Difficult Decisions

Sometimes people have so many different diseases that it's difficult to decide which one to treat. For example, one common conflict is between the heart and the kidney. If you have too much fluid in your blood vessels, and if your heart is weak already from other processes, that can make your heart even weaker and it can't pump all that fluid around. As a result, the fluid can build up in your legs and arms, and in your lungs, making you short of breath. The treatment for that is to "diurese" a patient - that is, use medications to make people urinate and decrease the amount of fluid in their veins. However, if your kidneys are sick, you need a higher dose of these medications, which can actually harm your kidneys even more. However, the higher doses may be a necessity to keep your heart healthy. It is not uncommon for there to be a natural conflict between the cardiologists (heart doctors) and the nephrologists (kidney doctors) over this very situation. In the end, often the cardiologists win out because while we can treat kidney failure (at least temporarily) with dialysis, if your heart fails, we don't have any sort of substitute for that.

There are many such decisions that clinicians often have to make. I tend to think that usually things work out ok - if we see signs that we made the wrong decision, we can always change and go the other way the next day. Unfortunately, some people are on such a fine balance that choosing the wrong path for even a few hours can sometimes be hugely detrimental. Hopefully through collaboration and talking together with many specialists, we can make the right decision the majority of the time.

The holidays

It turns out I will be working in the hospital over Christmas. The hospital can't stop over the holidays and not only will I be there, but many other doctors, nurses, staff, and of course, the patients. I have it better than most though - by pure luck, I managed to get off both Thanksgiving and New Year's. No doubt about it though, it definitely sucks to be in the hospital, whether as staff or as a patient, when you know your family and friends are out there having a good time. To be honest, I think it's worse for the patients - not only are they sick, but they're pretty much stuck at the hospital the entire time. For staff, even if they work a 36 hour shift or spend the entire actual holiday working, they eventually get to go home, perhaps see some friends or family if they're not too tired.

In general, I think most people are pretty good at making the most of it and that's probably the best anyone can do. The staff often have small holiday parties in the hospital, which they can attend in between duties with patients. The cafeteria and food services tries to make a nice meal for Thanksgiving or Christmas dinner and sometimes there are holiday activities for the patients, if they can attend or participate. Hopefully, families come to visit their loved ones in the hospital over the holidays, bringing a piece of home with them.

The sad cases are when you realize that a patient doesn't have any family to visit them, or even think about them. It happens quite often in the hospital, especially with the elderly. I haven't seen it myself (yet) but I've heard some families don't want to deal with an elderly relative, sometimes over the holidays, and they just drop them off at the emergency room with a real or fabricated problem, and they get admitted to the hospital for several days so the family doesn't have to deal with them. Sometimes the family doesn't have time, or the desire to visit the relative, even over the holidays. I had a patient once who lived with his daughter. The family was very nice, but the daughter was taking care of 3 of her own children, not to mention a few other younger siblings, and didn't have time to visit her father every day. The son would often come, but he was pretty much useless in terms of helping coordinating care for his father. Unfortunately, the father didn't know his own home phone number, or a way to contact his daughter, so even though we discharged him from the hospital, it was 3 days before we could get word to the daughter to pick him up! Incredible.

And finally, the saddest cases are when you realize a patient doesn't have any family at all. They may have a friend as an emergency contact, or worse, they have no emergency contact at all. Last month I had an elderly female patient who was very very sick - the only family she had at all was a sister who lived 2 hours away and was sick herself and couldn't make it to the hospital to visit, much less help with her care. We could speak to her over the phone, and let her know updates about her sister, but that's about it. Not surprisingly, the patient was pretty depressed and often didn't want to take care of herself or agree to different studies or take necessary medications. It's horrible - what can you really do in these cases?

It just makes me feel even more fortunate, especially during the holidays, that I have a very loving husband and extended family, who will support me no matter what happens.

