Thursday, January 31, 2013

Food at Princess Marina Hospital

My team was on call tonight and it was relatively busy – we got 4 patients, but all of them were handled well. There were some interesting cases, but instead of talking about medical stuff I think I’ll talk about food at the hospital a little bit.

The cafeteria is run by the restaurant Moghul, which is right down the street from our flats. The restaurant serves decent Indian food (so I’m told) but the cafeteria makes very affordable and excellent local (Botswana) food. It’s just one counter long, so there’s not much selection, but it’s always very good, and a full meal is about P14, which is only a little more than $2!

At the cafeteria, you choose from a selection of starches, such as rice, pap (maize meal), sometimes samp, sometimes dumplings (which I think are just these huge balls of steamed or boiled bread), and a one other thing I’m not familiar with – and they cover this with a little bit of sauce. Then you can either get chicken or red meat, and you get a hot vegetable. A common red meat dish is seschwa, which is sort of like pulled pork, but with beef and without the sauce. It looks pretty nondescript and boring, but it’s really really good. The often also have beef stew or oxtail stew. Being a red meat fan, I rarely get the chicken, but it’s often stewed, grilled or fried chicken with sauce. The hot vegetable can be cabbage, spinach (which is not exactly like our spinach), creamed spinach, carrots, and a few other possibilities, depending on the day. But there is just one vegetable made per day.

Further on down the counter, you then get 2 or sometimes 3 different salads – they make regular lettuce salad, sometimes there’s a potato salad, sometimes bean salad (which is basically cold baked beans), and sometimes there’s carrot or beet salad. All in all, it’s a huge amount of food, and I usually eat it all! As a result, my lunches have become the main meal of the day, and sometimes I barely eat any dinner at all because I’m so stuffed from lunch. The only thing is, you have to make sure you get there before 1:30 because the cafeteria starts to run out of food.

More recently, I’ve been going outside of the hospital to eat lunch. Right outside the hospital entrance there are many options for food. Some people have small tables set up where they have food in several pots and the food is very similar to what’s in the cafeteria, but cheaper and with much less selection. For example, for P10 you can get pap, seschwa, and spinach, but those are your only choices, and you get a little less food than you would at the cafeteria (which I actually welcome). There are also people in small huts selling food – there they have some pots too, and you can get a small little bowl of food (like chicken or beef stew or something) for like P4. They also have this pita-like thick bread called papata for P1 which is great to eat with the stew. Some of the huts also sell fresh-fried chips! They are so good. They come fresh out of the deep fryer into your little blue plastic bag, which you then take to the table to sprinkle on salt, vinegar, and hot pepper. It’s soooo good and it’s only P4! Lastly, my favorite is the sausage guy. He grills huge homemade sausages right there outside the hospital, puts them in a bun, and adds whatever toppings you want (mustard and tomato sauce – what they call ketchup here). It’s the most amazing sausage ever, and only for P6.

Another alternative is to walk the 10 minutes to the Main Mall, which is an outdoor mall. There are two pie places there (that sell meat and vegetarian pies) that are pretty good, a bunch of fast food, and again people selling food on the street. There are several sausage guys here, and they have small tables with women selling food in pots as well as grilling up big pieces of steak. They also have a few large groups of people who have set up long rows of tables with food in pots – the equivalent of the pot ladies, but super-supersized. They have even more choices than the cafeteria, and it’s only P12! And you can stuff as much as you can into your takeaway container – I’ve seen people pile it on incredibly high, with 3 or 4 different meats and tons of veggies. Also a 5 minute walk away is the museum - which serves similar food to the cafeteria at basically the same price, but there is a nice environment to eat it in. You eat at outdoor round tables, shaded by these grass roofs, and we often have our bi-weekly feedback sessions there.

Ironically, today, I was actually a little tired of stuffing myself every day and actually brought lunch – a salami and cheese sandwich. I think I just felt like eating something American for once, but it all worked out because when I got home, Lisa had made lasagna (sort of) and salad. So I ate a big dinner. :)

Tuesday, January 29, 2013

The beginning of intern year

Yesterday marked the beginning of my intern year at Pennsylvania Hospital. I haven't done anything clinical really since September when I was in Botswana. I guess I took a radiology elective, but really, I didn't work too hard. I had to get up at 6am! I know, it's a tough life. I'm hoping to be able to blog about life as an intern throughout this year with some stories and insights into hospital life, but this being intern year, we'll see how much time I have for that.

