Percentage of women who seek prenatal care, and are tested, with HIV in Botswana:
Age-----------------------2003------------------------ 2005
15-19---------------------22.8--------------------------17.8
20-24---------------------38.6------------------------- 30.6
25-28---------------------49.7 ------------------------- 44.5
30-34---------------------45.9--------------------------45.2
35-39---------------------41.5--------------------------40.2
40-49---------------------34.4--------------------------30.4
Tuesday, October 28, 2008
Tuesday 28 October 2008
Today was almost one of those “take the patient to the ICU and damn the consequences” type days except the patient died before I had a chance to get a good head of steam worked up. Now that I have been here for some time it’s interesting to me how different the various wards are. Since I take call (“second call”) about seven times a month I consult during the day one surgical patients with fevers and the like and then help the M.O.’s at night with difficult cases. Lately I’ve been able to visit Ob-Gyn, Surgery, and Ortho for simple stuff and have been impressed how the nurses gather around me and listen intently as I explain the pathophysiology of whatever and the best approach to it. They greet me as I come onto the ward and always are very professional.
The nurses of the male and female medical wards would have a difficult time being any more ambivalent. Today we had a woman crashing on the female side and getting a nurse to a) show interest and b) move was horrific. The passive aggression of the wards is deafening. And I think we share the fault to some extent. The HUP (read Penn) mentality can really come on strong and is somewhat off putting, even to an Oregon family doc like me. Apparently when this all began six (?) years ago there was a service of HUP only providers and as can be imagined the culture clash was significant.
This isn’t to say that this hasn’t been addressed and to some extent remedied by us but it is a long way from even and easy. And the patients suffer. We had two clean kills in four days where the nursing service admitted an unstable patient and dutifully noted that he was so, didn’t notify anyone and the patient quietly and inappropriately died.
So there’s one of the challenges. The nursing service isn’t used to questioning the wisdom of the admission and doesn’t see its role as doing anything other than carrying out the orders of the doctor. Hence; no orders-no therapy. Many has been the time we are blithely rounding only to find a patient admitted from last night that is unstable with nursing notes confirming that. On any other unit the nurses would be acting in the advocacy of the patient and would be notifying the world. Why not the medical wards?
The biking is great and my back is sore from the weird confirmation of the thing. Never the less I’m a happy guy. The flat is torn up at the moment as many tiles were loose and are being replaced, a good if very dusty thing. I’m hoping to get a peds gig in mid December to mid January as things slow down in outreach.
Best to you all. I Love hearing from anyone via the blog or e-mail. It makes my day.
Today was almost one of those “take the patient to the ICU and damn the consequences” type days except the patient died before I had a chance to get a good head of steam worked up. Now that I have been here for some time it’s interesting to me how different the various wards are. Since I take call (“second call”) about seven times a month I consult during the day one surgical patients with fevers and the like and then help the M.O.’s at night with difficult cases. Lately I’ve been able to visit Ob-Gyn, Surgery, and Ortho for simple stuff and have been impressed how the nurses gather around me and listen intently as I explain the pathophysiology of whatever and the best approach to it. They greet me as I come onto the ward and always are very professional.
The nurses of the male and female medical wards would have a difficult time being any more ambivalent. Today we had a woman crashing on the female side and getting a nurse to a) show interest and b) move was horrific. The passive aggression of the wards is deafening. And I think we share the fault to some extent. The HUP (read Penn) mentality can really come on strong and is somewhat off putting, even to an Oregon family doc like me. Apparently when this all began six (?) years ago there was a service of HUP only providers and as can be imagined the culture clash was significant.
This isn’t to say that this hasn’t been addressed and to some extent remedied by us but it is a long way from even and easy. And the patients suffer. We had two clean kills in four days where the nursing service admitted an unstable patient and dutifully noted that he was so, didn’t notify anyone and the patient quietly and inappropriately died.
So there’s one of the challenges. The nursing service isn’t used to questioning the wisdom of the admission and doesn’t see its role as doing anything other than carrying out the orders of the doctor. Hence; no orders-no therapy. Many has been the time we are blithely rounding only to find a patient admitted from last night that is unstable with nursing notes confirming that. On any other unit the nurses would be acting in the advocacy of the patient and would be notifying the world. Why not the medical wards?
The biking is great and my back is sore from the weird confirmation of the thing. Never the less I’m a happy guy. The flat is torn up at the moment as many tiles were loose and are being replaced, a good if very dusty thing. I’m hoping to get a peds gig in mid December to mid January as things slow down in outreach.
Best to you all. I Love hearing from anyone via the blog or e-mail. It makes my day.
Sunday, October 26, 2008
Better, bordering on great..
Sunday afternoon, 26 October 2008
I got a bike! And not just any bike, a Supa Hamba, a Chinese knock off, made in India, that is almost exactly like the one I rode in Sudan. It’s “all steel” which makes it heavy and indestructible. It has fat tires, and a coaster brake (here it differs from the one in Sudan in that I can stop this one). I bought it for under $100.00 as the exchange rate is P8.00 to the greenback, up (actually down as iy were) from P6.00/$1.00 on our arrival. I’m now about a 2min ride from the hospital, faster than by car as I can ride it on a dirt strip that cuts through the neighborhood straight to the hospital gounds.
Where we had a legitimate couple of saves! We had a guy with sepsis and a systolic pressure of 30mmHg for who knows how long before we got to him. He was comatose, wasn’t making much of a fuss and besides seemed comfortable so the cubicle nurse just dutifully recorded his pressure as “unrecordable” and moved on. We got to him on routine rounds and began vigorous resuscitation with gobs of fluids and what has become the antibiotic cocktail of choice here; cefotaxime, metronidazole, and vancomycin. Today, Sunday, he is alive, awake, and wondering what the big deal is. Another came in with sepsis and a CD4 count in negative numbers and is slowly doing better. The energy expended on simple vigilance here is staggering and takes its toll by weeks end.
On Friday we reviewed the death of a 22y/o woman who died with and from an acute abdomen. The old saw about how one should never let the abdominal wall stand between you and a diagnosis doesn’t play well with the surgery folks here, or at least some of them. We have an old ex-Soviet surgeon who is fantastic. Unfortunately for the patient he was off call. She came in with classic signs of infectious cholecystitis (a serious infection of the gall bladder). Before she would be accepted for “theater” she needed a chest X-ray, something that takes two days on average. Interesting that virtually everyone is admitted through A&E with a CXR that is many times of little use. So the surgeons have deniability built into their refusal to manage an acutely ill patient for whom surgery is clearly indicated , even without a blasted chest X-ray, and radiology continues to stumble along in all its passive-aggressive glory. Nicola and I have vowed that this is the last time this happens on our service and that the theater might just be the next site of a harried attending wheeling a sick patient across its threshold for definitive care, a la the ICU and me about three weeks ago.
