Tonight's Menu

Appetizer: cheese, crackers, and olives
First course: Mushroom soup (yum!)
Main course: Prime rib, with sauteed spicy broccoli and asiago cheese potatoes
Dessert: summer berry gratin

Pelagano art colony in Gabane

Today was a huge adventure! Lisa and I wanted to go to Gabane to see the art colony there and maybe buy some stuff, but we didn’t really know how to get there. We got the general directions that we had to take a combi to the combi station, walk over to the bus station and take a bus to Gabane. The combis are an experience in themselves! It’s Gaborone’s mass transit system, and it’s really just a bunch of rickety private vans that go on specific routes. They pack in as many people as humanly possible into each van, usually about 15 people, with people almost sitting on each other or crouching in the van. But they’re very cheap, only P2.5, which is like 40 cents. There are certain stops, but you can really flag them down anywhere, and you have to know where you want to get off because you shout it to the driver.

So first we get on the combi going the wrong way. We have to get off, cross the street, and flag down a combi going the opposite direction. Oh no, another 40 cents. :) Good thing for us, the combi stop is the last stop – and there are rows and rows of combis. It’s a pretty amazing site. Good thing we met this guy Reuben on the combi because he then took us to the bus/train station, which is across this big foot bridge – we would never have found it on our own. Or at least, it would have taken us a lot longer! And there are about 200 lines of different buses waiting to go to different towns and cities. They all say the name of where they’re going on the front of the bus, which is helpful, but he led us to the right one for Gabane. And these buses aren’t really buses – they’re really just combis, maybe a little bigger. And we squish in, and once it’s full, we were off for Gabane! Again, we rode it to the last stop, which took about 30 minutes, but we definitely did not see any art colony. So we had to ask around – good thing there are at least a few people who speak English and almost everyone is very willing to help out lost tourists. A guy basically told us that we had to walk 2 or 2.5 km down this dirt road to get to the art colony at the base of a hill, and that it was called Pelagano.

It’s not as desolate as it sounded though – there were cars that went down the road from time to time and people walking down it along with us. Every once in a while a car would honk at us and look, I think expecting us to hitch hike. We almost did it a few times, but it wasn’t that far to walk. It was pretty interesting too - there are domestic animals (donkeys, sheep, cows, etc) wandering everywhere, and we got to see what type of places normal Motswana (that's the term for someone from Botswana) live in. Most of them live in these cement square rooms, with an outhouse in the back. Some of them have thatched roofs. But they look tiny, and I'm sure a whole family lives in there, with a small stove and everything all squished in. The picture I took was of a really nice one with a store attached to it at the back. These guys kept coming up to us and chatting us up too. Most asked if we were single and things like that, but there was one guy who kept asking us if we wanted to buy his property! Pretty funny.

When we got to Pelagano, it seemed pretty deserted. But we wandered into one of the open doors, and met this artist Elijah. He was surrounded by all these large, nearly-life-size sculptures, and was working on this huge clay scorpion on the floor. We found out that most of those huge sculptures were made of fiberglass from molds that he designed – he also designed the outside entrance to the art colony. He seemed really talented! He had beautiful works in clay, fiberglass, metal, and watercolor, and we probably only saw a small portion of his work! And apparently he had a twin brother who did a lot of art as well – I think mostly glass-blowing. But we didn’t meet him. Anyways, after talking to him a bit, we wandered around. It was pretty empty, but he told us that it was much busier on the weekdays, when the colony was more open. It didn’t really matter though, people would see us walking by and invite us in. And the glass-blowing and pottery shops were also both open. It was very impressive stuff – if I didn’t think some of it would break on the trip back, I might get some of it. And it was not nearly as expensive as in the states, although it was probably expensive by Botswana standards. We ended up buying some stuff from this boy artist that looked like he was 13! He did some amazing stuff though – he painted on cloth, and he had wall hangings, linens, etc. The wall hangings were the most beautiful, but I already have so many that I can’t even hang up. Lisa bought a wall hanging and I bought these cloth placemats. Still super cool.

The Main Mall

Lisa and I went to the main mall, a 10-minute walk from the hospital during lunch hour because I had to change money and Lisa had to buy a cell phone. I ate from the ladies with food in pots on the sidewalk - it was really good food for only P12! It was similar to the stuff in the cafeteria, but even cheaper. The meat on the bone, which they barbecued on the spot, was really tough though. I think from now on I’ll just eat stewed meat, because otherwise it’s been too tough for me. There were also a lot of vendors selling really really cool touristy type stuff. I’ll probably buy some of it eventually. I think there may be a Chinese grocery store there too! Lisa got this phone that was really cute and the buttons looked way easier to use for the same price – it was a Nokia phone, whereas my phone is sorta just generic. Plus, her American electric plug for her American Nokia phone also works with this phone, so she could use it in the states too! I was a little jealous, but oh well, I’m only using this phone for 10 weeks or so. It’ll do.

So at work, I missed my first LP today – the patient was a super skinny guy and I went way too deep. The MO Maggie who was helping me took over, and she says she thought I’d had it at some point because she saw CSF in the needle, but I probably went past it. When she finally got the needle in, it wasn’t very deep at all! We also discharged a lot of patients just in time for a really difficult week. My team is on call Saturday (but I don’t have to go in), so I pick up a ton of patients on Monday. Then we’re also on call Wednesday and Friday.

Tonight I made fried rice and this really good cheese and onion-stuffed bread I bought for P6 (~$1) at the supermarket the night before. When Mike, Kristy and Kiona came back from call, they took the bread and some of the fried rice, so that was good. Lisa came over and we made plans to go to this relatively close by town that specializes in pottery. Or is it weaving, I can’t remember. I think we’re the only two going – everyone else is sick or busy. So for tomorrow, we’re going to have to take the combi to the train station, and then the bus over to this town… it’s going to be an adventure!

Doctor Shortage

People have been reporting about this for quite a while, but a friend just recently forwarded me this NY Times article about how there will be a severe shortage in doctors in the future, especially in the primary care field. It seems many people, including the current Obama administration are becoming increasingly worried about this problem. While some steps are being taken to try and delay this crisis, there are many many roadblocks.

Of the ideas that have been proposed or already instituted to try and solve this problem, one includes increasing the sizes and numbers of medical schools. Medical schools may have to admit more students that don't have science backgrounds - while some worry that this may decrease the quality of medical students and eventual doctors, I don't think this is a problem and may even be of benefit. Medical schools already admit plenty of students with non-scientific backgrounds and as long as they can build up a significant fund of knowledge either in medical school or in a year of study before entering, I think it's not a problem. In fact, it may even build diversity and bring new ideas and perspectives to the table, which is definitely a good thing.