For these first two days we have ACLS training. That is, Advanced Cardiac Life Support. We learn to run codes, which are when somebody suddenly dies, and you go through the appropriate steps to try to resuscitate them. Have you ever seen an emergency situation on a show like ER? And they yell out orders and give medications, and maybe eventually shock a patient with electric paddes? It's like that. Exactly.

It's actually pretty complicated. Depending what's wrong with the patient, you have to give different medications, treat them differently, order different labs. CONTRARY to what you do see on ER, you don't shock every patient and not every patient gets epi (epinephrine, also known as pure ol' adrenaline). And everything is happening pretty fast - the patient is getting bagged or intubated (getting a breathing tube shoved down their throat), they're getting put on the monitor, somebody is inserting an IV or two into the patient, someone else is drawing labs, someone is giving medications, someone is giving CPR and doing chest compressions, someone is monitoring their heart rate, blood pressure, and a few other things. Not to mention all the bystanders there either just looking on, or trying to be available to help. So there are probably 10-20 people crammed into this small room with the leader yelling out instructions, and sometimes it can be pretty difficult under pressure to remember all the things you have to do, and to communicate effectively with all the people.

That's what all the new interns got certified in today. This is certainly not an unknown issue, but it's a little scary to think of new interns practicing a medicine, much less running a code. I don't think we would be bad, but almost certainly slower. But interns have a huge learning curve. I think by the second week, people are usually up and running, and while the knowledge base is still building, interns can get things done pretty effectively.

I think I would feel relatively confident running a code. Maybe not perfect, but ok, and I'm sure that will improve. I think many of the interns were a little worried or scared about running a code. Thankfully, usually it is a senior resident (a 2nd or 3rd year resident) who runs a code. The interns usually just help out, and when they have enough experience, then they run the code. I know this is a horrible thing to say - I guess that's why I'm in medicine - but I'm a little excited to take part in my first code! Look at it like this - I don't want anybody to die, I just want to help bring someone back to life! :)

Sunday, January 27, 2013

A Bachelor of Arts Degree in HIV-AIDS: A self-Educational Guide



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Attitude

The longer I live, the more I realize the impact of attitude on life.

Attitude, to me, is more important than facts. It is more important than the past, than education, than money, than circumstances, than failures, than successes, than what other people think or say or do. It is more important than appearance, giftedness, or skill. It will make or break a company ... a church ... a home.

The remarkable thing is we have a choice every day regarding the attitude we will embrace for that day. We cannot change our past. We cannot change the fact that people will act in a certain way. We cannot change the inevitable.

The only thing we can do is play on the one string we have, and that is our attitude ... I am convinced that life is 10% what happens to me, and 90% how I react to it. And so it is with you ... we are in charge of our attitudes.

-- Charles Swindoll

This is what I need to think about when a patient complains to me for 15 minutes about how horrible the hospital system is and then refuses to let me examine him so that I can admit him to the hospital.

Friday, January 25, 2013

TB patients

I was on call tonight and I admitted 4 patients, which is a lot for me. There wasn’t anybody to really help me either… on the pink female side, they have 3 team members all working on the same number of patients. However, it seems like the female side gets many more admissions than the male side. I have a theory about that. I don’t think it’s that different than in the states. Women tend to come in for the health problems and for health maintenance more often, and sooner, than men do. So there are more women admissions. Our lists of patients on the male side also seem to be a lot smaller than on the female side. I think that’s also related to the men not coming in soon enough. So many times we get a male patient that comes in comatose, or barely breathing, and it’s really too late to do anything for them here. So more men die than women, and less men come in the hospital in general, keeping our lists smaller.