We are moved in and things are definitely better. Today I worked on my bike, did some yard work, went shopping for tools, drank some coffee at a local shop and watched the amazing array of peoples that populate this capital pass by. Many had kids with whom I’d play around and it was a hoot.
It’s the beginning of a new week that promises to bring change and challenge as I start outreach on Friday part time. It should be interesting. Thanks for joining this stream of consciousness.
I got a bike! And not just any bike, a Supa Hamba, a Chinese knock off, made in India, that is almost exactly like the one I rode in Sudan. It’s “all steel” which makes it heavy and indestructible. It has fat tires, and a coaster brake (here it differs from the one in Sudan in that I can stop this one). I bought it for under $100.00 as the exchange rate is P8.00 to the greenback, up (actually down as iy were) from P6.00/$1.00 on our arrival. I’m now about a 2min ride from the hospital, faster than by car as I can ride it on a dirt strip that cuts through the neighborhood straight to the hospital gounds.
Where we had a legitimate couple of saves! We had a guy with sepsis and a systolic pressure of 30mmHg for who knows how long before we got to him. He was comatose, wasn’t making much of a fuss and besides seemed comfortable so the cubicle nurse just dutifully recorded his pressure as “unrecordable” and moved on. We got to him on routine rounds and began vigorous resuscitation with gobs of fluids and what has become the antibiotic cocktail of choice here; cefotaxime, metronidazole, and vancomycin. Today, Sunday, he is alive, awake, and wondering what the big deal is. Another came in with sepsis and a CD4 count in negative numbers and is slowly doing better. The energy expended on simple vigilance here is staggering and takes its toll by weeks end.
On Friday we reviewed the death of a 22y/o woman who died with and from an acute abdomen. The old saw about how one should never let the abdominal wall stand between you and a diagnosis doesn’t play well with the surgery folks here, or at least some of them. We have an old ex-Soviet surgeon who is fantastic. Unfortunately for the patient he was off call. She came in with classic signs of infectious cholecystitis (a serious infection of the gall bladder). Before she would be accepted for “theater” she needed a chest X-ray, something that takes two days on average. Interesting that virtually everyone is admitted through A&E with a CXR that is many times of little use. So the surgeons have deniability built into their refusal to manage an acutely ill patient for whom surgery is clearly indicated , even without a blasted chest X-ray, and radiology continues to stumble along in all its passive-aggressive glory. Nicola and I have vowed that this is the last time this happens on our service and that the theater might just be the next site of a harried attending wheeling a sick patient across its threshold for definitive care, a la the ICU and me about three weeks ago.
We are moved in and things are definitely better. Today I worked on my bike, did some yard work, went shopping for tools, drank some coffee at a local shop and watched the amazing array of peoples that populate this capital pass by. Many had kids with whom I’d play around and it was a hoot.
It’s the beginning of a new week that promises to bring change and challenge as I start outreach on Friday part time. It should be interesting. Thanks for joining this stream of consciousness.
Tuesday, October 21, 2008
My service as of tonight, and more...
For the more medically inclined a run down of the service, all are male:
-35y/o with HIV on HAART for two weeks with crypto meningitis and a CD4 of <50
-81y/o with a ® parietal tuberculoma of the brain, seizures, inability to communicate or locomote for 1 wk.
-54y/o with inability to swallow for 1 wk, and as it turns out a host of other neurological deficits that span the upper and lower motor neuron spectrum with reflexes preserved making this a process that could really have only one diagnosis; ALS. Why is it that the really nice guys get this?
-36y/o with 3rd admission in one month for focal seizures and malcompliance with anti seizure meds.
-51y/o with HIV, low CD4 and ® sided weakness and chronic diarrhea.
-35y/o with HIV and alcohol withdrawal, panic disorder, and a CD4 in negative numbers.
-30y/o with crypto meningitis on day 10/14 of amphotericin.
-37y/o with HIV and now on HARRT with end stage pneumocystis of the lungs and chronic bronco-pleural fistulae necessitating bilateral now unilateral chest tube(s).
-36y/o with bilateral lower extremity paresis c/w with a Guillian-Barre like syndrome but he has had it long enough that is should be resolving to some extent by now. He has bloody emesis and was transfused three units, now more stable but with significantly depressed mental status.
-42y/o with HIV and recurrent TB.
-52y/o with numerous tumors of the lung and presumed mets to the brain.
-49y/o with HIV, DM II, and encephalitis that has improved and will go home soon.
-38y/o with XDRTB (extremely drug resistant TB) who is housed in an isolation ward such that it appears that he is imprisoned.
As I review this list I again marvel at the depth and breadth of pathology; ALS and XDRTB on the same service? I am definitely in the right place at the right time in my career. I miss CGFM to be sure yet this is so stimulating and fascinating, so immediate, requiring a creative approach to everything that I feel truly fortunate.
And as of tonight we have moved! Not lock, stock, and barrel but tonight is the first night in our own digs. The house here is wonderful and the Jones have been amazing hosts, and the bedroom will always be an icon for violation unfortunately. We simply need to have it behind us. I am surprised how insecure I feel at night. I have been in loads of worse places but never have had this happen to me/us and it will be nice to take a step forward. We have high speed internet wireless and will soon have DSL. Life has been good and this is a blessing indeed.
At the end of next week I start outreach and begin it full time in December. Wow, I am indeed blessed. Blessed to have the friends we have thus far with the Jones family at the top pf that list and many people from Gabs, Penn, Baylor, and elsewhere with whom to become better acquainted.
-35y/o with HIV on HAART for two weeks with crypto meningitis and a CD4 of <50
-81y/o with a ® parietal tuberculoma of the brain, seizures, inability to communicate or locomote for 1 wk.
-54y/o with inability to swallow for 1 wk, and as it turns out a host of other neurological deficits that span the upper and lower motor neuron spectrum with reflexes preserved making this a process that could really have only one diagnosis; ALS. Why is it that the really nice guys get this?
-36y/o with 3rd admission in one month for focal seizures and malcompliance with anti seizure meds.
-51y/o with HIV, low CD4 and ® sided weakness and chronic diarrhea.
-35y/o with HIV and alcohol withdrawal, panic disorder, and a CD4 in negative numbers.
-30y/o with crypto meningitis on day 10/14 of amphotericin.
-37y/o with HIV and now on HARRT with end stage pneumocystis of the lungs and chronic bronco-pleural fistulae necessitating bilateral now unilateral chest tube(s).