Another idea is to increase the use of non-MD sources of health care, including nurses and other health care professionals, which I think is a great idea. However, there is also a nation-wide shortage of nurses, so this avenue may be limited as well. Finally, it has been suggested that we use more minority as well as international doctors as there are many MDs from other countries who would like to practice in the U.S. Obviously this presents many problems as training in other countries can be vastly different than training in the U.S. and currently, depending on the country they come from, international doctors often have to retake licensing exams, as well as complete full residencies (after having already completed residencies or full training programs in another country) in the U.S. This is a huge deterrent for MDs coming from other countries to try and become MDs in the U.S. - I don't know how many international MDs I know who have instead become lab technicians or Ph.D. students or post doctoral students because the requirements for them to practice medicine in the U.S. are so overwhelming. However, I don't have a great solution for this as I do believe the training is different from country to country and that international MDs should practice in the custom of U.S. training, for legal purposes as well as medical.

Despite these efforts, I see a lot of hurdles for which there are no easy answers or solutions. One is that even though medical schools may be increasing their enrollment, there are a limited number of residency training spots available. These are being increased as well, but they cannot be increased as easily or at the same rate as medical school spots. Residencies are much more complex to set up, and must go through a thorough accreditation process every couple of years, which is not only cumbersome, but can be difficult to arrange and maintain.

Moreover, there is heavy competition for competent people by other professions, the major competitors being business and law. Now, with the economy being the way it is, business has been less attractive the last few years, and perhaps the medical pathway is getting a boost from the decrease in business school applicants or business jobs. However, law and business careers can be much more attractive than medical careers - the training is much shorter. School takes half as long, and after school you start earning a relatively good salary right away whereas in medical school, it can take 4-6 years, with 3-5 year of low-paying residency afterwards, sometimes followed by 1-2 years of low-paying fellowship. Once you finally get out of all this training, doctors (especially primary care) often still make lower salaries than lawyers and businessmen, and have to contend with other headaches and costs associated with malpractice insurance, insurance paperwork and red tape, etc. Until there is good health care reform, or salaries become more equalized (either doctors' salaries have to come up or other salaries should be lowered - probably the latter is better for various reasons), there's not much that can be done about this problem.

Finally, even with the increase in medical school admissions and residency spots, many people are still attracted to practicing in medical specialties rather than primary care, in which the doctor shortage is the most severe. Again, this likely is due to a salary differential as primary care doctors make much less than doctors in medical specialties. As with competition with business and law degress, not much can be done about this problem until the salaries equalize - in this case, I think primary care doctors should be valued more highly and their salaries increased.

Korean food in Philly

We've been really getting into the Korean food lately. There's an asian grocery store called H-Mart near the 69th street station, and on the second floor, there's a Korean fast food court. It's great. There's Korean food, Japanese food (with a Korean accent), Chinese food (with a Korean accent), a Korean bakery, and even a place that sells fried chicken (with a Korean accent). We always go to the Korean fast food counter - it's soooo good. They have all sorts of barbecued meats, soups, fish, tofu, you name it. Some of it's not spicy at all, but some of it is pretty spicy (one or two peppers on the menu). I think my favorite is the marinated beef short ribs. TASTY. And it's so cool - all the dishes come with rice (or noodles depending on whether you get a rice dish or a soup dish), maybe soup, and about 3 or 4 other small side dishes. They always give you kimchee, and the other 2 or 3 might be things like pickled vegetables, broccoli, bean sprouts, tofu, whatever. Even better, they recently put up pictures with their entrees, so now I'm not stuck wondering if that's what I got last time, or if that's something I'd like to try. I had been thinking of starting to take pictures with my cell phone and labeling them with the menu order number. Not a bad idea huh?

So for Pete's birthday yesterday, we went to a new Korean place, in the same general vicinity. However, this was an actual sit-down place where you order and they take it to you at your table, and you get tea and water and everything. It's called Moo Jin Jang. I didn't even realize it had my name in it until I got the receipt. I think it was a good omen. It's not a fancy place - there's no alcohol, they serve the tea in big plastic pitchers (not even a teapot), and the menu is this laminated card on every table that lists about 20 choices. The one waitress was the only one that spoke English, and I think she translated for her mom and dad. But everything still looked good. I only recognized maybe half of the menu - all the other items listed things I had never heard of before. I was tempted to try one, but I stayed with tried and true. I ordered the barbecued pork (spicy) and Pete got the beef short ribs. DELICIOUS!! And unlike the little fast food counter, this meal came with about 8 different little side dishes - it was great. We got fish, broccoli, bean sprouts, kimchee, pickled vegetables, hot pickled vegetables, little meatballs (which I think were marinated hot dogs), pickled potatoes, I can't remember them all. It was a lot of food, and of course I took it home. I'm pretty sure we'll go back at some point.

Heavy thoughts

Well, I don't know if I'm back for good, but I've been thinking about things sufficiently to write again... the world of lung cancer is not the most uplifting of worlds.

For example. I was talking to a patient that I like very much - one I empathize with, one I like personally, and one I even identify with. She's a hard worker, in a demanding career, still working through radiation we had given her previously, and chemotherapy, funny, witty, smart, had 3 children relatively late in life. We had a great conversation about how her daughter just went off the pill and was hoping she would get pregnant soon. I shared my story about how I got pregnant only a few months after stopping the pill, and the patient had the same experience. So she was hoping she would have a grandson or granddaughter soon. Her time is limited - she has metastatic lung cancer. In the world of lung cancer, her average survival would probably be about a year. And that's with chemotherapy, which, let's be honest now, will make her feel lousy half the time.

She started coughing up blood lately, and so we are going to give her radiation to her lungs at a low dose to shrink her tumor and hopefully stop her from losing blood. It's not serious. Not yet. I was doing what I do with a million other patients, I was explaining the side effects of radiation:
"You'll feel tired. But fortunately, that will pass."
"You might get a sore throat. But that will eventually go away too."
"You might develop a cough, fever, or shortness of breath, but that's not common."
ETC.

One of the last things I say is something like "Very rarely, radiation can cause a second cancer in the area we are treating you, but this doesn't happen for 5-10-20-sometimes 30 years."