It’s pretty sad – the other day, we had a man come in because he was barely conscious, and really struggling to breath. For those of you know what I’m talking about, he was already having Cheyne-Stokes respirations and barely responded to sternal rub. He had this huge mass in his neck that we FNA’d (fine-needle aspirated – it’s a way of taking a biopsy) and stained it to look for AFB (acid-fast bacilli – the sign of TB). And it was swimming in TB. We made a token effort of putting him on anti-TB medications, and giving him oxygen, but really we were just waiting for him to die. It wasn’t worth sending him to the ICU because in this resource-limited setting, only people who have a pretty good chance of making it through an ICU stay go to the ICU. And he was definitely not one of them. Not to mention the fact (as you’ve seen in previous posts) that the ICU doctor is horrible and has no idea what he’s doing, so most patients, even though with relatively good prognoses, rarely make it out of there alive. Anyways, he lasted until 11:30pm that night. And this is a disease that is easily treatable. If only he had come in a week or two earlier. It’s awful.

Tonight I also admitted an XDR TB patient! So a patient first diagnosed with TB is put on first-line anti-TB treatment (ATT). They have to go to the clinic every single day to get their medications, as part of the DOT (directly-observed therapy) program for TB treatment. This program was started because patients weren’t taking their medications, and they weren’t getting better, but more importantly, their bad drug adherence was resulting in the emergence of resistant strains of TB! And we just had a lecture about this – because there’s no money in developing TB drugs, and it’s really a third-world problem, the last effective TB drug was developed in 1960 (or something like that)! So we only have a limited set of drugs to work with. Anyways, so I had a patient who was diagnosed with TB in 2005, was on 6 months of treatment, and then relapsed and was diagnosed with TB again a month later. He probably had multiple-drug resistant (MDR) TB. So in 2006 he was placed on second line treatment for 6 month, got better, and then after another month, relapsed again! They finally cultured his sputum (which is tough to do here), and it turns out he’s resistant to 4 of the 5 commonly-used TB drugs (XDR TB). So now he’s on all these weird medications, many of which aren’t indicated for TB, but probably have some effect. There’s really no other choice for this guy.

However, the problem isn’t that we can’t treat this patient, the problem is that he’s in the hospital! In the states, there are all these negative-pressure isolation rooms that you can put patients in. Here, there is no such thing. There is an isolation room that you put all the MDR patients in, but sometimes patients who aren’t even proven MDR go into the room. And our XDR patient went in there too – meaning he’s probably going to give all the other patients XDR TB. Plus the room is not negative-pressure. We just open all the windows to improve ventilation, and try to keep the patients in the sun for the UV exposure (which actually helps to kill TB). We wear these N95 masks that are supposed to protect us to some extent from TB, but it’s not 100%. If you’re lucky, you can sometimes get your MDR or XDR TB patient put into a private room in the private ward (no such thing in the public wards – there are 10-12 people per large room, or cubicle). But those rooms are still not negative-pressure. I’m not too worried because I’m only working here for 6 weeks, but apparently of the students who have stayed for a year or more, 3 of them (I don’t know out of how many) have converted their PPD – meaning they have TB in their system, although it might not be active. Scary.

Thursday, January 24, 2013

Keeping fit as an intern

It's impossible. Especially now that I'm pregnant. But even when I was really busy before, I still was able to get some exercise in, sometimes at the gym, and sometimes playing ultimate frisbee, which has basically been my most enjoyable form of exercise for the last 6-7 years. It's well-known that interns often gain 10-15 pounds during their intern year, and in general eat a lot unhealthier and get a lot less exercise. They say (jokingly) that the doctors are often the least healthy people in the hospital... obviously it's important to stay healthy, for their own sakes as well as to set a good example for their patients, but it can be extremely difficult.

I think the best way to combat it is to try and get into something active you really enjoy - for me, that's ultimate frisbee. To be honest, this post is really just a plug for my sport. :) I guess since I'm a woman, and play ultimate frisbee (not to mention captained a women's club team and multiple league teams in the past), many people have forwarded this New York Times article to me. It's mostly about women and ultimate frisbee, and I think it's great that the sport is finally getting mainstream attention.