-36y/o with bilateral lower extremity paresis c/w with a Guillian-Barre like syndrome but he has had it long enough that is should be resolving to some extent by now. He has bloody emesis and was transfused three units, now more stable but with significantly depressed mental status.
-42y/o with HIV and recurrent TB.
-52y/o with numerous tumors of the lung and presumed mets to the brain.
-49y/o with HIV, DM II, and encephalitis that has improved and will go home soon.
-38y/o with XDRTB (extremely drug resistant TB) who is housed in an isolation ward such that it appears that he is imprisoned.
As I review this list I again marvel at the depth and breadth of pathology; ALS and XDRTB on the same service? I am definitely in the right place at the right time in my career. I miss CGFM to be sure yet this is so stimulating and fascinating, so immediate, requiring a creative approach to everything that I feel truly fortunate.
And as of tonight we have moved! Not lock, stock, and barrel but tonight is the first night in our own digs. The house here is wonderful and the Jones have been amazing hosts, and the bedroom will always be an icon for violation unfortunately. We simply need to have it behind us. I am surprised how insecure I feel at night. I have been in loads of worse places but never have had this happen to me/us and it will be nice to take a step forward. We have high speed internet wireless and will soon have DSL. Life has been good and this is a blessing indeed.
At the end of next week I start outreach and begin it full time in December. Wow, I am indeed blessed. Blessed to have the friends we have thus far with the Jones family at the top pf that list and many people from Gabs, Penn, Baylor, and elsewhere with whom to become better acquainted.
Thursday, October 16, 2008
Musings
It occurs to me that I’ve used this space too frequently of late as an avenue for venting and the occasional rant. Those of you kind enough to respond have been very supportive and that has been most welcomed. The last week has been a little tough as sleeping is frequently interrupted after the break-in to our bedroom. From the shadow of the guy and the size of the shoes he left by the window he was small, probably just a kid but the sense of violation of security is quite real and a pain to process through.
We are prevailing however. Lynne is incredible in that I never expected to see her grow so much and so fast. She is at ease with most anyone here, and is well known in many circles. Me, I’m just the guy that commutes to the hospital every day. Although I will state categorically that this has been most invigorating. I truly have no regrets. I think it will take about 6 mos before the pratfalls, pitfalls, and stupid foreigner stuff eases back. I feel myself changing ever so slowly; thinning out, looking for the teachable moment on the wards, becoming more comfortable with the breadth and depth of disease, more pragmatic about death.
Certainly death is frequent here, often referred to as being “late”. It is a privilege to witness it first hand and know the dignity that accompanies it. An added bonus is to vicariously experience it through my students who often are seeing it for the first time.
Nicola and I get together every Wednesday evening to talk shop and drink some beer and whiskey. It’s fascinating how we come from such different backgrounds, different eras in medicine (he is two years older than our eldest) and share similar values, ideas regarding teaching and treatment, and the like. Lynne is a great host in that she quietly rolls her eyes as we giggle like little boys caught with our hands in the cookie jar, but we get a lot done on these evenings. I get to osmoze some infectious disease info and he gets to unwind and just be himself for an evening.
We are in spring now with temps routinely in the high 30’s (remember 36C is roughly 99F) and the climate is at its driest time of the year. Because of the break in we sleep with all windows closed and a fan on in our room so it’s hot, not as hot as Sudan, but hot enough to be bothered by it. In any case is makes for a challenging night’s sleep, and a nap each day.
I’m slowly getting a hand on the pathology of male patients with HIV and look forward to travelling to outlying hospitals and with Lynne around the country. That will come in time. The rhythm is slower here, refreshing at some level once one gets used to it, costly if you are on our ward for the weekend and get sick as you might not come to the attention of the medical staff unless a capable nurse speaks up. We simply are understaffed on weekends and can’t round on everyone.
It is derisively referred to as “Botswana time” by expats. I actually like the pace, the down side being that there is potential medical cost to pace that is more measured. Finding middle ground will come in time.
We are prevailing however. Lynne is incredible in that I never expected to see her grow so much and so fast. She is at ease with most anyone here, and is well known in many circles. Me, I’m just the guy that commutes to the hospital every day. Although I will state categorically that this has been most invigorating. I truly have no regrets. I think it will take about 6 mos before the pratfalls, pitfalls, and stupid foreigner stuff eases back. I feel myself changing ever so slowly; thinning out, looking for the teachable moment on the wards, becoming more comfortable with the breadth and depth of disease, more pragmatic about death.
Certainly death is frequent here, often referred to as being “late”. It is a privilege to witness it first hand and know the dignity that accompanies it. An added bonus is to vicariously experience it through my students who often are seeing it for the first time.
Nicola and I get together every Wednesday evening to talk shop and drink some beer and whiskey. It’s fascinating how we come from such different backgrounds, different eras in medicine (he is two years older than our eldest) and share similar values, ideas regarding teaching and treatment, and the like. Lynne is a great host in that she quietly rolls her eyes as we giggle like little boys caught with our hands in the cookie jar, but we get a lot done on these evenings. I get to osmoze some infectious disease info and he gets to unwind and just be himself for an evening.
We are in spring now with temps routinely in the high 30’s (remember 36C is roughly 99F) and the climate is at its driest time of the year. Because of the break in we sleep with all windows closed and a fan on in our room so it’s hot, not as hot as Sudan, but hot enough to be bothered by it. In any case is makes for a challenging night’s sleep, and a nap each day.
I’m slowly getting a hand on the pathology of male patients with HIV and look forward to travelling to outlying hospitals and with Lynne around the country. That will come in time. The rhythm is slower here, refreshing at some level once one gets used to it, costly if you are on our ward for the weekend and get sick as you might not come to the attention of the medical staff unless a capable nurse speaks up. We simply are understaffed on weekends and can’t round on everyone.
It is derisively referred to as “Botswana time” by expats. I actually like the pace, the down side being that there is potential medical cost to pace that is more measured. Finding middle ground will come in time.
Tuesday, October 14, 2008
Yes, one for the team!
Things have slowed down a little and have allowed me to be a touch more reflective from a more experienced point of view.
Virtually all our patients on the male side are HIV+ with some co morbid problem; TB, pneumonia, wasting, hepatitis, pancreatitis, fever of unknown origin, meningitis or some combination thereof. All are younger than 40 and all are at various stages of use of Highly Active Antiretroviral Therapy (HAART). The meds are administered by the local clinics and are so tightly controlled for compliance that even if I order them here on the ward, they won’t be administered unless initiated by the Infectious Disease Control Clinic (IDCC). So today I walked over five charts of our patients that needed to start or restart HARRT. It’s important to emphasize that the majority of hospitalizations are avoidable if compliance of the patients was better. Even at that, the evidence is that compliance here in sub Saharan Africa is around 95% vs. 55-60% in Europe and the US. On rare occasion we will have a patient with routine hypertensive emergency with a diastolic pressure of >140 and headache or status asthmaticus, or the “feel bads” and are dropped off at the A&E by the family who is going for a vacation. This might be one of the larger down sides of medicine available to all in this country, we will have a service that is best described as more nursing home than acute hospital.