She snorted and said "if I get another cancer in 10 years, I'll be very happy. Right?" And I nodded my head in understanding and made an mm-hm sound. Then she started crying. I gave her some tissue, she coughed up some blood, and I put my hand on her back. Nothing to say. She pulled herself together, and said, "okay, let's get on with this." And she thanked me for being honest with her.

Here I am, feeling horrible about mentioning a side effect that realistically, she will never ever have the chance to feel, and she thanks me for it. Maybe this is a lesson that I should stop mentioning this particular side effect to certain patients. Or maybe it's not that deep, it's just a manisfestation of a really sad situation, one that I will have to get used to.

Medical Time Suck

I cannot believe the time I spend doing non-medical things for my medical patients. Some of course are necessary, for example - speaking to patient's families. In a way, you can consider that part of a patient's health, especially if they partially or completely depend on their family for assistance at home or for their medical care. However, I would bet that the majority of my time is spent doing non-medical tasks. Let me give an example.

Today I had a patient who was admitted several days ago from a shelter for fainting and having chest pain. At first it sounds serious, but it turns out he probably is an alcoholic and "passed out" after drinking too much, and his chest pain looked clinically like a mild rotator cuff injury. Moreover, he had no idea what his medications were, which shelter he lived in, what kind of past medical history he had (cardiac or otherwise). For this patient, not only did I spend hours on his medical care, but I also spent hours calling 4 or 5 different shelters trying to find out where he lived and what medications he took. I called his health center many many times trying to get a hold of his doctor, and when I finally reached her, she didn't know anything about him. I spent time talking to the medical records department of another hospital, getting the patient's authorization for medical record release on paper, faxing it to the medical records department, and then waiting for them to fax me the studies he had when he was admitted there. Then finally, it took quite a while to get him discharged as we had to involve social work so that he could get sent to a shelter using a cab voucher and could get medical follow-up (which he probably will not do) with our cardiology department.

These are all very frustrating things, and unfortunately it's the poorest and neediest patients who often need all this extra attention. Sometimes they come in to the hospital partially to find a warm, dry place to sleep, a place to clean themselves, and 3 meals a day in addition to medical care. I think a lot of doctors and nurses often take a look at these patients and brush them off since they don't have a good medical reason to be in the hospital or sometimes are actively lying and trying to deceive us in order to stay in the hospital. However, I see it like this - if you spend the time on them now, then hopefully they will have good medical follow-up afterwards and won't get to a state where they have to be admitted to the hospital again, thereby decreasing the amount of our work. Of course, some patients are just hopeless - they're well known to the Emergency Department and the medical staff, and I guess that's just something we all have to accept.

Walking home

Nothing much happened again today. I had very few patients – I think our list is down to 8 people! So I finished all my work by 11am, and went to Main Mall again with Betsy for about an hour and a half. We stopped at the Spar (a grocery store) for some household items, and I came back and helped Phil and Lisa out a bit but still got home pretty early. I was willing to stay later and help them some more, but they pretty much insisted that I go home. I have to say, it was a little disconcerting walking home alone, even though it was still light out. We use these back paths to get to the hospital because it’s closer and faster than walking along the main roads, and unless it’s morning “rush hour” or evening “rush hour” it’s pretty deserted even during the daytime. And people have definitely gotten mugged before, even when it’s light out. It's funny - I end up saying hi to everyone, as a sort of prophylaxis. And others do it too! I guess we figure that if we seem nice to someone, they won't mug us. And it's not like it's strange - it's actually very common for complete strangers to say "Hello, ma'am/sir" passing each other on the street. So it was a little weird, but nothing happened.

I got home and finished my personal statement. Woo hoo. I sent it to Pete to have a look at it. But I’ve seriously got to get working on the rest of my applications for residency!

Little Fish

We just went to Little Fish for dinner tonight. It was excellent - enough so that I have to blog about it. :D

For appetizers, we had diver scallops with orange, almond and serrano ham as well as peekey toe crab with red beet, tarragon butter and shaved fennel. The crab was very flaky with an excellent texture - a little plain, but still good. However, the diver scallops were excellent - cooked to perfection with a wonderful flavor, and surprisingly good with the almonds and mandarin orange slices.

For entrees, I had the skate (a type of ray) with truffled spaetzle and shredded leeks. I think this is their most praised entree. This was absolutely amazing! The skate was fried lightly so that it was crispy on the outside but very soft and moist on the outside. The sauce was a salty parmesan broth that complemented it very well. The leeks were also tasty and complemented the strong-tasting fish very well. Pete had mahi mahi with a sweet potato puree which I believe was also very good, but not nearly as good as the skate. I would go back to eat skate at this restaurant any time.

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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100 Questions & Answers About HIV And AIDS

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EMPOWER YOURSELF! Whether you're a newly diagnosed patient, survivor, or loved one of someone suffering from HIV or AIDS, 100 Questions & Answers About HIV & AIDS offers essential and practical guidance. Providing both doctor and patient perspectives, this consise and authoritative resource answers to the most commonly asked questions about Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS) including diagnosis, treatment, post-treatment quality of life, alternative medicine, targeted therapy, and coping strategies. Written by Joel Gallant, Professor of Medicine & Epidemiology and Associate Director of the Johns Hopkins AIDS Service, this patient education title is an invaluable resource for anyone coping with the physical and emotional turmoil of this disease.

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Proper Use of the Emergency Room

I had a patient the other day who came in to the emergency room (the ED) at the suggestion of his primary care doctor. He had extremely high blood pressure at his doctor's office, but by the time he came into the ED, he had taken the blood pressure meds he was supposed to take, and his blood pressure had dropped significantly - almost normal! In addition, even though he had extremely high blood pressure, he never had any symptoms from it, and so although we might take steps to lower it in the ED, we likely would not admit him, especially now that his blood pressure had come down to almost normal after taking his blood pressure medications, which is how it should be.

The patient was livid. He had paid his $50 to get evaluated in the emergency room and demanded that he be admitted. He claimed his doctor had promised him an admission, which was not true, as we talked to that doctor ourselves.

Although not great, I use this as an example of how people misuse the ED and have the wrong preconceptions about it. Some people I understand - they don't have insurance, so they basically use the ED as their primary care. I don't like it, and I think there are better ways to deal with this or solve this problem (a whole topic in itself), but I understand. What I don't understand is why some people come into the ED at all when they have good primary care or have non-urgent problems.