Getting to Jo'burg

Well, I was supposed have a short flight on United from JFK airport in NYC to Dulles airport (IAD) in DC on Thursday August 9^th, 2007, then a longer flight on South African Airways from DC to Johannesburg (Jo’burg), that took me into the afternoon of August 10^th, 2007, and then finally a short flight on South African Express from Jo’burg to Gaborone (Gabs) in the late afternoon of August 10^th, 2007, which was a Friday. Due to weather in DC, we sat on the tarmac in the plane at JFK for several hours, and then they finally let us off to get some food back at the terminals. I was only supposed to have a 1.5 hour layover in Dulles so I completely missed my 5:20pm flight to Jo’burg, and since I was sitting on the plane on the tarmac, and they wouldn’t let us off earlier, I also completely missed a 5:20pm flight from JFK to Jo’burg. I thought, well, I can do the same exact route a day later, since I had arranged to be in Gabs several days early to prepare for working. However, the South African Airways reservation agent told me the flight from DC to Jo’burg the next day (Friday) was completely full! And there was only one spot left on the Friday flight from JFK to Jo’burg! So I really had no choice to but to take that spot. It turns out later that another student was on that DC to Jo’burg flight on Friday, and said there was plenty of room! So maybe there were a lot of no-shows? I dunno. Anyways, another problem was that the flight from JFK to Jo’burg got there several hours later than the flight from DC to Jo’burg, even though they both left at 5:20pm. This was partly due to the fact that the flight from JFK to Jo’burg had a short stopover at Dakar. That meant that I would miss the last flight from Jo’burg to Gabs on Saturday late afternoon and would have to stay the night in Jo’burg at my own expense to catch the first flight out Sunday morning.

So on Thursday night, I waited about 1 hour for our luggage to get sorted and finally come out of the plane (most others were still waiting for the plane to get off the ground to DC, which probably was not going to happen for at least 8-9 hours). Then I waited about another hour for Super Shuttle to pick me up and take me back to Carol’s house ($50 round trip!). I didn’t get back until after 8pm, and emailed all the appropriate people saying I was going to be late, and started looking for places to stay in Jo’burg Saturday night. I was so tired Thursday night, I was falling asleep at the computer around midnight, so I emailed a few lodges, and decided to finish it up Friday morning. The super shuttle wasn’t picking me up until around noon. The next morning, I made arrangements at a place that was going to cost R550 (Rand, or ZAR – at the time, ~R7 = $1) that had 1 free airport transfer, and I think would have cost another R200 or something for the 2^nd airport transfer. But then Kiona and Kristy, who I had emailed about my situation, emailed me about the Thulani Lodge in Melville, Jo’burg, where they stayed Thursday night, and it was R450 per night. So I switched to the Thulani Lodge. Little did I know that the airport transfers were not covered – they were R300 each! So I ended up having to pay a total of R1050 (about $150) for the overnight stay. Man was I pissed!!! I ended up having to fork over close to $200 for the delay. :( I guess that’s just international travel…

The flight from NYC to Jo’burg was long. There was a stopover halfway in between the 18-hour flight in Dakar. We didn’t get to get off the plane though. There was this super bitchy white South African woman (Afrikan?) who was supposed to sit next to me. I had the aisle seat in the middle row of 4 seats, and she had the seat to the inside of me. She seemed really nice at first… she was talking to the young undergrad on her other side and giving her all this advice about traveling in South Africa and Johannesburg and everything. She even gave out her phone number in case people needed help. She was basically super nice to everyone but the attendants and the black natives. Before the plane took off, she switched seats to an aisle seat and talked to this other girl from America for a long time. She practically became the tour guide of the plane – people started asking her all sorts of questions, and she was super super helpful. Very nice. But she sorta had attitude. She stowed her small carry-on under her seat instead of in front of her, taking up someone else’s space, but the African couple behind her didn’t have it in them to complain, I don’t think. The first incident that really got me disliking her was after we had a meal (i had like 3 meals on my flight! - 3 big ones!) and they took most of her tray, but for some reason she had the silverware left, so she threw it in a plastic bag with all this other trash (candy wrappers, napkins, plastic cups) and threw it on the floor where her seat was - she was sort of like that in general. Her trash was everywhere, like she expected to be cleaned up after. So her trash is on the floor and somehow makes its way out to the aisle, and a flight attendant comes by and picks it up, and says, whose is this (she had gone to the bathroom)? And the girl sitting next to her says it's the bitch's, who then comes back from the bathroom. The flight attendant says miss, I just want to let you know that the silverware is stainless steel, and we don't throw that away – we reuse it. And immediately she got very aggressive and angry for not a very good reason. I couldn't hear exactly what she said, but it was a very angry tone, and the flight attendant sort of got angry too and he said, well, it's stainless steel, and we don't throw that out, and she got more mad, and said something back, and at that point, the flight attendant, said whatever or nevermind or something like that and walked away. The bitch turns to the girl next to her and says something like "can you believe that man?" If I was that girl sitting next to her, I’d either say something rude back, or just try to ignore her from that point, even if she was very helpful earlier with travel tips.

