, and isn't fun. I'm never going to get out of here, so I offer to admit the kid. This kid is "HIV exposed." Will we intubate him if needed. Again, no vents or ICU beds at our hospital...

 

There are still 4 waiting for admission, and it's 1130. I grab what should be a pretty simple admission. The pedi ED note basically says 3 week old female with vomiting. This is a slam-dunk admission. I can get a history, spinal tap, bloods, bladder tap, and IV, and write orders on this kid in 45 minutes if I am really lucky! But the history is more complex than simple vomiting. The exam shows mild respiratory distress, fairly unremarkable abdominal exam..  So I feed the kid  some clear rehydration solution in hopes of proving that this kid really isn't projectile vomiting. But of course, when the kid vomits (old milk from 3 hours ago, and no bile) all over the place, the mom shrugs, as if to say, I told you so... (there is more to this, but I want to be in bed in 10 minutes). My admission differential is vomiting due to pneumonia/uti/NNS, maybe due to abdominal pathology (possible pyloric stenosis but kid is young for it, obstruction)..

 

So I finally leave just before 1am... And arrive back at 5:30 this am..

 

#4: The child with pertussis got too tired breathing an hour or two before I got to work, and I walk in to find him intubated. And being placed on a stretcher headed for another hospital who have graciously accepted him for admission.

 

#5: 8:30, just as we start to round on the 23 admission from last night, one of the kids admitted for kwashiorkor has just coded. He doesn't make it.

 

Flash-forward to 3pm. It has been a marathon day. We admitted sick, sick kids last night. Have spent the better part of the day drawing blood, doing LPs, starting IVs, getting essential studies such as ultrasounds, EKGs etc done and trying to basically stabilize the ward before we leave for the afternoon. Nobody has left the ward to go eat all day. We have been so busy with the kids who were admitted that we won't discharge any of the old kids who could have gone home today, because we've basically run out of time to sit and do the paperwork to get them out the door. And we all just want to leave. We are pushing to get out at 4...

 

And at 3pm, my vomiting 3 week old comes back from ultrasound. And she has radiological proof of pyloric stenosis. It's a small mental victory. When I was tired and grumpy last night, I still managed to stick to the fundamentals of being a good clinician. I took a good history, included a broad differential, and made a plan to evaluate with that differential in mind. I was actually shocked it was PS, I had thought that is was going to be more infective etiology. It's an affirmation about being thorough and systematic.

 

Goodnight.

 

 

 

 

Maropeg Pics

 

be sure to check out: http://notesfrombara.blogspot.com/ for some pics from Saturday

Home-My favorite subject

I am willing to bet that "Home" is in the subject line of more blog posts than any other word.

 

I've made some good friends here in the short time that I've been here. I'll point out that this is kind of unusual. In moves previously, I think it's taken longer to make some good friends. Keep in mind, that as of today, I have been here 8 weeks, and will be departing in 10 months.

 

I'll give the full lead up to this...

 

I met CD for brunch today. He is in his early 20s. It wasn't just he and I though. All day long, when talking or walking in the park or hanging out, I had the notion that my 23 year old self was there with us. (Or maybe it was the hallucinogenic mushrooms I had in my omelet-kidding). I kept thinking of who I was at 23, and what I was doing with my life. That was 10 years ago. I could picture myself walking around the park with EW, sitting on the swings in the great Denver sun and drinking iced coffee. About to graduate college, having been rejected to medical school (ps-thanks CU, that rejection was one of the best things that has happened), in a job that I had grown tired of, going out clubbing regularly. It was just bizarre. I thought about my friends who were 10 years older than me at that time, and realized, that I have become them.

 

Anyway, after CD and I departed, I called S (the other S is out of town) because it was such a beautiful day that I needed to have beer outside and people watch. So S met me and we were chatting, catching up (because we hadn't talked in 36 hours). I was telling him about my daytrip Saturday to Maropang. He said something about getting out and seeing things, and I mentioned that I only have 10 months left here in SA! And he gave me a jab, saying that I'd never come to visit once I leave.