The Emergency Room is supposed to be for EMERGENCIES. It is for people who can barely breath from pneumonia, not for people suffering from run-of-the-mill colds. It is for people who have broken bones and fractures, not for people who have had lower back pain for the last 6 months. It is for people who are vomiting so much or have so much diarrhea that they are seriously dehydrated, not for people who may have one episode of vomiting or diarrhea but are still able to eat and drink just fine. It is for people who are having a heart attack, not for people who have had "chest pain" that has been proven to be not related to their heart for the 10th time.

Not only is it a huge waste of public and hospital funds, but I don't understand why people would want to spend hours and hours in the uncomfortable waiting room of an emergency room when they can make an appointment with their primary care provider. In fact, when it gets super super busy, and people stay outside in the waiting room for hours and hours waiting to get seen, you can actually see people start to leave. In my opinion, if they weren't sick enough to stay and wait, they shouldn't have been there in the first place.

Kaiser and their electronic system

This is an interesting article about how Kaiser instituted their electronic medical record system.

I had written a previous post about this subject and still think it's a great idea, although possibly prohibitively expensive. However, one argument is that electronic records could eventually lead to cost -savings- as medical tests and studies are not unnecessarily repeated. Interestingly enough, the article says that the costs savings aren't really there as people are living longer with better care, and thus require more health care resources in the end, which off-set the potential savings in medical costs. Nevertheless, the article does point out that shared electronic medical records lead to better care and for that reason, it's still worth it to attempt implementation of these systems in all hospitals. Hopefully they will all eventually even be compatible with each other, if not already part of a common universal electronic medical record keeping system.

Sex with a Shooting Star (The Junkie Tales)

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From The Junkie Tales collection comes a short story about sex, love, and the secrets we keep. Benjamin Coleman is in love. Jodie Dean has a secret. Will either survive sex with a shooting star?

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My first game drive!

We had lunch around 1pm, which was one course – we got to choose between steak with peas and mashed potatoes or calamari salad. They both sounded good, but of course I got the steak. It was sooo delicious! It was incredibly tender and had great flavor, and the sauce that it came with was good too. The salad also looked very good, and people said the vinaigrette dressing was great. Steve stayed for lunch before he left, so with such a big group, we didn’t finish until about 2:45 pm. And they told us that we were going to meet for high tea at 3:30 before setting off on our first game drive at 4pm! So we were going to have half an hour before we were supposed to eat and drink again! But not to worry – it was just tea and these super buttery small cookies/biscuits. I tried only one, but they were so good I grabbed another for the road as we set off for our first game drive.

We all piled into this huge 4WD car/truck that seated 11 people, including the driver. So it was perfect for our group since we had 10! This car was super heavy duty, and it was really good we had it, because some of the dirt roads were pretty uneven, and we did a little off-roading as well. The way the game preserve works is that there are probably about 10 different lodges that have access to the preserve. And there are more traveled dirt paths that are pretty even and stamped out, and there are more private dirt paths that are often pretty small and uneven. The driver/guide, whose name was Hein (he was a pretty cute Afrikaan guy), told us that during the wet season, even these heavy duty trucks get stuck in the muddy ruts sometimes. And these trucks can go off-roading as well, although the drivers have to be careful of course, because there are all sorts of incredibly thorny shrubs and trees in the way, not to mention the uneven terrain.

So the game drive started out with a bang – the first animals we saw were two lions who were brothers. Lions sleep 20 – 24 hours a day, so we didn’t see them active or anything, but just lying curled up against each other on the ground. We got really close, and our guide told us that of course, the lions know we’re there – they have super keen senses – but don’t perceive us as a threat. They were breathing really fast, so Hein told us that they probably recently had a meal – they eat until they’re bursting, but they only eat once every 3 days or so. They eat so much that they don’t have room for their lungs to expand so they have to breathe really fast. It’s so funny! Sounds like me when I eat too much. :) Apparently close by, other trucks saw a mother and 5 lion cubs, but we didn’t get to see them. Hein told us that 3 of those cubs were hers, and 2 were her sister’s. Her sister died, leaving 3 cubs. One of them died, and just when the other 2 were about to starve to death, they were found and sort of adopted by their aunt. Kind of a cute story. We tried to find them again the next morning, but it was sort of cold and windy, so she was probably hiding them away in some shelter.

The next things we saw were two bull elephants. All the female elephants stay in a pack, but once male elephants reach about 13 years old, they get kicked out. So they often stay solo or keep company in small bull packs of 2 or 3 animals. They can get pretty aggressive though and charge at the truck, like they charge at each other. One of the bull elephants started getting a little aggressive, and our guide backed the truck up a little bit, which the elephant took as a sign of us backing down, and stopped being aggressive. I was a little worried, because those elephants can go pretty fast – Hein said up to 30-35 km per hour. But he didn’t charge us, so it was okay. We also saw them using their trunks to drink water and eat – they were pretty impressive. That snout has a lot of flexibility and strength!

Then I saw far off in the distance two giraffes! Everyone congratulated me on spotting them. :) We couldn’t get any closer, but my camera was able to get some questionable pictures of them. If you look closely, you can just see their shadowy outline. Apparently giraffes have the same number of vertebrae in their neck as humans do – 7 cervical vertebrae. Their vertebrae are just huge! They also have this sensor in the back of their head that monitors their blood pressure. Normally, like when they’re eating, they have to maintain a very high blood pressure so that enough blood gets to their head. Because their heads are so high, if they lower their head to drink from water, the blood pressure could shoot up as the blood flows downward, and they could pass out! What this sensor does is monitor when the giraffe lowers its head, and decreases the blood pressure while the head is lowered. This makes me wonder if there are mutant giraffes out there with malfunctioning sensors, who are passing out every time they try to drink some water. That’s probably selected against in evolution. :)

Then we saw some white rhinos. There are two types of rhinos – white and black, although I was told that because of political correctness they have renamed them to something like wide-snout and horned-snout. I’m sure I’m not getting those correctly. Compared to black rhinos, that usually eat from trees and keep their heads up (and have the correct type of snout/mouth to eat from trees), white rhinos tend to keep their nose to ground because they eat grass, and also have wider snouts, ideal for eating off the ground. They also are supposed to have different horn patterns, which I know nothing about. Black rhinos are supposed to be more skittish too – we certainly didn’t see any during our safari.