There is a lot of drinking here. My past ventures have been to either remote places or Muslim populations or both so the alcohol use was lighter. Here it is heavy and frequent on the weekend. And I find myself looking forward to some hooch in the evening. We have lousy beer and garden variety whiskey but it still does the job. Coming from a long line of drunks as I do, I find myself treading uncomfortably close to the ragged edge, and know it. The last time I was this close was in KY when I had just started practice. I need to exercise and will start as soon as the month is out and we are moved into our own digs, and I feel more comfortable on the wards, all are within about two weeks time. I’ll be OK, no need to worry, but can really see how my dad looked forward to it at the end of the day. He used to say in reply to me when I would raise the issue, not to worry as it helped him relax. I now get the seduction.
As it turns out the neighborhood in which we live that has enjoyed some measure of ambivalence on the part of the robbing establishment. No longer, each morning there is new discussion about who was hit. Suffice it to say we weren’t the only
--------------------------3hr later------------------------
I was interrupted by a stat page to the ICU by our M.O., Christine. One of our patients was dribbling off the court and she needed a hand. I zoomed over to the hospital from here (the UPENN office where I have internet connection) and she wasn’t there. OhhhKaaay, back to the male medical ward to find her with our patient, a 59 y/o male, intubated and being bagged but with a blood pressure after a mg each of atropine and epinephrine (called adrenaline). It was obvious that we needed to transfer him to the ICU so I called them to ask if this was OK. Nope, gotta call the anesthetist and get his approval. Approval??!!, he’s intubated and needs a damn respirator!! Sorry…..
Bleep! So I paged the bleeping anesthetist, and his bleeping partner, a bleeping THREE TIMES! Even called him at home, no luck, and now it's 30m later. Bleep it, we’re going to the unit anyway. So off we went with Christine learning how to manage the head and airway and me pushing. The nurses of the male medical ward largely came along as they perceived the confrontation that was in the offing.
We entered the ward and were met with dead silent looks of disbelief. I found myself asking for meds and then looking at each of the eight nurses and pointedly asking each one if they were going to call the anesthetist as I was a touch busy running a CODE. After some more stunned silence I shoved aside a gurney at a bed station and moved our guy up there. He was being well ventilated and had a palpable pulse, for about the next minute. Then crash, no pulse and once the staff realized we had a CODE on our hands they all pitched in and after another mg of atropine and a total of 3mg of epi; pulse and BP(!!!!) It gave me the opportunity to congratulate all of them and joke that the patient would name his next grandchild after them. Along came the anesthetist who placed a central line and put him on the ventilator and on dopamine to support his BP. The prognosis is perfectly awful, but better than dead for now….And I left in the good graces of the anesthetist, like could give a bleep.
Then off to the mobile phone place as mine had broken and needed to be replaced. I met Lynne there who is better from a stomach bug and showed up with all the necessary paper work,..except that box that it came in. See they need the box to do….. what, hell I don’t know and I don’t have the bleeping box. So after a few exchanges and me invoking the fact that I was a doc at Marina and needed to be back (truth, but still very unlike me to play that card) they acquiesced and gave me a replacement. So now I have a new phone. They have no replacements for Lynne’s one that was stolen and little idea when they might come in.
To my credit I have been fairly patient, for me. Our kids are laughing out loud at this but, TO MY CREDIT (I certainly could use some) I’ve been fairly well behaved.
Virtually all our patients on the male side are HIV+ with some co morbid problem; TB, pneumonia, wasting, hepatitis, pancreatitis, fever of unknown origin, meningitis or some combination thereof. All are younger than 40 and all are at various stages of use of Highly Active Antiretroviral Therapy (HAART). The meds are administered by the local clinics and are so tightly controlled for compliance that even if I order them here on the ward, they won’t be administered unless initiated by the Infectious Disease Control Clinic (IDCC). So today I walked over five charts of our patients that needed to start or restart HARRT. It’s important to emphasize that the majority of hospitalizations are avoidable if compliance of the patients was better. Even at that, the evidence is that compliance here in sub Saharan Africa is around 95% vs. 55-60% in Europe and the US. On rare occasion we will have a patient with routine hypertensive emergency with a diastolic pressure of >140 and headache or status asthmaticus, or the “feel bads” and are dropped off at the A&E by the family who is going for a vacation. This might be one of the larger down sides of medicine available to all in this country, we will have a service that is best described as more nursing home than acute hospital.
There is a lot of drinking here. My past ventures have been to either remote places or Muslim populations or both so the alcohol use was lighter. Here it is heavy and frequent on the weekend. And I find myself looking forward to some hooch in the evening. We have lousy beer and garden variety whiskey but it still does the job. Coming from a long line of drunks as I do, I find myself treading uncomfortably close to the ragged edge, and know it. The last time I was this close was in KY when I had just started practice. I need to exercise and will start as soon as the month is out and we are moved into our own digs, and I feel more comfortable on the wards, all are within about two weeks time. I’ll be OK, no need to worry, but can really see how my dad looked forward to it at the end of the day. He used to say in reply to me when I would raise the issue, not to worry as it helped him relax. I now get the seduction.
As it turns out the neighborhood in which we live that has enjoyed some measure of ambivalence on the part of the robbing establishment. No longer, each morning there is new discussion about who was hit. Suffice it to say we weren’t the only
--------------------------3hr later------------------------
I was interrupted by a stat page to the ICU by our M.O., Christine. One of our patients was dribbling off the court and she needed a hand. I zoomed over to the hospital from here (the UPENN office where I have internet connection) and she wasn’t there. OhhhKaaay, back to the male medical ward to find her with our patient, a 59 y/o male, intubated and being bagged but with a blood pressure after a mg each of atropine and epinephrine (called adrenaline). It was obvious that we needed to transfer him to the ICU so I called them to ask if this was OK. Nope, gotta call the anesthetist and get his approval. Approval??!!, he’s intubated and needs a damn respirator!! Sorry…..
Bleep! So I paged the bleeping anesthetist, and his bleeping partner, a bleeping THREE TIMES! Even called him at home, no luck, and now it's 30m later. Bleep it, we’re going to the unit anyway. So off we went with Christine learning how to manage the head and airway and me pushing. The nurses of the male medical ward largely came along as they perceived the confrontation that was in the offing.