 

But I will visit. This is my home right now. I'm not here visiting. Denver has been home. Dublin has been home. Massachusetts has been home. And now here is home. The friends and experiences thus far are way to meaningful to not feel some kind of permanent tie to this area.

 

What's also been spurring this on is that fact that I'll be home-less in December. For a day or so I contemplated taking December off from Bara, and doing something. In fact, I thought about this enough to plan many trips in my head. India. China. Northern Africa. Australia. I feel a bit guilty travelling somewhere that wouldn't include a chance to visit friends. Also, I don't know if I want to give up summer to head into winter and end up somewhere cold (I'm mailing or giving away warm clothes when summer is over here). But, I thought that maybe what I should do is take a month to go back home. Fly to Dublin, spend a week there. Fly to Denver, spend 2 weeks there. Fly to Massachusetts, spend a week there. I felt like I would be cheating if I visited one home and didn't see the others as well. I couldn't fly to Denver and not pop over to Massachusetts for a few days, and vice versa.

 

There was the guilt that I'd also be cheating myself out of my last month of pediatrics, and thus have decided that I will find a new home here in SA in December and complete my 6 months of pediatrics...

 

 

 

_

Floating

I am not floating.

 

The thoughts in my head are.

 

I feel like it has been ages since I've made any significant mentions. Many things have floated through my mind today, like, oh gee, I should mention that, but then it kind of seems that the names may have changed, but the story is largely the same. Also, I think I've hit that comfort zone where things really don't phase me. For example, called to see a baby on the ward with bleeding in the mouth, show up to find the baby being coded (little momentary respiratory distress). A sodium value GREATER THAN 200!. Walking into cubicle 9 this am, which I think has all the trouble making toddlers in it, but are cute as can be, and finding to kids with taking their mercury thermometers and placing them in their mouths, and banging them on the cribs. These are the things that float through my mind as the day passes.

 

The mantra of today was 4pm.

 

It doesn't matter what the hell happens, 4 pm will arrive and then we are outta here! It's been a long week, and we're all tired and just thrilled to have a golden weekend, so at 8am this am we started the countdown until 4pm.

 

Now that my car is legal (and there is still a story to tell there, but I'm too superstitious to post it on the web, and there are many stories to tell about my car in general), I was thinking I'd get out of the country (just sounds cool to say that) this weekend, and hit Lesotho, or Swaziland, or Batswana. But in fact, I'm just too tired to think about driving somewhere, and decided to hold off until Sept to do more traveling on weekends. Am looking forward to a Mon-Fri schedule!

 

So that's about it. My lovely friends S&S have invited me out for dinner, so must get ready to head out and start the weekend off right, with a great steak and some wine and good friends.

 

 

Home Sweet Home

I'm moving at the end of the month (it really isn't cool to post the reasons on this site; there are many reasons I need out of this house). But, the great news is that the new place has a landline, and internet, which means access to phone calls and Skype. Unfortunately, all of the rooms are rented for December, so will have to work that out as time gets closer, but thankfully I have vacation then so will only need to find a place to stay for 2 weeks. Crazy, I know...

 

Anyway, speaking of home, check out this article from the NY Times on the Denver art scene

 

Cheers!