By this time, it was getting pretty dark and we saw a beautiful sunset. Hein stopped the truck and we all got out and took more pictures - we all climbed on top of the truck canvas too and took a good look around. It was pretty cool. He set up drinks and snacks, and I had some biltong – that’s beef jerky – and it was amazing!! They told me you can’t take it back with you to the states due to regulations, but it’s the best beef jerky I’ve ever had. We drove around for about an hour more after this, with Hein shining this huge penetrating light around to search for animals, but we didn’t see too much more.

We did see some really cool insects. There are these huge termite mounds everywhere, and at some point, Hein stopped and showed us these huge African ants. These ants go en masse to a huge termite mound, kill all the termites, and bring them back to their ant mound for the rest of the colony. We saw a huge line of incredibly large ants (and they can sting!), each carrying a dead white termite on their back, going back to their hive. It was somewhat scary.

We also saw a dead rhino skin. It apparently died about 6 months ago, and was immediately eaten up, leaving only the skin. It looked like leather, and Hein said around their neck, the skin can get up to 3 inches thick – pretty tough for animals to eat or chew through.


We got back around 8pm, and I finally could pee. :) Then we had a few minutes to freshen up, and then basically went straight to dinner, which was delicious! The appetizer I chose was smoked salmon on top of a potato cake on top of smoked kudu, on top of another potato cake. And there was this good sauce spread all around it. The entrée I chose was roast duck, which also had this really good tangy sauce all around it. And for desert I got a cheese plate with 4 or 5 different cheeses, some jam and some honey. Yum!!!! I left feeling very full and satisfied.

After dinner, we went upstairs, and some of us checked email, some of us just hung out, and some of us played pool. Only Kristy, Hein and I kept drinking, and I eventually played pool with them. My partner, the bartender, had to leave to settle up, but I beat them even though I was down by 3 balls! There was definitely some big-time flirting going on between Kristy and Hein, so eventually I left them alone and went to bed. Everyone else had already gone. Apparently that night, he took her on another midnight game drive! But he had to leave his gun because he was a little drunk – but I guess not too drunk to drive the 4x4 truck. :)

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Past ICU stories

Today was just an okay day – the whole ICU thing sorta blew over, so it was alright. Dr. Stefanski basically said that no female student should ever go into the ICU alone, and he, Boipelo and I all went in to the ICU as a group to see our patient today. And the doctor was very civil. They both told me all these stories about this ICU doctor. Boipelo told me that when she was an intern, she had a patient in the ICU, and this doctor said “go away, and never talk to me again! I don’t talk to interns.” And that’s just crazy! Often an intern is the only person taking care of the patient!

Dr. Stefanski also told us a story about how he had this critical asthma patient that he transferred to the ICU. The ICU doctor refused to use epinephrine on this asthma patient, who was breathing like 50 breaths per minute and really struggling. And for those of you non-medical people, epinephrine can be a huge life-saver for asthmatics – it can open up your airways until the attack has died down a little bit, otherwise patients can literally suffocate to death. Anyways, the ICU doctor refused to use it because he said it was never done, and there was no proven benefit. So Dr. Stefanski got two big legitimate papers that described in large multicenter randomized studies that epinephrine was of benefit for severe asthma attacks, and he gave them to the ICU doctor. The ICU doctor just threw them away. Apparently, the patient kept going in her awful suffocating state for about 3 or 4 days, and then the ICU doctor finally said, okay, she’s not getting better, maybe we should try the epinephrine. And the day they finally tried it, it was basically too late – the woman was so tired from breathing so hard for so long that her body just gave out and she died. I would say that this ICU doctor was personally responsible for this woman’s death, which was very preventable.

Oh, and in case anybody cares, his name is Mkubwa. So if you ever bump into a Dr. Mkubwa that runs an ICU in Gaborone, Botswana, I hope it’s not as a patient.

Night Coverage

Clearly, doctors can't be at the hospital 24 hours a day, 7 days a week, so for at least some of the time, their patients have to be cared for by somebody else. Different hospitals handle this in different ways. At Pennsylvania Hospital, there is a night float system. Most of the interns leave the hospital at night and sign their patients out to a single night float intern who works from about 5pm to 7am. The good thing is that most interns actually get to leave the hospital at night and are refreshed the next day to do work. The bad thing is that the night float intern is taking care of probably about 80-100 patients a night, and since you get signout on so many patients, it's not that detailed and you really only remember the really sick patients or make a note of specific things you have to do for certain patients. That means that night float doesn't know most of the patients very well at all - they just handle critical issues at night. Most patients are sleeping at night, and there's not much going on, so it's manageable, but if there are quite a few sick patients that night, it can get very busy and complicated. The good thing is that there is a resident or two for backup if things do get ridiculously busy.

Some other hospitals do it differently. They have teams that round together, and at night, 3 interns will sign out to one other intern for the night. The good thing is that that since they all round together, that intern staying overnight is supposed to know all the patients relatively well. The bad thing is that one out of every 4th intern stays overnight, making 25% of the interns extremely tired and miserable the next day (since usually they get very little to no sleep) and also decreasing the work force by 25% the next day since they have to leave by noon.

It's hard to say which is the better option. It's bad to have so many interns tired working the next day as studies show that the more tired doctors are, the more mistakes can be made (not that they are common by any means). This is an argument for the first system, like at Pennsylvania Hospital. However, newer studies are starting to show that the more times care is transferred between different doctors, especially doctors who are not super familiar with the patients to begin with, the more mistakes can be made (again, not that they are common). This would be an argument for the second system.

In fact, there are rumors of new legislation in the works that forces interns to take a nap (!) in the middle of call for at least 3-4 hours. During this time, they would have to somehow sign off their patients to someone else, and then get them back at the end of their nap. This is all part of ongoing legislation reform about duty work hours (a whole other post). However, the problems with transfer of care may be an argument against doing this sort of thing. Until hospitals have more money to hire more helpers (e.g. RN's, NP's, etc) that can at least do part of the work of interns, I guess we'll have to make do.

Zahav

We went to Zahav last night for restaurant week. It's supposed to be a modern Israeli restaurant, and it was spectacular. A nice treat on a non-call and non-post-call night. Sometimes restaurant week is hit or miss because some restaurants become overloaded with customers and they're not used to - so the service goes downhill as well as the food. I think the really good restaurants though, ones that are often busy all the time and are used to the customer load, do just as well during restaurant week as they do during other times.