Tuesday, January 22, 2013

The first day at the Princess Marina Hospital

This was the first day of work! I started my first day on call on the pink male ward (there are female/male pink/green/blue wards). Kiona and Kristy are on blue female. Philip is on pink female, so we are on call the same nights. The good thing about being on call Monday is that the rest of the week is free! However, I only got 4 hours of sleep the night before. So the morning was rough. Every day starts out with intake at 7:30 am, where we go over the previous day’s admissions. Monday intake is super long because it includes all the weekend’s admissions in addition to Friday’s admissions. Then I rounded with Boipelo Lecoge (an MO, or medical officer, which means she’s finished internship at some point and may be working or in transition to residency) and Dr. Stefanski, a specialist (what they call attendings) from Australia. The residents act as specialists here, so Sarah would have been my specialist, but she left yesterday for 2 weeks to go back to the US to take boards. So Dr. Stefanski is covering for her. Mike Chattergoon is also a resident from HUP who is a specialist here, and he is on blue male, so he can be a resource for me when I’m looking for help with procedures or other things.

It wasn’t too crazy of a day, but I ended up admitting 3 patients all by myself – Dr. Lecoge did all the ongoing patient work while I was going to lecture and admitting. She had to go home at 4pm and came back at 9pm because she was on call. Mike left early because he got sick, so I didn’t really have him to help me out either. All the other students are on the female side so I don't really have their support either. Meanwhile this other MO Suna was the covering MO for both the female and male wards and she was awful. She kept disappearing for an hour at a time and she didn’t really want to help me out until Dr. Stefanski made a point to ask her to help me out. All in all it was an okay day. It will definitely take a while for us to adjust to this new hospital and figure out how everything gets done.

Monday, January 21, 2013

Surviving HIV: Growing Up a Secret and Being Positive



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Surviving HIV: Growing Up a Secret and Being Positive is the true story of Jamie Gentille, a girl in her 30s who defies the odds by living a healthy and productive life after contracting HIV during a blood transfusion at age 3 during open heart surgery.
This book follows Jamies life as a child, to whom the medical world was a second home, through adolescence and adulthood. Along the way she encounters pain, joy, adversity, despair, ignorance, and above all, hope. Her journey takes the reader through a time when HIV and AIDS was a highly stigmatized terminal disease, to groundbreaking hope in the form of medical advances, to an age of full life expectancy and near normalcy.
The books style is a playful balance between dry, self-deprecating humor, and raw emotion. She describes heartbreaking experiences as a child enduring painful medical procedures, and the terrifying reality of a terminal illness. The book poignantly describes Jamies process of coming to terms with her own mortality at the age of 10. While the reader is moved by these sobering stories, they will also laugh at loud at Jamies irreverent humor and light-hearted style. Interwoven throughout Surviving HIV is a theme of stark reality, and enduring optimism that can offer the reader a new perspective on their own lives.


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Sunday, January 20, 2013

Tele-dermatology at PMH!

This was the first day for a new dermatology resident – Jeremy. He’s from Stanford, and is going to work with a derm attending from HUP (Carrie), who is supposed to arrive over the weekend. It’s pretty interesting – they are actually going to set up a tele-derm system. She did her training at Baylor, and so has already set up a few other African hospitals that have Baylor pediatrics up with this tele-derm system. Basically, you take pictures, email them and a clinical history to a pediatrician in the states (usually her) and after a few days, you get a probable diagnosis. I’m sure some of you are wondering why dermatology is at all needed in Africa… There’s actually quite a few dermatology cases related to the diseases you see here, like HIV, TB, Cryptococcus, all sorts of parasites, etc. Often a patient hasn’t been diagnosed with something yet, but the dermatology (along with a biopsy of a dermatological lesion) can provide the diagnosis less invasively than a biopsy somewhere else. So hopefully this will work out. Other than this tele-derm system, Carrie is hoping to be here about 6-8 weeks a year, and trying to get a senior dermatology resident out at Princess Marina 6 months out of the year.

Nothing else really happened today – got off work at around 5:30 and went to Riverwalk with Amy, one of the new Penn residents that arrived last weekend. The other one is named Joanne (Mazzarelli). We bought Amy a phone, and went to Pick N Pay where we spent P510!!! But we were cooking dinner for everyone that night, including the on call people. I directed everyone – I was the head chef. :) We made enchiladas, which were ok – I don’t have quite the right ingredients here. But I think everyone was satisfied. I made both chicken and eggplant enchiladas because we have so many vegetarians here.