We entered the ward and were met with dead silent looks of disbelief. I found myself asking for meds and then looking at each of the eight nurses and pointedly asking each one if they were going to call the anesthetist as I was a touch busy running a CODE. After some more stunned silence I shoved aside a gurney at a bed station and moved our guy up there. He was being well ventilated and had a palpable pulse, for about the next minute. Then crash, no pulse and once the staff realized we had a CODE on our hands they all pitched in and after another mg of atropine and a total of 3mg of epi; pulse and BP(!!!!) It gave me the opportunity to congratulate all of them and joke that the patient would name his next grandchild after them. Along came the anesthetist who placed a central line and put him on the ventilator and on dopamine to support his BP. The prognosis is perfectly awful, but better than dead for now….And I left in the good graces of the anesthetist, like could give a bleep.
Then off to the mobile phone place as mine had broken and needed to be replaced. I met Lynne there who is better from a stomach bug and showed up with all the necessary paper work,..except that box that it came in. See they need the box to do….. what, hell I don’t know and I don’t have the bleeping box. So after a few exchanges and me invoking the fact that I was a doc at Marina and needed to be back (truth, but still very unlike me to play that card) they acquiesced and gave me a replacement. So now I have a new phone. They have no replacements for Lynne’s one that was stolen and little idea when they might come in.
To my credit I have been fairly patient, for me. Our kids are laughing out loud at this but, TO MY CREDIT (I certainly could use some) I’ve been fairly well behaved.
Saturday, October 11, 2008
Dammit...
Sat AM,
11 October
It’s been a week (I think I keep saying that). Things had smoothed out on the ward as the nurses gave me wide berth and were quite attentive to the needs of the patients of our team and the male medical ward in general. Everyone said I should bring chocolates. Nope, not to reinforce what had happened and make nice, that has been tried and since the ambivalence about the episode was deafening, better to keep ‘em guessing for a while. The head nurse won’t meet my eyes but is very attentive to our patients. It’s not something about which I’m proud and it won’t happen again, soon. Hopefully my frustration meter never gets past yellow and I can handle it better. Hopefully accountability and initiative will creep into the culture of the ward. Hopefully.
I had the privilege of hearing about a death witnessed for the first time by my student. We had a young man who had multi-system failure from the usual suspects and died as she was preparing to do a procedure. She counselled the family and proceeded from there without any input from me and with great skill and compassion. Many of us have this happen in training, indeed if we are fortunate, and I had not anticipated how much a privilege it would be to see it through some one else’s eyes for the first time.
Then early this morning…..
We had heard some rumors about break-ins in the neighbourhood here. This is supposedly a secure development as it is an enclosed neighbourhood with just one entrance guarded by a watch man. Bottom line is that at 0330 Lynne awoke to a man at her side of the bed in the process of stealing her laptop and phone. He had to have known where to look as it was quite a distance from where he entered the house and without that info would never have risked entering our room. The school marm in Lynne came out in force as she yelled at him to get out and chased him down the hall with me trying to get passed her to kill the guy. He ran back down the hall and dove back through the window and vaulted the wall. I went to the entrance of the neighbourhood and awoke the guard (not a good thing) and reported it to him and called the cops who took a report.
All the homes here are walled in. The walls have either razor wire on top or spikes or broken glass or any combination of the above and most place have obnoxious dogs. We have none of the above. Having said that, the home has been secure since it has been occupied by the Rev. Jones. That or there really is honor among thieves.
Other than feeling hugely violated we’re safe and Lynne is processing this as best as can be expected. She’s scarred, scared, pissed, righteously indignant (our lives were on that laptop), and fearful all at once. And she is amazingly brave and courageous. Not sure how this will develop. She may want to head back across the pond and return when we are moved into our new, and more secure, digs at the end of this month. For right now, just too much stuff flying around to be able to easily sort it out.
11 October
It’s been a week (I think I keep saying that). Things had smoothed out on the ward as the nurses gave me wide berth and were quite attentive to the needs of the patients of our team and the male medical ward in general. Everyone said I should bring chocolates. Nope, not to reinforce what had happened and make nice, that has been tried and since the ambivalence about the episode was deafening, better to keep ‘em guessing for a while. The head nurse won’t meet my eyes but is very attentive to our patients. It’s not something about which I’m proud and it won’t happen again, soon. Hopefully my frustration meter never gets past yellow and I can handle it better. Hopefully accountability and initiative will creep into the culture of the ward. Hopefully.
I had the privilege of hearing about a death witnessed for the first time by my student. We had a young man who had multi-system failure from the usual suspects and died as she was preparing to do a procedure. She counselled the family and proceeded from there without any input from me and with great skill and compassion. Many of us have this happen in training, indeed if we are fortunate, and I had not anticipated how much a privilege it would be to see it through some one else’s eyes for the first time.
Then early this morning…..
We had heard some rumors about break-ins in the neighbourhood here. This is supposedly a secure development as it is an enclosed neighbourhood with just one entrance guarded by a watch man. Bottom line is that at 0330 Lynne awoke to a man at her side of the bed in the process of stealing her laptop and phone. He had to have known where to look as it was quite a distance from where he entered the house and without that info would never have risked entering our room. The school marm in Lynne came out in force as she yelled at him to get out and chased him down the hall with me trying to get passed her to kill the guy. He ran back down the hall and dove back through the window and vaulted the wall. I went to the entrance of the neighbourhood and awoke the guard (not a good thing) and reported it to him and called the cops who took a report.
All the homes here are walled in. The walls have either razor wire on top or spikes or broken glass or any combination of the above and most place have obnoxious dogs. We have none of the above. Having said that, the home has been secure since it has been occupied by the Rev. Jones. That or there really is honor among thieves.
Other than feeling hugely violated we’re safe and Lynne is processing this as best as can be expected. She’s scarred, scared, pissed, righteously indignant (our lives were on that laptop), and fearful all at once. And she is amazingly brave and courageous. Not sure how this will develop. She may want to head back across the pond and return when we are moved into our new, and more secure, digs at the end of this month. For right now, just too much stuff flying around to be able to easily sort it out.
Thursday, October 9, 2008
It's all small stuff except when it ain't
Right now my frustration meter is pegged in the red zone. The morning began with a conference with some docs from the ministry of health, a matron (head nurse) from another hospital, and the sister of one of our patients on the private service. Like a lot of places with medicine that is accessible to all, at government cost, the line can be be shorter if you pay as you go. This patient was a transfer from an outside private hospital because they had run out of ideas and he had had a fever for a month. His sister was politically well connected.