Last night, they started us off with some pickles and olives, and then brought some large trays of amazing hummus with this homemade bread called laffa that reminded me of naan. Then they brought an appetizer of 8 different vegetables/salads prepared different ways: pickled turnips, beets, carrots in a peppery marinade, cucumbers, a pepper pesto, eggplant, and a couple other things I can't remember off the top of my head. They were all excellent - the beets were my favorite, as well as the table's favorite.

Then we each got to choose two appetizers and an entree. As you can imagine, there was a lot of sharing. I personally ordered the fried cauliflower (one of their specialties) and mini stuffed peppers. The fried cauliflower was soooo good. Pete got bulgar wheat stuffed with ground lamb (sort of like an empanada) and chopped liver. It was probably the best chopped liver I've ever had. From other people at the table, I also tried the fried sheep's milk cheese, which was amazingly tasty and rich, and also these leek and mint fritters, which were mild, but I thought really really good and creamy.

For entrees, we all got similar items. I got a ground beef and lamb entree (the "bulgarian) while Pete got a ground beef and lamb sausage ("Monsieur Merguez"), which was very very tasty, with good spiciness and texture. Then for dessert we shared a cashew baklava with white chocolate argan ice cream and a "konafi" which looked a little bit like sugar and chocolate deep fried noodles, topped with ice cream.

I think I'm still full. :)

John P. Pryor

We recently read some bad news about John Pryor, a trauma surgeon at the Hospital of the University of Pennsylvania, who died on Christmas day in Iraq.

I never met this guy, but I heard of him. Seems like he was an amazing guy.

Doctors in training

A family member sent this article to me, and there's a link within the article to another related column.

They basically talk about the culture of negative reinforcement for medical interns and residents. It's fairly common for residents to get yelled at or chewed out by attending doctors for various things in the hospital. Moreover, these episodes can often be about relatively unimportant things, or things that are in no way the fault of the intern or resident, and the attending if often venting their anger and frustration on those that are beneath them. As the article points out, I think most people can agree that such public displays of anger and criticism are not useful or constructive in any way. As the second article explains, positive reinforcement and constructive criticism is much more useful. However, this doesn't stop certain attendings from taking out their anger on their subordinates, which clearly isn't right and can often drive interns and residents out of the medical field altogether.

Being an intern, I've definitely seen plenty of things like this first-hand, although thankfully I've very rarely been on the receiving side. I think the best way to deal with people like this is to simply provide the best medical care you can, and, to be perfectly honest, ignore the attending for the time being! Obviously, if something should have been done differently, either medically or otherwise, you take that lesson with you, but if someone is yelling at you unnecessarily and unhelpfully, you would probably make the situation worse if you speak up about it at that time. It can be a very difficult position as the attending has a lot more power and influence than you and it can be very intimidating. If you feel very strongly about it, there are usually avenues you can follow (such as taking the issue to a program director or an ombudsman) to address it later. I think the best lesson to learn from an episode like that is how you do not want to be an attending like that in the future, knowing how it made you feel as an intern or resident. I think also, that interns and residents should have a thick skin and be prepared to shrug things like that off as long as the abuse was truly unwarranted.

For what it's worth, I think certain specialties are more prone to this type of abuse by attendings, and I also think the incidence is declining as programs and doctors become more aware of it and interns and residents are more outspoken about it.

Arranging travel plans at Game City

I had been stressing about how I was going to get from Gaborone to Livingstone to meet Pete, then from Maun back to Livingstone after our safari, then from Livingstone to Windhoek to meet Bruce, and then from Windhoek back to Gabs. I decided that I could take this overnight bus from Gabs to Livingstone, and Pete and I could either rent a car or take public transportation for getting from Maun to Livingstone. Both trips seemed pretty secure, and I had reliable sources tell me that they were possible.

However, taking public transportation from Livingstone to Windhoek, and then from Windhoek to Gaborone was not only unpredictable and uncertain, but it would also take a ridiculous amount of time! Between the two trips, I think I would have been en route for a total of 45 hours! And there was the possibility of missing transfers (I think the Livingstone to Windhoek trip alone would have required something like 5 or 6 transfers to different combis and buses), or there not being buses at all, leaving me stuck in some pretty small towns. So I bit the bullet and bought a $1000 plane ticket taking me from Livingstone to Windhoek and then eventually from Windhoek back to Gabs. Both flights go through Jo’burg since it’s a South African Airlines flight. It’s super expensive, but I think if I was traveling for 45 hours later, I would be cursing myself for not buying the ticket. So this afternoon we finished way early and I went to Game City (another American-style mall) to the SAA office and got my plane ticket. I’m so relieved!

Game City is pretty interesting – it’s the only completely indoor mall in Gabs, and it’s very westernized. There are tons of clothing stores, a movie theater, some restaurants and a food court, and other little shops selling random things. After school, teenagers were everywhere, dressed as nice as possible. J I had lunch at the Mug N Bean (a big yummy chicken burger with avocado, cheese, etc) and wandered around a bit.

The supply chain in Botswana

This was a relatively boring day at the hospital since this is our easy week, so maybe now I’ll talk about some another issue at the hospital – the supply chain! This is a favorite topic of Dr. Stefanski's, so we've had quite a few discussions about it.

So here at Princess Marina Hospital, probably the largest public hospital in Botswana, there are often problems with the availability of medicine, or of certain medical instruments, even very common ones. Last week, we ran out of amphotericin, which is a drug we use to treat cryptococcal meningitis - that's an infection in the cerebrospinal fluid that surrounds your brain and spinal cord. It's the type of thing that we diagnose with an LP, which I described in previous posts. Because a lot of people have HIV and AIDS here, a lot more here come down with meningitis than in the states - some of it is due to TB, some bacterial, some bacterial, but more often than not, it's due to cryptococcus. And amphotericin is really the only option they have in Botswana to treat it. Alternatively, you can use a whopping dose of fluconazole, but it doesn't work as well, and we also ran out of that for a few days last weekend. As a result, all these people in the hospital (and in the clinics probably) had no amphotericin, and also no fluconazole - their cryptococcal meningitis went untreated! Now, even if they had come in immediately and started treatment right away, this is an awful disease, and chances are not great that they'll survive. But if treatment is delayed or halted for a couple of days, chances are even worse! Our team didn't have anybody die, but I know other teams that did.

Dr. Stefanski told us this story about how last year, they ran out of the solution needed for peritoneal dialysis, which is a substitute for your kidneys, if your kidneys have failed. Dialysis isn't as common here as in the states, but there are still quite a lot of people on it. And they were out of it for a month! People were basically getting admitted to the hospital to die of kidney failure. Awful.