Saturday, January 19, 2013

Our litiginous society

I've known for a long time that there's a problem with the medical legal system in this country that needs to be fixed. However, I recently heard this story that rams home the point.

There was a patient who had multiple medical problems and normally is seen by doctors at the hospital medical clinic. Due to various reasons, usually the clinic is used by patients who have little insurance or bad insurance, and so they cater to many of the inner city population. The doctors rotate there as well, so continuity of care is not always the best, and the patients don't often follow up with their appointments. The clinic is often also abused, with people walking in constantly without appointments and expecting to have 10 different medical complaints addressed in a single visit.

At any rate, for reasons I won't go into, this patient had to be anticoagulated - that is, her blood had to be kept thin with medications so that she would not develop a clot. Clearly a clot can be a very bad thing - it can travel to the heart and cause a heart attack, it can go to the brain and cause a stroke, it can go to the lungs and cause a pulmonary embolism or a "lung attack". So it's important that her blood is kept thin so that the clot doesn't get any bigger and perhaps would even dissolve away eventually. However, as with any other medications, there are risks. The particular medication you use as an outpatient (coumadin) needs to be monitored closely. The levels are usually tested every 1-2 weeks at an outpatient laboratory or clinic, and if your blood is too thin, there is certainly a risk of bleeding. This can be very serious as well, causing yet another type of stroke, or patients can lose so much blood that they become very sick or die. So monitoring the level of coumadin in your blood every once in a while is very important until you reach a good regimen that keeps you consistently at the right blood thinness.

This woman had been admitted to the hospital several times in the last several months for unrelated issues, and each time, her coumadin level was not right. Sometimes her blood was too thin, and sometimes it was not thin enough. They would always get it just right before sending her home and tell her to follow up at the hospital clinic to get it checked out a week or two later. Sometimes she did this, sometimes she didn't. Finally, one particular instance, she was supposed to be seen at the clinic and missed her appointment. Two weeks later, she was admitted to the hospital where her blood was much much too thin, she started bleeding, and bled so much that she ended up dying.

Her relatives are now suing everyone that has ever been involved in her care, including a cardiologist who saw her only once during one of her hospital stays, an excellent medicine attending who saw her once at the clinic 2 years ago, and doctors from other hospitals as well who have been involved. Even though there has been no wrong-doing on anybody's part at all, and their lawyers agree they could win this case, pretty much everyone involved (and their insurance companies) has finally decided to settle out of court and pay instead of fighting this because it would be much cheaper. Just as an example, it would cost them $2 million to fight this battle in court after all the lawyer fees, etc whereas settling out of court they pay the family $200,000. Easy money for the family.

The only point someone brought up is that when the patient missed her appointment, nobody called her to ask her to come in or to reschedule. But is that our responsibility? Patients get a reminder call, and when they don't come in, I don't necessarily think it's the health system's responsibility to beg them to come in. At some point, you have to ask the patients to take responsibility for their own health care and participate.

This story exemplifies one of the reasons why health care costs so much for everyone. The $200,000+ that the family won (which doesn't even include the doctors' time, paperwork, other court fees) is basically being paid by all the other health care users out there. There needs to be some sort of reform within the medical-legal system. I don't have any great ideas, but something needs to be done.

Thursday, January 17, 2013

The first day of internship

Today was my first day of internship at Pennsylvania Hospital! There were a few hitches - we didn't have our own long white coats (the universal symbol of being a doctor), so we had to borrow other people's. Not a big deal - we put tape over their names, which are stitched over the pocket. A few of us also didn't have our logins or passwords to one of the main computer programs used in the hospital. Without it, we couldn't enter electronic orders, or really check labs on patients. It took a couple hours to sort it out, so that definitely ate into our working time. Also, I still don't have my email account. Oh well - hopefully nothing crucial was sent to us! All this was a little annoying, because you would think these things would all be taken care of weeks ahead of time, since we found out we were going there in May. But it's not a big deal.