Weekend (and then some) Update

Friday finished work nice and early. Ran to the gym, the grocery store, the watch battery store, the bank. Headed up to S&S house (the gorgeous one I have written about earlier). When I had dinner w/ them last weekend I had mentioned how I would need a social outing when I finished this 14 day stretch on Friday, so they made plans. Basically told I would show up Friday and then head home saturday night. Friday night we had wine sitting outside in the perfect afternoon/evening light, catching up. Then we went out to dinner with some other friends, and then a smaller crowd of us went to meet up with Tim (US professor who is headed back to the US-actually lives in MA). Finally ended up home in the wee hours. Saturday woke up on and off to protests going on outside. Thought I was dreaming of anti-zimbabwe protestors outside, and when I finally got up, realized that the anti-Mugabe protests were starting in the lot across the road! Ended up going for a great brunch and then some walking around and shopping in the Parkhurst area, which rivals melville for having some outdoor seating, shopping, and good people watching. Went back to their house, spent a few hours in the afternoon drinking coffee, reading outside, and I fell asleep outside and took a nice nap! The we went for Sundowners-the art of sitting, enjoying friends and beverages, and watching the sunset. We went to the Westcliff (5 Stars) hotel and it was spectacular. I don't have pics, but S&S do and I will get them, for sure! We then headed out for a Braii, which was also a house-warming for a Norwegian friend of theirs who works at the UN. And what a fun party with so many interesting people!! Unfortunately, I didn't get home until 1 am, and then was up at 6:30 for work. And it was busy, so I ended up leaving work at almost midnight, and then up at 5 yesterday. Needless to say, the excess of work and pleasure have left me slightly wrecked. On rounds today, I started to count down the days left on general wards. The big improvement this month has been my working relationship with the 2 other Regs (Senior Residents) and being treated more like a peer, but the downside has been that while 2 of the other MOs are good, the other 2 are quite lacking, and the medical students are somewhat difficult to manage.

 

More soon...

 

 

A Day of Joy & Taking Steps

I've shown up to work the past 2 mornings with unrealistic demands. Basically have regressed to where I was when I arrived, and find myself getting all bent out of shape that things don't get done as ordered. No neb treatments all night long. No oxygen sat readings. Wrong volume feeds being given to my 8 week old kid with new heart failure. Getting frustrated and all bent out of shape doesn't change anything, except to make me grumpy.

 

We had a great day. We only had 11 admissions yesterday to our ward (4 to other wards), and a pretty light work load...

 

One of the things that has been bothering me since I got here is how un-inspiring the ward can be at times. Little stimulation for the children. Like I mentioned before, one coloring book.

 

And then today, a bag of donated toys appeared. It was like Christmas (or like all the kids had a birthday on the say day, don't want to force Christian holidays on anybody). Of course, "S" got first dibs! Today really felt like what a children's ward should be. (I may have a pic from today, but it's not going up now). At one point, in Cubicle 9, KM, a 3 y/o was on the floor, playing with 2 other kids, and they were eating oranges all at the same time! Smiling. Laughing. Pretending to shoot each other with toy guns (ok, not that the toy gun thing makes me happy, but what the hell)...

 

Today was joyous for other reasons..

 

Step 1:

We have a 9 year old girl on the ward who has cerebellitis (infection of the cerebellum, portion of the brain which controls fine motor) after having had Hep A. Rare, but has been reported before. And she's had really poor coordination (cerebellum-portion of the brain which takes a hit with alcohol, so you can guess how she walks, and in fact, I completely plan on walking that way in 24 hours from now). Today she was actually outside with the PT/OT group (nice sunny day) and was making small progress and taking some steps.

 

Step 2:

We have a 10 y/o boy who was admitted with pneumococcal meningitis and septicemia. I remember when we did a spinal tap on this kid last week, he didn't even flinch. At one point I looked at home to make sure he was actually still breathing. He was basically comatose for a few days. But he has slowly woken up. Here's a plug for crunchy parents, if you don't want to vaccinate your kid, and they get pneumococcal meningitis, they are in for a bad, bad time.  (Where's that damn soap box...) Oh, so anyway, he's actually made a bit of progress. (I thought it was a bit cruel that for the past 2 days it's just been him and the 2 y/o with TB meningitis-who is basically left in a vegetative state. Anyway, the 10 y/o sat up in bed yesterday, and with the help of holding on to 2 PT assistants, took some steps.

 

Step 3:

I know I go on and on about S. But seriously, this kid wakes up happy, smiles, laughs, giggles, and is such a ball of joy to have in the ward. He is SPOILED, Rotten. But, after a week or two of neglect in the ward, when we realized that he is never going to get placed (we joke that in 12 years he'll get transferred to the adult ward), we've set some goals. Basically, get him walking and talking. I don't think he is really developmentally delayed, but rather hasn't had enough stimulation and will catch up nicely. And today, with much coaxing, the other Reg and I got him to take 2 steps!! Woo-Hoo.

The most amazing thing about today is that we were post-call and didn't have the normal crazed post-intake madness that usually keeps us from goofing around and having fun. It was really a joyous day.