Apparently, the problem is not lack of money - the ministry of health has plenty of money. It is the largest ministry in Botswana, and controls the largest budget by far. The problem is that somebody or some group, whoever is in charge of ordering medical supplies for the country, did not realize that we were running low on drug X, or medical supply Y, and didn't order it. So the entire country will be out of whatever it is for a month at a time! Supposedly, they've had 3 big consulting companies (probably each making millions of dollars each time) come in and make suggestions as to how to correct the problem, but obviously that hasn't happened. It seems that every time there is a change in who's in charge, they get a new consulting company in (probably they're friend or relative's company) and get new recommendations, which aren't followed. It's such a ridiculous problem, and a very exasperating one that all the doctors complain about. I guess it's another thing to be thankful for in the States.

STUPID ICU DOCTOR

I was the only one on my team that showed up today – the MO Boipelo was sick, and Dr. Stefanski is not at Princess Marina Hospital (PMH) on Tuesdays, plus he’s been sick himself. So I had a few problems today. The morning was great! I got all my work done, and it generally went smoothly as I rounded by myself, but I definitely hit a few snags this afternoon.

The main person that ruined my day was this stupid ICU doctor. The first thing he did was yell at me in the morning, as I was standing there doing nothing but writing my note in the chart for my one ICU patient. He was yelling at me about all the other ward doctors not coming everyday to round on their patients in the ICU. And went off on a tangent about how the ward doctors d/c (stop) medications inappropriately once their patients get to the ICU. He must have ranted for about 10 minutes and all I could say was that, well, I’m rounding on my patient in the ICU and this the reason we d/c’d the tuberculosis medications. So he was like, ok that’s reasonable, and said he didn’t mean to rant directly at me. But he did.

So my patient in the ICU was supposed to get a CXR (chest x-ray) two days ago when he was transferred, and they dropped the ball and never got one, so I asked for one this morning. Then this afternoon, I looked at it, and I was a little panicked because he had a collapsed lung and a left pneumothorax! That’s air in the thoracic cavity, and can be really really bad if it starts compressing other structures, like the heart. So I run all the way back to the wards to ask an attending about the CXR to make sure I wasn’t totally interpreting it wrong, and she said I was right, and that I should call a surgeon immediately to put in a chest tube and decompress the air in the thoracic cavity. So I did. The surgeon said he’d see the patient in the ICU, and I went there right away. He got there at the same time I did, and the ICU doctor saw us right away, and came in storming. “WHO CALLED SURGERY?” And that started another rant. I told him the patient had a pneumothorax and he said there was no way. I said I was pretty sure, as both Dr. Gluckman and another attending had seen it. He still didn’t believe me and made me show him the x-ray, and then he got really mad. I think showing him wrong set him off – he started accusing me of trying to tell him how to do his job, and doing things the wrong way (apparently I’m supposed to tell him about the problem, and then he would call surgery). He must have yelled for about 10 minutes and went off on me with things like “WHY did you not call me first?”, “YOU AMERICAN DOCTORS THINK YOU CAN WALK IN HERE AND DO WHATEVER YOU WANT?”, “YOU’RE TRYING TO TELL ME I DON’T GET THINGS DONE RIGHT??” and “YOU DON’T THINK I’M CAPABLE?” I couldn’t get a word in edgewise, and finally I said I’m leaving, and he said FINE GO I DON’T NEED YOUR HELP HERE GO! I was super upset and, actually, pretty angry. I didn’t realize that I had to tell him first – I thought that since we rounded on the patient, and he wanted us to round on the patient, that we were calling the shots. But apparently he just wants us to round on them and not do anything. Absolutely ridiculous. And he definitely could have told me that I did things wrong in a better way than yelling at me for 10 minutes. Plus, he’s a moron – he didn’t diagnose that pneumothorax and I think he was pissed that I did.

So after I calmed down a bit, I called Dr. Gluckman and told him there might be a problem with the ICU doctor. He told me three main things. One, that I probably should have told the ICU doctor first because they are super super territorial. Apparently about two years ago there was a huge fight between the residents and the ICU doctors because the residents were changing the vent settings because they didn’t think the ICU doctors were setting them correctly. And the ICU doctors resented it. I understand their feelings though – I would probably resent it too if a bunch of foreign doctors came in and started trying to tell me what to do. Still, I think this is a stupid system – what’s the point of us rounding on them if we can’t do any management? If we transfer them to the ICU, the ICU doctors should just take over their care. The second main thing Dr. Gluckman told me was related to this – that in general, the ICU doctors resent all foreigners and automatically are biased against them. So it’s difficult for us to get anything done with them. And finally, he told me that they have a problem with women. So being a foreign woman, he probably didn’t like that fact that I pointed out that he didn’t see the pneumothorax on the CXR, even if it wasn’t my intention to highlight his stupidity. And actually, Dr. Gluckman said that he wrote a note (which I didn’t see) saying that if the pneumothorax was stable, we could probably wait until tomorrow to call surgery.

Anyways, at the end of the conversation, Dr. Gluckman said that if I was brave enough to go get the ICU doctor’s number, he was willing to talk to the guy. I told him who it was, and he was a little surprised – he said that he and the guy were sorta buddies! I was a little surprised too. I wonder if I mispronounced the name, or if Dr. Gluckman was thinking of a different guy. So I went back after calming down a bit, and talked to the guy. I apologized for any misunderstanding there might have been, and said that my intentions were not to imply that they were doing a bad job, but to help the patient. He was actually quite civil, but still quite condescending. I know now I should have gone to him first, but it sort of galled me to have to apologize to the guy when he couldn’t even diagnose the problem. And then he had the nerve to say that he did call the surgeon, but he didn’t think it was a pneumothorax!! He was going to let the surgeon make the decision about what to do, but he thought it was a mucous plug! I highly doubt it, and I argued for a brief second, but then I said, well, why don’t you just talk to Dr. Gluckman about it and asked for his contact number. He sorta was like, OH, Gluckman is your attending? And I said yes, because he basically was today, and has been helping me out for the last few days since nobody else on my team has been around. When I talked to Gluckman a few minutes later, he was like there’s no way that is a mucous plug. It doesn’t look like it on the CXR, and plus, this guy has PCP pneumonia, and getting a pneumothorax is actually pretty common in patients with PCP pneumonia.