Despite it being the first day, I think it went relatively well! I had 7 patients to start, and 3 of them were discharged. My resident helped me out, as well as the other intern on the team quite a bit since we didn't know these patients at all. We were also lucky - my co-intern (Christina) and I both know the programs and the system relatively well, so we were able to do things much more efficiently (I imagine) than some of the other new interns. Some of the newbies definitely had frazzled looks on their faces. :)

Tomorrow will be much harder for us - we're on call. Christina has to stay until 10pm, and I am staying overnight until the next day at 1pm, and we are taking patients during most of that time. That means not only will we be busy with the patients we already have, but we will also be admitting patients from the ER, which takes on average 1 - 1.5 hours per patient. We can each take up to 5 new patients, in addition to the ones we already have. It's gonna be interesting!

Doctors and arrogance

I know a lot of arrogant doctors. I probably am an arrogant doctor. It's probably a good general statement for lawyers and businessmen too, but it's definitely a trend in doctors.

For one, I think it's a self-selecting group. Not many people can say that they want the responsibility of caring for someone else's life. And if you think about it, it takes a certain amount of arrogance to think that you are capable of doing such a thing. In fact, it takes an even greater amount of arrogance to do something wrong the first time around (potentially really affecting someone else's life) and try to do it again. But the surgeon who started the first heart transplant failed something like 5 times before he succeeded. Meaning the first 4 times, someone died. It takes a lot of guts to keep doing something like that with those potential consequences. But in the end, it can mean great strides in medicine positively affecting the lives of thousands of people.

Secondly, I think a certain amount of arrogance can be good for doctors as well as patients. If a doctor had a personality that beat themself up every time they made a mistake, they wouldn't survive. Every doctor makes mistakes once in a while, no matter how good they are. Some mistakes of course are more costly than others. But in the end, you have to be able to move past it, learn from it, and never ever do it again. On the patient care side, the last thing any patient wants to see is that his doctor is uncertain. If a doctor is undecided about a certain course of action, of course they should admit it, but once a course of action has been decided upon, the doctor should be very confident about it. I think if a doctor is visibly uncertain about something, that definitely adds to the patient's stress. I think it also makes the patient lose confidence (subconsciously) in the doctor's ability to make medical decisions, etc.

I guess whether good or bad we're stuck with it.

Tuesday, January 15, 2013

Dialysis

Anyone with end stage renal disease qualifies them for Medicare coverage. Currently this amounts to about 11 million patients in the US, with over 350,000 of them on dialysis - so about 2% of Medicare patients are on dialysis. For one patient, for one year, Medicare pays $67,000 for dialysis totally over $20 billion per year for dialysis, which takes up close to 10% of their budget. This means that 2% of Medicare patients take up close to 10% of the Medicare budget! And the numbers are only increasing.

I find this disturbing for a few reasons. For one, patients on dialysis are generally relatively sick. The 5-year mortality rate for patients on dialysis is 60%. That means that even with dialysis, a very expensive intervention, 6 out of every 10 patients on dialysis still die within 5 years.

Secondly, it's ethically questionable to spend so much money on a relatively small number of people. With a limited budget, the money could be used in countless other ways to prolong the lives or improve the health of a greater number of patients. Given the fact that 60% of patients still die within 5 years of starting dialysis, the cost-effectiveness of this intervention seems very high.

Finally, irrespective of ethics or efficacy of the treatment, can the U.S. afford this at this time? With rising rates of kidney failure and more and more patients needing dialysis, it may not be a possibility for the United States to continue paying for dialysis for all patients in the future. Not really a question I'm qualified to answer.

So what's the answer? Once someone has Medicare and is on dialysis, it's definitely ethically questionable to take away that treatment and send them on their way towards death! I don't have any great solutions, but perhaps the government will eventually have to stop providing payments for dialysis, with some sort of grandfather clause for those already on dialysis.

Of course, I'm sure if someone I cared about, or I myself, were on dialysis, my opinions and thoughts would be completely different.

Hiatus

Well, it's been a while since my last post. I have every intention of starting up again, but first let me explain why:



My daughter, Cecilia Jang Lubetsky, was born on May 21st, 2009. Having her and raising her is the hardest thing I've ever done (and am doing), including med school, my PhD, internship, everything. She's also the most rewarding thing I've ever done (and am doing) and I would not change a thing.

Monday, January 14, 2013

The First Year: HIV: An Essential Guide for the Newly Diagnosed



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Product Description
This supportive resource explores the next generation of HIV/AIDS drugs and also includes new research on HIV and crystal meth, as well as new insights for the hardest hit population African Americans.