That wasn’t it with the bitchy girl either… so in Dakar, they tell everyone to go back to their original seats because it's completely a full flight. The girl decides not to, and to wait it out and see if somebody comes - which I sorta understand, i've done that too. She actually asked the flight attendant (a new one since they switched crews) if anyone was sitting there, and the flight attendant looked at her seating chart and said she didn’t think so, but there might be people flying stand-by that were going to have the seat, and said the girl might have to move if that happened. The girl basically said she wasn’t moving unless someone showed up, and the flight attendant rolled her eyes and basically let it go. But the girl did say she would move if someone showed up. People start boarding, and of course, this tall, big black guy shows up and says that it’s his seat. The flight attendant comes over and says she has to move, and the girls starts arguing! Can you believe her nerve??? She basically argued to the point where the flight attendant agreed to let her ask the other guy personally if he would mind trading seats with her (and he's watching this entire exchange by the way), so she does, and he says it's okay with him - but i'm sure he's just too nice to say no. He's also this big guy and he’s in this inside seat now. Plus, he's next to me, and he's so big (not fat, just big and skinny) that he's half into my space so that gave me a legitimate reason to hate her. :) That’s about it, but she really got my dander up. :)

The flight itself was pretty amazing though. The flight attendants were sooo courteous and there were so many amenities. Of course each person got a little bag of goodies (socks, toothbrush, night mask, etc), a pillow and blanket, and their own personal television. This television let you watch from a selection of like 16 movies, watch a number of TV shows, play video games (pretty hokey ones), and some other things. I ended up watching like 4 or 5 movies. One was Paris Je t’aime which was like 9 little vignettes about couples of all sorts in different quarters of Paris. It was an alternative movie, and sorta interesting at first, but it got tiring very quickly. There was no overall plot, but there were a ton of pretty famous people in it! Then I saw Blades of Glory with Will Farrell in it – it was just ok. I didn’t really even crack a smile until near the end, but it definitely had a few scenes at the end where I was totally laughing out loud. Then I saw Lonely Hearts with John Travolta, James Gandolfini (Tony Soprano) and Salma Hayek, which was super good. It was about the couple that became serial killers. Very good. Then finally I saw Jane, which is about a real-life flirtation that Jane Austen had with some guy. They took a lot of liberties with the story, of course.

Anyways, so by the time I got to my lodge in Melville, Johannesburg, I was exhausted. I set up my computer and rested a bit, and begrudged my overnight bill of over $200. But I eventually explored a bit – it’s supposed to be a pretty Bohemian and safe area. I ate around the corner and had a huge steak at Melville grille for like R105 (like $15!). I didn’t realize it was going to be sooo huge! I ate all I could and it was like only a third of it – it was a yummy T-bone. I ended up giving the rest of it to the maid of the lodge. It actually looked like a pretty hopping area… girls were really dressed up in makeup, jewelry, high heels, etc and there I was in my jeans and t-shirt. Oh well. The room was pretty cool at Thulani Lodge too, too bad I didn’t get to enjoy it too much. The keys were these old-fashioned metal ones, but the outside door to the lodge had a real lock, so I wasn’t too worried. :) I didn’t stay up too late because I had to get up at like 4:30 the next morning to get picked up for the airport. My flight the next day was scheduled for 8:15am.

A lesson well-learned

The call system for Pennsylvania Hospital is a little different from other hospitals. I won't go into it now, but suffice it to say there are three types of calls - short call, medium call, and long call. Over the last 3 weeks, on medium call, I've generally been able to get out at 6 or 6:30. So I thought yesterday would be no different. In fact, we had already bought tickets to go to a large music festival with the rest of our friends. The plan was for me to get out, Pete would pick me up, and we would go directly there to join everyone around 6:30 or 7. It was a pretty crazy day and I picked up the max number of patients I could possibly pick up (which has been the case for the last 6 calls I've been on), and there were some complications with other patients. I didn't get out of the hospital until close to 8:30pm, at which point, not only was I exhausted, but I hadn't eaten, and we would only get to enjoy about an hour of the music festival by the time we got there. So I just went home.

The moral of the story? Don't buy tickets, especially expensive ones, ahead of time unless you are sure that you will get out in time.

Perspective on Costs

I hear arguments or complaints all the time about how we're denying so many people health care because "an insurance company won't pay for it" or "it's too expensive for them to cover it". For example, many times, patients and their families (and their doctors) will fight with insurance companies to get them a really expensive treatment or get an exception to get a certain patient a treatment that usually the insurance company would not approve, either because it's too expensive or isn't indicated. While I'm the last one to support the insurance companies and I think they could be doing a lot more to cut costs and provide more and better health care, I think that many people are lacking perspective about this topic.