We have him on broad spectrum coverage and, of course, did the one remaining test yet to be performed at the outside hospital, an HIV. Which was positive. See you can be getting top of the line antibiotics, but nothing will happen in the absence of an intact immune system. They seemed to understand but that will be an officious 90mins I'll never get back....Why weren't we doing more blood work; because the bleeping lab looses the blood or the ordering system has changed back to the computer system so anything ordered for the last two days manually is ignored. Why don't we get a CT scan; because it won't change the management and takes a week for OB to dethrone and condescend to allowing and reading it. What about outside lab; not needed as the HIV is the most revealing test and no other tests are necessary, other then time.
Then back to the ward where we had a somatisising guy in his mid 30's who allegedly had hip pain, or was it leg pain, or was it buttock pain. So I stood him up to the deeply inhaled chagrin of the team and low and behold, A MIRACLE, he can stand....Anti-inflammatories and get this guy off my service.
We have a high needs cubicle of eight or more beds and one of the guys in there is HIV+ (OK they all are) with a big peri-rectal abscess. During rounds I checked on the site that had been drained by the surgeon only to find that it was awash in stool. Deep breath....clean the stool, retract the packing to show no stool and re apply the nappie (adult diaper), all of this as three nurses stood around watching this. As I asked for an item, it took multiple requests to get their attention. I lit up (our kids are rolling their eyes as they read this) and said how this wasn't cooperation or help and was beneath all of us that a nimrod like me was doing all of this solo. And of course that got me nowhere, and with a headache and worsening reflux to boot. I know, there is a lesson in there for me. To my credit, meager though it may be, this was the first time I blew it.
On to the next patient on whom we got a chest X-ray yesterday only to find that ALL the films were under penetrated that were taken yesterday and are of no value, we of course were kept quietly out of that loop. Arrrrgghhh!!!! So home he went without a CXR that would document that we had done a bloody thing for him.
I've been here long enough to appreciate the difficulties of practicing here, not how to creatively solve the hindrances to good care. It will come.....
We have him on broad spectrum coverage and, of course, did the one remaining test yet to be performed at the outside hospital, an HIV. Which was positive. See you can be getting top of the line antibiotics, but nothing will happen in the absence of an intact immune system. They seemed to understand but that will be an officious 90mins I'll never get back....Why weren't we doing more blood work; because the bleeping lab looses the blood or the ordering system has changed back to the computer system so anything ordered for the last two days manually is ignored. Why don't we get a CT scan; because it won't change the management and takes a week for OB to dethrone and condescend to allowing and reading it. What about outside lab; not needed as the HIV is the most revealing test and no other tests are necessary, other then time.
Then back to the ward where we had a somatisising guy in his mid 30's who allegedly had hip pain, or was it leg pain, or was it buttock pain. So I stood him up to the deeply inhaled chagrin of the team and low and behold, A MIRACLE, he can stand....Anti-inflammatories and get this guy off my service.
We have a high needs cubicle of eight or more beds and one of the guys in there is HIV+ (OK they all are) with a big peri-rectal abscess. During rounds I checked on the site that had been drained by the surgeon only to find that it was awash in stool. Deep breath....clean the stool, retract the packing to show no stool and re apply the nappie (adult diaper), all of this as three nurses stood around watching this. As I asked for an item, it took multiple requests to get their attention. I lit up (our kids are rolling their eyes as they read this) and said how this wasn't cooperation or help and was beneath all of us that a nimrod like me was doing all of this solo. And of course that got me nowhere, and with a headache and worsening reflux to boot. I know, there is a lesson in there for me. To my credit, meager though it may be, this was the first time I blew it.
On to the next patient on whom we got a chest X-ray yesterday only to find that ALL the films were under penetrated that were taken yesterday and are of no value, we of course were kept quietly out of that loop. Arrrrgghhh!!!! So home he went without a CXR that would document that we had done a bloody thing for him.
I've been here long enough to appreciate the difficulties of practicing here, not how to creatively solve the hindrances to good care. It will come.....
Tuesday, October 7, 2008
The ward on a Tuesday
The service has expanded to about 24; 4 with meningitis of various varieties, one with TB meningitis and hydrocephalus (pressure on the brain), some with the “feel-bads” that are refractory to any attempt at intervention until today when we one dressed and ready to go (something about a woman), many with somatic complaints that resolve before we can effectively start treatment, and most with HIV and co-morbidities. We did three LP’s today (make that Kathleen did them) and all were successful. One of our patients started to decompensate at about 1500 and was showing signs of elevated pressure on the brain by his posturing; arms extending with wrists flexed and comatose.
To get a CT scan on an emergent basis one must get on bent knee and address the chair of the radiology department:
“Good afternoon Dr._____, how is your beautiful family”
“What do you want?”
“We really need an emergent CT scan of our patient who has decompensated in just the last half hour.”
“Can’t it wait until tomorrow?” (it was about 1515h).
“Uh, no because you see it is and emergency at this is happening rapidly and indicates worsening clinical status.”
“Can’t it wait until tomorrow?”
(“No you officious and power hungry b-----h, it’s an EMERGENCY!!, but maybe you haven’t heard of that as all you do is read films and do crosswords all day!!!”) “It really can’t as we would like to know if there is an intracranial process and affect treatment as soon as possible.”
Gesturing, “OK, sigh, bring him here as soon as possible and it better be quick.”
(“Thanks you OB”) “Thank you, I’m sure the family is grateful, as are we.”
The CT was revealing for communicating hydrocephalus secondary to presumed TB meningitis. Unfortunately the treatment will be too little too late.
We are getting a little bogged down and need to thin the service before the weekend. On occasion we try to discharge only to be met with resistance on the part of the family as they are either scarred or simply want their family member to stay longer to give them a break, something that happens a fair amount around the Christmas holidays and is perhaps the underbelly of the “socialized” system here.
In any case I came home with a monstrous head ache, am now recovered, and ready to try again in the morning. We continue to get closer to moving in. The place has been cleaned but not painted and it is more difficult to know who is responsible for what. We leapt at this in the first week of our stay here and it may not be the best option for us for several reasons. Still we look forward to our own turf if only so we can move in and put away the suit cases.
We have been blessed indeed with the home in which we live. Still, it’s time….
To get a CT scan on an emergent basis one must get on bent knee and address the chair of the radiology department:
“Good afternoon Dr._____, how is your beautiful family”
“What do you want?”
“We really need an emergent CT scan of our patient who has decompensated in just the last half hour.”
“Can’t it wait until tomorrow?” (it was about 1515h).
“Uh, no because you see it is and emergency at this is happening rapidly and indicates worsening clinical status.”