That wasn’t it – after I finished with that ordeal, I had to come back and the relatives of this comatose guy were all there asking about him. So we had a family meeting (which I was hoping Dr. Stefanski or at least Boipelo would be around for) and I told them the prognosis really was not good. I told them they could meet again with Dr. Stefanski the next day, but I think I conveyed everything pretty well. But it was pretty tough too.

So that was the day… I was pretty drained at the end, and I went home at about 5pm. I felt guilty about that too – I normally stay and help Phil and Lisa out until we can all go home together, but I was drained. I didn’t tell them the story, but I think they understood.

ICU incident #2

I had another run-in with the ICU doctor today. My team went to the ICU to see our patient with PCP pneumonia and the pneumothorax. He had ended up getting a chest tube that night I had the first confrontation with the ICU doctor. We were in there seeing the patient when the ICU doctor came in. He asked me what I thought was wrong with our patient – I said the oxygen saturation was 86% (for normal people the oxygen saturation in the blood should be 100%), which is super super low, and pretty worrisome. He asked if that was okay, I said I didn’t think so, that I would prefer that it be above 90%. He asked if I knew why the patient had such a low sat, and I said because for some reason, he was unhooked from the ventilator. He said I was wrong, and in this case it was okay for the saturation to be this low. Then he asked Boipelo the same questions, and she answered the same way, and he just turns to both of us and says, you are both wrong and YOU KNOW WHY! And he stalks out of the room. We were like, okayyyyy. And we look at Dr. Stefanski, and asked him if he knew why, and he says no. That ICU doctor is such an idiot. So we write our note, and then we leave the room and run into the ICU doctor again, and Dr. Stefanski says to him “so I think you were trying to make a really good teaching point back there – could you tell us what the reason was?” And I pipe up and ask if it was because the patient looked clinically well despite having a very low oxygen saturation, and he just interrupts me and says “YOU INSULT ME LITTLE GIRL” and he stalks into his office. I was absolutely dumbfounded, as was the rest of my team! Boipelo starts laughing and Dr. Stefanski just says don’t worry about it. What an ass.

I was on call today too. It was finally pretty busy – I admitted 3 patients, and there were two more to admit when I left. That’s when Boipelo came back (she leaves from 4-9pm, but has to stay overnight) and she saw the two patients sitting there. I felt pretty bad, but I was pretty busy with other admissions and also from getting calls about random patients needing IV’s or falling out of bed, or getting nose bleeds. Things like that. She kinda gave me a hard time about leaving her all that work, but I think she was joking. Plus when we take call, we’re sort of “extra” help anyways – if we weren’t there they’d have to take all the patients themselves, so I don’t feel too bad. I had to get home, I was so tired, and I was still sick and coughing up a lung.

When we got home, it was really nice though – Kristy and Kiona had made dinner for us! They made us eggplant parmigiana and salad! They complained that it tasted like barbecue sauce, because the pasta sauce here is different from in the states, but I still really liked it. I had two servings! I was pretty excited, because the next day, we were going to go to Tau!

The patient wards at Princess Marina Hospital

So this might be a good time to talk about the hospital a little bit. I may have mentioned some of this before, but there are several wards at Princess Marina Hospital. Each ward is self-contained in a one-story building. The Penn people work mostly in the male medical ward and the female medical ward. There is also a private ward, an orthopedic ward, an oncology ward, a pediatric ward, an obstetrics ward, and maybe a few others I can’t remember. Baylor also has a huge ostentatious glass-covered air-conditioned two-story building that is for outpatient pediatrics. I say ostentatious because they just sorta came in and built this building on their own – this building uses so many resources when so many of the other wards are super crowded, have no supplies, and have no air conditioning. In fact, as it’s getting hotter hear, it’s getting smellier – I can’t imagine what it’s like in the summer!


Each of the wards are a little different, but I hear the male and female medical wards are the most crowded and the most lacking in common supplies. The private wards are the nicest – patients either get a room to themselves, or they share with only one other patient. The nurses are a lot nicer and more competent on the private ward, and they always have enough supplies and medicine. Of course, patients have to pay 80 pula per night, which is quite a lot for the average Motswana. For example, our maid makes only P600 a month. In contrast, for the general male and female medical wards, patients pay a processing fee of P2 (I think) at the A&E (accidents and emergency – the equivalent of our ER) and if they get admitted, everything is covered by the hospital – that is, if you’re a citizen of Botswana. There are quite a few Zimbabwean citizens here (probably because the situation is not very good in Zimbabwe) and a lot of the prisoners are also Zimbabwean.

The oncology ward is always super crowded, but the specialist there (there’s only one) is really good – his name is Dr. Paleski and he’s Polish or something like that. He’s very political, with a definite liberal bent. He’s famous for asking someone when he first finds that they’re American – so what party are you, or so what do you think of Bush (in his accent)? Even though he’s not connected to the U.S. he hates Bush and republicans, and writes letters to them all the time. It’s pretty hilarious. I think he and Pete would get along pretty well - I bet they visit the same blogs. :) He’s pretty brusque and somewhat brutal too, with everyone, but he’s very good. Like he’ll do a bone marrow biopsy without asking the patient if it’s okay – he just jabs a huge needle in the patients sternum, the patient screams for about 10 seconds, but then he’s done. And he works very hard. He sees all these patients at clinic during the day, as well as the people in his inpatient ward, and does all these consults and biopsies of other patients in other wards as well during the day, and then goes home and looks at slides all night to make diagnoses. I think he’s burning out.

I haven’t been in the pediatrics ward or the obstetrics ward, but I believe they are pretty similar to the public male and female wards, but perhaps less crowded. The pediatrics ward is only for those patients under 14! So on the male and female wards, we still see quite young patients, who in the U.S. would be considered pediatric patients.

It’s funny – the gripes you hear at the hospital here are in some ways very similar to the gripes you hear at American hospitals. We’re constantly wondering why a patient needs to be admitted to the hospital – ideally a patient should only be admitted if they really need critical care in the hospital. If they can be managed as an outpatient, then they should be. We also wonder why some wards transfer patients to us. For example, the orthopedics ward is famous for transferring post-surgical patients to us because they say they don’t know how to manage somebody’s heart condition. Of course, that didn’t stop them from operating on the patient! Likewise, obstetrics transferred a patient to us for us to manage HELLP syndrome, which is an obstetric issue! I hear a lot of the same complaints at the U.S. hospitals, which is sorta funny. :)

There’s a lot more to talk about, but I think I will save a discussion about the patients themselves for a little bit later.