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...

 

 

 

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