 

 

Safety Net

The hospital is suppose to be the safety net of the system. To be there to provide medical care for all in the community. And if people don't have access to a regular medical practitioner, then the ER becomes the ultimate safety net. But I don't understand, yet, how the safety net here fails to catch people. Are there holes in the net, or are people (kids) just too far out of reach of the net?

We had a monthly review meeting yesterday. A review of the stats from the previous month. This review is only for the 4 general pediatric ward teams. The stats don't reflect newborns/NICU/hemeatology-oncology/pedi ED, pedi surgery or the metabolic/refeading units.

 

In July there were 507 admissions, and 37 deaths. Each team reviewed the overall picture of the kids who had died. And it was quite interesting to note that more than a few of these kids died the same day they were admitted, or even within a few hours of coming into the hospital. What is keeping these kids from showing up earlier, and therefore, maybe having a better chance of making it?

 

Certainly, many of these kids had gone to local healers (aka sangoma) as a first option. This is culturally related. But also there is a delay because as far as I understand, one must go to the local clinic first to be seen (likely a wait there) and then be referred to the pedi ED (more wait) and then eventually seen, and eventually admitted.

 

Some of these deaths were not completely unexpected. A few, well-known, kids with chronic medical conditions died during the month, having exhausted medical therapy. But it seemed that so many of the deaths were related to poor nutrition and living standards. It's always been one thing to read statistics of child mortality and know that diarrheal diseases and respiratory infections are big offenders, but there has always been a disconnect in reading this information. But having seen these kids the past few weeks, it's really, really appalling to know that many of these deaths have been preventable!

 

I was kind of tuning out thinking about how many preventable deaths occur over the year when something caught my attention.

 

"Baby S, and 8 month old discharged from ward 18 2 week prior. . ."   And so now I'm really curious to know who this kid is. . .  "had been admitted initially w/ dehydration and severe malnutrition. . ." This is beginning to sound familiar. . . "Was readmitted for -blank- and died the next day."

 

-blank-

-blank-

 

Blank isn't some mysterious medical condition or something that I'm too worried to share, but blank is exactly what happened in my mind as I realized who this kids was.

 

My Baby S! The one I wrote about last month.

 

Shit!

 

And I think this sucks. He had follow up in place, but somehow something happened, and he either fell through the safety net, or missed it completely on his way down.

Address Change

Hi-

If you have my current address in South Africa, please hold off on sending me anything for the time being, as my address may be changing.
 
Cheers

Caca

Me: Grandma, how is the baby's caca?

 

Caca is the appropriate term for it. I've seen more variation in Caca than I ever thought was possible. I've seen the classically pasty white stools of biliary atresia. The malnourished kids have liquid yellow caca (which kind of reminds me of egg drop soup). So, asking about caca is routine. It's routine elsewhere too, here is really no different. In fact, I remember being told once, when you need time to think about what other questions to ask, as about bowel movements as a stall tactic.

 

Grandma: Oh Doctor! The caca is very, very nice.

 

That's it. Nice caca. Now I've heard it all. Grandma loves this boy. So much that even his caca is great. It's almost like she is describing a place I should visit. Oh Doctor! Clarens is very, very nice. Or a bottle of wine. Or a cheese. But caca...

 

This saying has been playing over and over in my head. Last night as I was running on the treadmill I laughed as I thought about me asking her that question in the admission ward. Oh Doctor! The caca is very, very nice.

 

I headed in a bit earlier than usual today, looking forward to getting out maybe a bit early and enjoying an afternoon run.

 

Today, was caca. And there was nothing nice about it.

 

I walked into the ward, looked into cubicle 10 to see if the 2 year old had made it through the night. His bed was empty, but with ward shuffle, there could be a chance he was still alive, though it would be a miracle, but not necessarily a good one. As I sat down to check labs, one of the nurses came over to me.

Sister: Doctor, there is a resus going on.

Me: Where?

Sister: In the resus room. (Which seems like a good place to do it).

