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.
Saturday, October 11, 2008
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
Subscribe to:
Posts (Atom)
