Intake

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Compare...

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

 

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

 

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

 

Baby S should weight 8 kg/17 lbs

Baby T should weight 6.5 kg/15 lbs

 

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

 

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

 

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

 

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

 

Baby S is HIV negative.

Baby T is HIV positive.

 

The only way to tell is to test.

Not For

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

 

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

 

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

 

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

 

The kid is no longer "not for."

 

 

 

 

Square One, and Hiearachy

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

First Day

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

 

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

 

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

 

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

 

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

 

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

 

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

 

Cheers.

Driving "home" with Cat Stevens

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cops vs Cops in Shootout

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

 

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

 

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

 

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

 

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

 

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

 

Cheers

 

 

Take your phone-in case you get mugged

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

I'm sure I'll be sore tomorrow.  

 

 

 

 

Hats off to Bank of America

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

 

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

 

 

 

 

Mantra

The mantra for today: "Stay Left."

 

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

 

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

 

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

 

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

 

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

 

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

 

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

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

 

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

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

 

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

 

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

 

Cheers,

 

 

 

 

Failure of Ownership

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

 

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

 

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

 

I strongly believe in taking full responsibility for patients.

 

Patients

in

the

hospital.

 

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

 

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

 

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

 

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

 

I believe in ownership.

 

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

 

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

 

I introduced myself.

 

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

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

 

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

 

And there I sit looking at a broken soul.

 

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

 

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

 

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

 

Today is a failure of patient ownership.

 

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

 

Final Week

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

Reality...

Has set it.

 

It is crunch time. And I feel it.

 

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

 

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

Northern Exposure

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

 

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

 

I needed mountain air and solitude.

 

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

 

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

 

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

 

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

-Himalayan Base camp doctor

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

-Med-Peds hospitalist at DG

-Cruise Ship doctor

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

-Be employed by WHO/UNICEF

-Take a tropical medicine course

-Spend time doing locum tenems

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

 

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

 

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

 

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

 

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

 

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

Party Antics..

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

Full Circle

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

 

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

 

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

 

It's all good.

Getting Sued

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

 

Ironically, this was the highlight of my afternoon.

 

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

 

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

 

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

 

I look GV square in the eye:

 

Me: You want to sue me

GV: Yes

Me: Oh really. What for?

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

 

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

 

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

 

Me: Yeah, so?

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

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

 

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

 

GV: Five thousand dollars.

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

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

 

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

 

It's a small reprieve.

 

 

Websites

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

 

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

 

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

 

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

 

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

 

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

 

 

BPB

Nocturist

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