 

I had walked past the room on the way into the ward, the door was closed, so I didn't think anything of it.  This is also our procedure (blood draw, IV, spinal tap) room. So I head to the room. And of course, I put 2 and 2 together, and wonder why the 2 y/o is in the resuscitation room, certainly his file clearly indicated he was "not for" active resuscitation.

 

And as I step into the room, I see an exasperated pedi registrar (senior resident), and 4 month old infant. Caca. Not nice caca.

 

Me: What's the story?

Her: low sugar, can't get an IV. dehydration.

Me: who is this kid? (I can't figure out why he is in here, though he looks familiar)

Her: it's your ward, do you know this kid?

Me: (grabbing the chart) yes.. (we'd reviewed him at 4pm, he was in with pneumonia, went back on oxygen in the afternoon, but was fine otherwise).

Her: Is he for active resuscitation?

Me: (I hesitate to say yes, because in my mind some days all these kids are still for active resuscitation). Yes, he's negative (HIV), he was getting better, and was likely going home in a day or two.

Her: This is the fourth resuscitation of the night.

Me: damn, that's not good.

Her: On this ward.

 

Oh caca. Really, really not nice caca.

 

We fumble for an IV. It's getting drastic, this kid is literally crashing before our eyes, and we don't have an IV. We tackle from opposite ends. There is still an airway, there is still breathing, there is still circulation (barely) but there isn't glucose, and there isn't enough fluid in the system. She's trying for a femoral line, and I'm going for an intraosseous (needle into the shin bone). And we both are striking out. So we literally switch sides. I'm working on the central line, she on the intraosseous. I ask the nurse to find some glucagon (like this kid is going to have any glycogen in the liver...). Glucagon doesn't ring any bells to the staff... I ask her to call to casualty and find some. Also, asking to drop an NG and give the kid some oral until we get an IV.

 

His breathing is slowing down.

 

Caca.

 

Time to make the decision.

Me: It's time to intubate.

Her: he is definitely for ventilation

Me: yes.

Her: Ok, can you grab a tube?

 

So I reach to the emergency trolley. And that's when I see the failed third resus attempt. I'm caught off guard. Apparently, that kid had just died when they literally whisked this kid into the resus room, and literally there wasn't time to do anything but move the body off to the side.

 

[I hesitate to write that part. But to me the reason to mention is that this hospital is amazing. You have incredibly sick kids being take care of by a staff-both nurses and doctors, who work against such tremendous odds at times, and when the shit hits the fan sometimes you are literally moving from desperate situation to desperate situation, and there wasn't even time to remove the body from the resuscitation room].

 

There is a trend here to nasally intubate kids and confirm placement/finish placement with forceps using the laryngoscope. I don't understand this method. To me it just takes longer. It's a tough intubation.

 

I offer to try, and she agrees. I haven't intubated an infant in a long time. But as I insert the laryngoscope, the cords drop into view and I get the tube it. I'm so surprised that I actually got the tube on the first try that I damn near inserted the thing the whole way.

 

We start bagging the kid. By this time, others should be around, and she gets on the phone and calls for back up. Who arrive.

 

We start full CPR. Get IV access (finally an IO), but it's really too late.

 

By the time we decided to stop, the entire team, is in this room. It's sinking in that in addition to the kid who we knew was going to die, that 3 others died as well. One of those wasn't too unexpected. But 4 deaths overnight takes a toll on morale. I absolutely must point out here that these kids were sick. All of them would have been in the pediatric ICU back home, or at least would have been moved there well before demise. There isn't any sense of wrong doing or negligence at all, but rather a sense of defeat by the level of poverty, the disease burden, and the lack of ability of the system to fix these kids.

 

The day ends when I discharge the child with the nice caca. I see the grandma walking out, carrying her grandson on her back, as is custom here, and I think about the nice caca and laugh to myself. Thank god this day is over.

 

Ward 18 Mascot

This is a pic from the day we took S on our tea break. He came in having gotten into organophosphates (an effective, cheap pesticide, which is bad to ingest). He's been abandoned. He's always got this smile and happy-go-lucky persona. Though, we were reminded that he screamed and cried for the first 2 days on the ward, back in early July. He's 13 or 14 months, and there's been a slight rally around him recently, now that it seems he may be on the ward for many months. We've come up with the goal of getting him talking and walking. He's mostly developmentally appropriate, though maybe slight language delay. This morning he was crawling down the hall as we were in the first cubicle on rounds, and I grabbed him and carried him on rounds until I got too tired and had to set him free.