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Sunday, January 13, 2013

Children of Men

Tonight Amy and I watched the movie Children of Men, an excellent movie. It’s a British film, set in the future, where for unknown reasons, people have become sterile, and no more babies are being born. The last person was born 20-something years ago, he’s basically a celebrity because of that, and the movie starts out with him dying. The whole world has become chaotic, with London being the last refuge of order, so all these people are trying to illegally sneak in. The main plot involves this woman who is surprisingly 8 or 9 months pregnant, and they are trying to smuggle her into London. The human race is facing its own extinction and she may be their last hope for survival since nobody else can produce babies. It’s an interesting concept, and I think they filmed the movie in a very interesting way.

Friday, January 11, 2013

Top Ten #1: Reasons Your Patient is NOT in 10 out of 10 Pain

10. The patient is sitting in bed doing a crossword.
9. They are jabbering non-stop on the phone with the friend.
8. They ate their entire dinner and then asked for more.
7. They tell you that they're in 10 out of 10 pain in a totally dead-pan bored voice.
6. The patient gets up and walks around the hospital floor all the time.
5. Their blood pressure and heart rate are completely normal.
4. They are supremely worried about the channels they get on TV.
3. They will only take IV pain medications and will not try anything by mouth at all.
2. They are "allergic" to morphine.
1. They don't LOOK like they're in any kind of pain.

Is this cynical? Maybe.

Thursday, January 10, 2013

The Patient from Zim

I was on call again this week and my team admitted 7 patients. It wasn’t too bad because it was dispersed throughout the day. Except this morning during rounds we mixed up two of the patients and we wrote a note after having examined the wrong patient. But actually, they had similar presentations, and a similar clinical picture and everything still applied, so it was okay. I felt really embarrassed because they were my patients, but I wasn’t that familiar with them since I hadn’t been around the week before when they were admitted. I felt a little better after we saw another team rounding, and they were talking to a patient and wrote a note on him, and then later, we found out that it was our patient they were talking to! So they did the same thing! It was pretty funny. :)

The most incredulous thing that happened today concerned a patient who I admitted last week. He spoke English very well, and was very nice, and it turned out, very religious. HIV tests are the norm here, and although we’re supposed to (I think) ask for consent, almost every patient, if we don’t know their HIV status, gets tested whether they want to or not. I actually went to the trouble of asking this patient, and he refused! Boipelo wanted to go ahead and test him anyways, especially since it had already been sent from the A&E without his knowledge. But anyways, the patient refused, so I had to call the lab and track down the blood and cancel the order. I tried for a long time to talk him into it, telling how important it was, and how it would help us diagnose and treat him. He said he wanted to get tested, but that he was very religious (praise the lord and all that) and wanted to get tested together with his wife. He promised that as soon as he was out of the hospital, they would go together to get tested. I actually sorta believed him, he seemed so credible.

This patient had come in with several months of weight loss, night sweats, productive cough, and progressive shortness of breath. He was a very fit guy – said he worked out for 2 hours every day – but obviously became short of breath even when walking. On his chest xray, he had a classic round “water-bottle” heart suggestive of a pericardial effusion (that’s fluid around your heart), which was confirmed by echo – that’s basically an ultrasound of the heart. It was only a moderate effusion though and wasn’t squeezing his heart significantly, and was probably too small to be drained, so we left it along. The upshot of this whole picture is that this patient very likely has TB, and although it’s not definite, if he has TB, he likely has HIV. We found a big lymph node in his neck which I biopsied, and stained for AFB, and it was swimming in it. He eventually consented for an HIV test, and we started treating him for TB over the weekend.

