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.