“Can’t it wait until tomorrow?”
(“No you officious and power hungry b-----h, it’s an EMERGENCY!!, but maybe you haven’t heard of that as all you do is read films and do crosswords all day!!!”) “It really can’t as we would like to know if there is an intracranial process and affect treatment as soon as possible.”
Gesturing, “OK, sigh, bring him here as soon as possible and it better be quick.”
(“Thanks you OB”) “Thank you, I’m sure the family is grateful, as are we.”
The CT was revealing for communicating hydrocephalus secondary to presumed TB meningitis. Unfortunately the treatment will be too little too late.
We are getting a little bogged down and need to thin the service before the weekend. On occasion we try to discharge only to be met with resistance on the part of the family as they are either scarred or simply want their family member to stay longer to give them a break, something that happens a fair amount around the Christmas holidays and is perhaps the underbelly of the “socialized” system here.
In any case I came home with a monstrous head ache, am now recovered, and ready to try again in the morning. We continue to get closer to moving in. The place has been cleaned but not painted and it is more difficult to know who is responsible for what. We leapt at this in the first week of our stay here and it may not be the best option for us for several reasons. Still we look forward to our own turf if only so we can move in and put away the suit cases.
We have been blessed indeed with the home in which we live. Still, it’s time….
Sunday, October 5, 2008
Sunday reflections
We both hit a bit of an emotional wall today. Lynne has been unbelievably patient with the banking dilemma in which we find ourselves and innumerable other little aggravations. The short version is that we had a sum wired to here the first week of our sojourn. It made it here in two days (average) but because the bank didn’t recognize the number and because it was $30.00 less than what was wired it sat there in ambivalent never land for 17days. With the aid of some very indulging and diligent staff we (Lynne) was able to get this squared away and the bank will add interest and restore the original amount.
We of course are used to online banking and our bank here “offers” it but the short of this is that the traditional method of deposit/withdrawal in person is still such an institution that our online balance isn’t ever current so we have only a rough idea of our worth. If one is an “I dotter” and “T crosser” not unlike the woman to whom I am married this is uncomfortable at least and fraudulent at worst. We joke about “Botswana time” and the truth is that with gentle but firm persistence Lynne is slowly becoming a customer advocate in that the bank is eager to learn what her expectations are. And it takes a toll. So today there were tears from both of us as we had little to do for the morning other than dwell on the annoyances of the aggregate.
It’s easy to feel homesick for the efficiency and the familiar. We realize it for what it is, small stuff, but that doesn’t make it any easier to shake. Thankfully we have the Jones tribe just down the street that have opened their home and, perhaps even more important, their wireless connection so we can stay in touch. We thoroughly enjoy the company and hope we can at least pay it forward to the next soul(s) that moves here and longs for the familiar on occasion.
This evening we had an early dinner with the Jones and went to the local game reserve where they have incorporated the local sewage treatment ponds into the park and they were full of birds of all kinds; lots of new additions to my list. The ibis were incredible and everywhere. On the way in we saw zebra (with a new foal), wart hogs of all ages, impala, kudu, mongoose, monkeys of all sizes and mischief, and others I’ve forgotten. The termite mounds are huge and everywhere.
This week we’ll try to swim at UB and Lynne will volunteer at a local AIDS orphanage that should help get us out from behind our eyeballs. The week will be busy and will end with me on call on Saturday. And it’s OK as it still is what I/we want to be doing at the time of life we want to do it in. It’s rare a guy like me who can say that and see the love of his life move forward in so many new and different ways. We are blessed indeed…
We of course are used to online banking and our bank here “offers” it but the short of this is that the traditional method of deposit/withdrawal in person is still such an institution that our online balance isn’t ever current so we have only a rough idea of our worth. If one is an “I dotter” and “T crosser” not unlike the woman to whom I am married this is uncomfortable at least and fraudulent at worst. We joke about “Botswana time” and the truth is that with gentle but firm persistence Lynne is slowly becoming a customer advocate in that the bank is eager to learn what her expectations are. And it takes a toll. So today there were tears from both of us as we had little to do for the morning other than dwell on the annoyances of the aggregate.
It’s easy to feel homesick for the efficiency and the familiar. We realize it for what it is, small stuff, but that doesn’t make it any easier to shake. Thankfully we have the Jones tribe just down the street that have opened their home and, perhaps even more important, their wireless connection so we can stay in touch. We thoroughly enjoy the company and hope we can at least pay it forward to the next soul(s) that moves here and longs for the familiar on occasion.
This evening we had an early dinner with the Jones and went to the local game reserve where they have incorporated the local sewage treatment ponds into the park and they were full of birds of all kinds; lots of new additions to my list. The ibis were incredible and everywhere. On the way in we saw zebra (with a new foal), wart hogs of all ages, impala, kudu, mongoose, monkeys of all sizes and mischief, and others I’ve forgotten. The termite mounds are huge and everywhere.
This week we’ll try to swim at UB and Lynne will volunteer at a local AIDS orphanage that should help get us out from behind our eyeballs. The week will be busy and will end with me on call on Saturday. And it’s OK as it still is what I/we want to be doing at the time of life we want to do it in. It’s rare a guy like me who can say that and see the love of his life move forward in so many new and different ways. We are blessed indeed…
Saturday, October 4, 2008
Saturday stuff
Today I went to PMH to round and see what it was like on a Saturday in anticipation of being on call next weekend. Nicola is on call today and showed me how what seems to work on the male and female side of the medicine wards. The computer system “is up” but that unfortunately doesn’t mean that the desired info has been
a) registered on the system,
b) generated by the lab or x-ray,
c) placed back on the system,
d) under the right name and accessible.
I find that I have been here just long enough to experience the frustrations of the immense lack of efficiencies but not long enough to have creative ways of working around/through them. This morning was delightful as there were few people on the wards and the nurses were very collaborative and could more easily approach me. The happy median is out there, I know it, just can’t quite find it yet.
North Side School, a private school where many expats enrol their kids is having a school fair to raise money. The mix of ethnicities is amazing; orthodox Hindis with top knots, orthodox Moslem, shorts wearing westerners, some Batswana. Interestingly there were many over weight kids that you simply don’t see on the play ground of a national school.
It looks like I’ll start part time outreach in another month and then assume it fulltime in January. After six weeks I continue to marvel at the luck, pluck, and challenges we (mostly Lynne as this is ALL new to her) have and are faced with. At some very real level we ARE truly fortunate to be this age and stage and facing this life, together.
a) registered on the system,
b) generated by the lab or x-ray,
c) placed back on the system,
d) under the right name and accessible.