The contrasts on the ward are extreme.

This afternoon three of us spent the better part of an hour trying to "drip" a kid (aka get an IV). This kid doesn't need an IV though. What he really needs is some pain control, and to be held. He will be dead by morning.

This morning, I was debating (in my head), whether I should test my 13 day old kid for HIV. Which means test the mom (who has told me she is negative, but doesn't have a copy of her results), or do a PCR on the kid (expensive). And I decided not to. Why, because I trust this mom. Which is silly, because the newborn is my patient, not the mom.

After an hour, and multiple, multiple stabs, I got an IV. Luck. This kid is 2. He's smaller than S. He was past the point of flinching with IV stabs. And he didn't bleed from them, but oozed serous fluid from where the IV cannulas pierced the skin.
What is remarkable, is that this is his first visit to the hospital. This kid has never walked. Can't feed himself. And is wasted. We tried to figure out where to lay the blame. How could this kid, who will die tonight from HIV, TB, malnutrition, end up in this state?!?? This is more a rhetorical question, as this is a complex problem, and blame won't bring about change.

And then I thought back to my 13 day old baby. And realized the answer to my debate from earlier. Yes. Of course, the kid should be tested. Any chance to diagnose a kid with HIV, and get them appropriate medical care for their status, and hopefully prevent them from dying in the hospital at age 2, should be jumped on.

Reality needs to trump Trust.

To end this on a lighter note, S shit on me yesterday. But we're still pals, I just check diapers regularly now.

Cleaning House

I theoretically could have had no patients when I get to work in the morning. But one will be left (who will be bounced back to his ward tomorrow). Once you're admitted to a ward at Bara, pediatrics, you basically go back to that ward until you're 14, if you are re-admitted.

 

I discharged the 8 y/o with TB (pulmonary and abdominal), HIV, Anemia, Depression, severe malnutrition. The palliative medicine physician scored major bonus points with me and was so concerned about this girl that she found a placement within 4 days! So she's off to hospice to get some better rehab care before going home. She was actually beginning to perk up a bit too!

I also discharged the kiddo who came in with status seizure last week. Amazing what the human brain can endure, this kiddo seems to be back to her normal self.

 

There was also an silence on the ward this morning. M, our 3 year old who suffered a head injury and has lived on the ward for months was finally placed. I don't know the full story, but think there is suspected child abuse, and she was kind of abandoned, or they couldn't figure out to whom to release her, but she is now gone. She was cute, usually walking around the ward (nekked), smiling and holding the lone coloring book of Ward 18. She didn't have much verbal skill, but she always had a smile!

That leaves S. Our currently orphaned 13 month old, as the sole Mascot for Ward 18. "Are you sure you don't want to adopt him?" A question I've been asked numerous times. He's such a ham! We've taken him to the break room with us, and last week he was spotted in the cafeteria with one of the staff.

We're on call tomorrow.

g'night.

New Family

Our new niece, held by Uncle Kevin

Missing Out...

Tomorrow I'm missing a wedding.

 

There will be many things I miss in the next 11 months. When I started to plan this a year ago, I didn't take into consideration the events I would miss out on. I knew there would be things that happen that I'd like to witness. Both things planned, and unexpected.

 

This is the second wedding that I'll miss while in South Africa. The first was in 2003, when my little brother got married. This time, one of my dearest friends is getting married in San Francisco. Ona introduced me to my favorite coffee in the world, has hosted me numerous times when I needed to hang out and needed an escape. She was one of the people I clubbed with regularly, many, many years ago. If I were able to make it to her wedding, I would take Mint Aero Bars as a wedding gift, because when she visited in Dublin we ate Aero Bars and made outrageous jokes one night...

 

Tomorrow night, I'll have a silent toast and some mint aero bars to celebrate from afar.