Anyways, to get to the interesting part of the story, when we saw the patient this morning, he was visibly upset, and had bruises all over his body, and had several teeth knocked out!!! We pieced the story together from several different sources. Apparently after we all left on Friday night, the patient started praying very loudly and disturbing other patients. He’s also Zimbabwean (there are a lot of Zim immigrants everywhere right now, but that’s a different discussion), although he has a Motswana (a person from Botswana) wife, and I guess started praying in a manner that let people know he was foreign. As the story goes, he was confused and acting strangely and wouldn’t be quiet, and he got up, and touched a prison guard on the shoulder, or perhaps slapped his shoulder or his face – it depends who you talk to. A single nurse claims to have seen the slap, the patient says he touched the guard on the shoulder, and the guard of course claims to have been hit. There were four guards camped out there in the male medical ward at the time – watching over 2 or 3 of the prisoners we had as patients. They had nothing to do with my patient, but after my patient touched/hit one of them, they ganged up on him, dragged him into the procedure room and held him down and beat him up!!! Absolutely awful!!! Even if he did hit a guard he was reportedly “confused” and should only have been restrained at the most. It was ridiculous what happened. Unfortunately, I think a lot of this happened because he was a foreigner.

The patient’s wife was incredibly upset, and rightly so. She took the matter to the police, and there’s going to be an investigation, supposedly. Although since the matter concerns prison guards, nobody believes that anything is going to happen. Boipelo had to fill out paperwork and give a statement about what might have happened, and the superintendent of the hospital had to get involved! It was pretty crazy. The poor patient – he had to go to the dental clinic the next day to get his teeth pulled.

And about a week later, a story appeared on the front page of one of Botwana’s papers – I have it at home, called “The View.” It had a head shot of my patient with his missing teeth and a somewhat exaggerated story about what happened to him at the hospital! Crazy. I’ll upload the article when I get home, but it’s pretty ridiculous.

Personality

Personality plays a large role in many different careers - it's no difference in the medical world. If you have a good personality, patients often like you better and think you're a better doctor. Similarly, if other medical colleagues get along with you well, they usually think more highly of you as a clinician. This all leads to more referrals, by patients and doctors alike. I think personality is supremely important in a doctor, and certainly is part of being a good doctor - you don't want a clinician who is callous or unfeeling, or someone who does not deliver bad news well.

However, personality is not everything. I think many good clinicians often lack in the personality area, or at least the empathy/sympathy area simply because they are too busy. And unfortunately, many times patients will label them as bad doctors because they don't like their attitude or the way they present themselves. I think that's totally valid, but I also think sometimes patients may be losing out on very good care because they may be too demanding and not understanding enough of their doctors.

I think it's even worse when other medical professionals assume that someone is a good doctor just because they get along with them well, or that person has a good personality. I've met plenty of people who I like to hang out with, but who I don't necessarily thing are the best clinicians. I don't necessarily think they're horrible, or even bad, but some people think they're great because they are really easy and fun to get along with, and I just think they're ok clinicians. I think that first and foremost, a doctor has to be a good clinician (making good clinical decisions, etc) and then secondly, should be empathetic and have good relationships with his patients. If the doctor can do both well, then that's great, but the first characteristic is the most important.

Wednesday, January 9, 2013

Comfort Zone

One thing I've run across lately are a lot of radiology reports that seem to make statements or recommendations that are a little, well, off. First, let me make clear - my field is radiation oncology, NOT radiology. Another thing that I have to make clear is that in most cases, the radiologist that looks at images from a CT scan, MRI, ultrasound (etc.) never meets the patient, and often doesn't know their clinical history.

So why is it that I often read in radiology reports things like, "fibrosis and scarring consistent with radiation-induced pneumonitis"??? Sometimes the patient hasn't even had radiation! Moreover, pneumonitis is a clinical diagnosis, not just a radiologic one. In a day and age when patients can access their own results, including radiology reports (which I am in favor of), this can be very dangerous to claim. And sometimes downright wrong.

Another thing that happens is that in the report, it reads something like, "5 mm area of enhancement not clearly imaged by CT. Recommend follow-up with CT in 6 months," or "Recommend additional MRI study." I find that it's interesting they can recommend this without even knowing the clinical situation. For example, what if the patient had some clinical condition that easily explained the imaging abnormality, but now because of this report, it's almost necessary to order this additional (and sometimes costly) test. If the reports said something like, "based on clinical scenario and judgment of the ordering physician, a follow-up CT scan may be indicated," I think everyone would be much happier.

Just to give an example - I certainly do not tell a cardiologist how to prescribe or dose anti-hypertensive medications. I expect other specialties to respect the same boundaries.