I find that I have been here just long enough to experience the frustrations of the immense lack of efficiencies but not long enough to have creative ways of working around/through them. This morning was delightful as there were few people on the wards and the nurses were very collaborative and could more easily approach me. The happy median is out there, I know it, just can’t quite find it yet.
North Side School, a private school where many expats enrol their kids is having a school fair to raise money. The mix of ethnicities is amazing; orthodox Hindis with top knots, orthodox Moslem, shorts wearing westerners, some Batswana. Interestingly there were many over weight kids that you simply don’t see on the play ground of a national school.
It looks like I’ll start part time outreach in another month and then assume it fulltime in January. After six weeks I continue to marvel at the luck, pluck, and challenges we (mostly Lynne as this is ALL new to her) have and are faced with. At some very real level we ARE truly fortunate to be this age and stage and facing this life, together.
Friday, October 3, 2008
I had to come to this area to see...
What follows is probably of more interest to the medical types in and out of the fam:
Today we were looking at a CT of the brain with a radiology resident from Penn. He is GREAT in that he is used to being prompt, accurate and communicating findings to us in person, a welcome change from what can appear as passive aggression on the part of the department. True I should and am getting used to the SOP here but to have some one like him is huge. Today we were looking the CT from a guy with HIV and a CD-4 count in negative numbers. There were many white matter lesions all over the place and the radiology resident was a little hesitant to give a definitive call. Up pipes Kathleen (a fourth year student), "Looks like PML!"
That's Progressive Mulitfocal Leukoencephalopathy, a rare disease process of the brain white matter, somewhat like multiple sclerosis, seen more commonly in HIV. But very rare. After I picked my jaw off the floor and all of us exchanged looks of "well I'll be" we agreed that she was probably right on the money. An unfortunate diagnosis for the patient to be sure but, wow, made by a med student.
The uncommon is so frequent here. Today I saw a classic case of milary tb on CXR. They see this so often that it wasn't any big thing, except to me. And this afternoon witnessed an echocardiogram on a 30y/o with HIV cardiomyopathy and an EF=40%. This damn disease can kill you in so many ways.
I continue to be blown out of the water by the pathology. I'm a better diagnostician, but I hope I never lose the "wow gee-whizz" side of things here.
Today we were looking at a CT of the brain with a radiology resident from Penn. He is GREAT in that he is used to being prompt, accurate and communicating findings to us in person, a welcome change from what can appear as passive aggression on the part of the department. True I should and am getting used to the SOP here but to have some one like him is huge. Today we were looking the CT from a guy with HIV and a CD-4 count in negative numbers. There were many white matter lesions all over the place and the radiology resident was a little hesitant to give a definitive call. Up pipes Kathleen (a fourth year student), "Looks like PML!"
That's Progressive Mulitfocal Leukoencephalopathy, a rare disease process of the brain white matter, somewhat like multiple sclerosis, seen more commonly in HIV. But very rare. After I picked my jaw off the floor and all of us exchanged looks of "well I'll be" we agreed that she was probably right on the money. An unfortunate diagnosis for the patient to be sure but, wow, made by a med student.
The uncommon is so frequent here. Today I saw a classic case of milary tb on CXR. They see this so often that it wasn't any big thing, except to me. And this afternoon witnessed an echocardiogram on a 30y/o with HIV cardiomyopathy and an EF=40%. This damn disease can kill you in so many ways.
I continue to be blown out of the water by the pathology. I'm a better diagnostician, but I hope I never lose the "wow gee-whizz" side of things here.
Thursday, October 2, 2008
Randomness rules
Some (more)random thoughts:
A wind blew through last night and with it the first hint of rain. It left us with a humidity that we haven't had since arrival. At this elevation (900meters) and with a desert environment things are at their driest. Everything is shades of brown or dark brown-green. The humidity makes for an interesting time on the wards especially when doing procedures.
We had three LP's today and I was in a flop sweat by the end. Two of them were diagnostic so they needed the proper tubes to be sent for analysis. The third was for reducing ICP (intra-cranial pressure) secondary to cryptococcal meningitis. I still find myself in too big a hurry to treat/perform procedures vs teaching. The excitement of intervening is too seductive and I need to back off already. Generally I do this well as I teach but today for some reason I was too aggressive.
We, Christine (the M.O.) and I, have a new student from Penn, Kathleen Tran. She is every bit as bright as the rest and a Rhodes Scholar to boot. She has fit right in and is making great contributions in the discussion of differentials, etc., where I simply look dumb and try not to drool on myself. I'm slowly getting there, but jeez its slow.
Today, Thursday, is the second workday of the week as Tuesday and Wednesday were national holidays celebrating Independence from Britain. I'm on second call today and will be six times this month including two weekends which are rather a mess. I thought I had finessed that back in HR, but alas, the call gods have followed me here.
Lynne continues to be a champ. She has run head first into the sense of propriety around here as she has negotiated her way through bank accounts, checking, debit cards, electricity hookups, water, and Internet wireless. It hasn't been easy but she has kept her sense of humor and pace about it. She continues to amaze...
All for now, more later. Thanks for your posts of support, they really mean the world.
Mike
A wind blew through last night and with it the first hint of rain. It left us with a humidity that we haven't had since arrival. At this elevation (900meters) and with a desert environment things are at their driest. Everything is shades of brown or dark brown-green. The humidity makes for an interesting time on the wards especially when doing procedures.
We had three LP's today and I was in a flop sweat by the end. Two of them were diagnostic so they needed the proper tubes to be sent for analysis. The third was for reducing ICP (intra-cranial pressure) secondary to cryptococcal meningitis. I still find myself in too big a hurry to treat/perform procedures vs teaching. The excitement of intervening is too seductive and I need to back off already. Generally I do this well as I teach but today for some reason I was too aggressive.
We, Christine (the M.O.) and I, have a new student from Penn, Kathleen Tran. She is every bit as bright as the rest and a Rhodes Scholar to boot. She has fit right in and is making great contributions in the discussion of differentials, etc., where I simply look dumb and try not to drool on myself. I'm slowly getting there, but jeez its slow.
Today, Thursday, is the second workday of the week as Tuesday and Wednesday were national holidays celebrating Independence from Britain. I'm on second call today and will be six times this month including two weekends which are rather a mess. I thought I had finessed that back in HR, but alas, the call gods have followed me here.
Lynne continues to be a champ. She has run head first into the sense of propriety around here as she has negotiated her way through bank accounts, checking, debit cards, electricity hookups, water, and Internet wireless. It hasn't been easy but she has kept her sense of humor and pace about it. She continues to amaze...
All for now, more later. Thanks for your posts of support, they really mean the world.
Mike
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