I don't think anyone would disagree with the statement that the budget for healthcare is limited. We can't spend all the money we want to save everyone in the world. In the US I think this is often not understood well because we have a relatively wealthy country, but it 3rd world countries, like many in Africa, or in countries that have 3rd world elements (like India or China), this is readily apparent.

When someone or a group of patients can't get a treatment because it's too expensive, many people react with indignance and outrage. While I certainly understand this sentiment, and probably would feel it myself if I or one of my family were the patient, there's another side to the story... By providing that one patient (or group of patients) with that expensive treatment, you are essentially denying health care to another group of patients. Just take for example that a treatment costs $100,000 per patient to save their life. Of course you can't put a $ value on a life, but say that $100,000 could be spent on 100 other people to treat something else to save their lives. Or maybe to, say, treat their hypertension and prolong their lives for 20 years each. It's hard to say which is the right way to go, but personally, I think it should be spent for the greater good.

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Dialysis

This was a pretty busy day at the hospital, probably because we admitted a lot of patients yesterday. I had a lot of LP’s to do today. One surprising thing involved this one young patient – 30ish male, who was pretty sick and we didn’t know why. He was confused, and as a side issue, his family mentioned that he hadn’t peed in like a week! So we measured his creatinine and he had like a creatinine of 18. Meaning he had renal failure, and it probably was a chronic problem that acutely got worse. To make a long story short, we did a few tests (you can’t get a kidney biopsy here) and eventually came to the conclusion that he had end stage kidney disease. And this is something else that is vastly different from the united states. At home, you get free dialysis for life. Here, there is only peritoneal dialysis (through your abdominal cavity), and many of the patients, if they’re on it for more than a couple of weeks, eventually get infections and die. So dialysis here is really for people with acute kidney failure who just need support for a week or two, and will probably recover. This guy’s kidneys were shot (probably due to HIV), and he would never recover. So again, we were just waiting for him to die.

It’s weird with some of these young guys – in the states we would be doing everything possible to try and save them. Sometimes I think that’s bad though. We push the limits of life so much at home, and often it just leads to more suffering for the patient and their family. It’s not a pretty site. And often they still die anyways. We counseled the family and he died two days later.

We also went to Chutney for dinner – it’s this really good Indian restaurant in Gaborone. Interestingly, there is a pretty large community of Indians here. Not so many Chinese. But anyways, we’d all had a tough day/week so far, so we were all glad to go out to dinner. Kristy and I decided to drink a bunch of beers. :) It actually took quite a while for the food to get to us, so we had maybe 3 beers before the food got to us, and we were pretty tipsy. It was pretty fun. :)

The theory of addiction

I'm sure this is a subject that has been explored many many times, but the other night I got into a debate that eventually involved the definition of addiction. Here is the definition according to Webster:

ad·dic·tion
Pronunciation: \ə-ˈdik-shən, a-\
Function: noun
Date: 1599

1: the quality or state of being addicted <addiction to reading>
2: compulsive need for and use of a habit-forming substance (as heroin, nicotine, or alcohol) characterized by tolerance and by well-defined physiological symptoms upon withdrawal; broadly : persistent compulsive use of a substance known by the user to be harmful

And then the definition of addicted:

¹ad·dict
Pronunciation: \ə-ˈdikt\
Function: transitive verb
Etymology: Latin addictus, past participle of addicere to favor, from ad- + dicere to say — more at diction
Date: 1534

1 : to devote or surrender (oneself) to something habitually or obsessively <addicted to gambling>
2 : to cause addiction to a substance in (a person or animal)

The first definition is what I would argue at first thought - that there is a biological basis for addiction. Not only are the physiologic rewards of using the substance, but there is tolerance of the substance (i.e. as someone uses the substance over time, it takes larger amounts of the substance to get the same high) and if you take it away, there are symptoms of withdrawal. Now the first thing this made me think was that substances that many people think are not addictive, probably are actually addictive by this definition. For example, drugs like marijuana, acid, and mushrooms are not thought of as biologically addictive, however, I think if you use these substances often enough, there are definitely symptoms of withdrawal, although they might not be as severe as some other substances. So are these substances than addictive? I think so - which is a change from how I used to think.

This leads into my second thought - that the "addictiveness" (how fast you can get addicted to a substance, or how long it takes) and symptoms of withdrawal are very different depending on the drug. Some drugs people can take once (e.g. cocaine, meth) and get immediately addicted whereas others it seems that you can use for a while before getting physiologically addicted (e.g. tobacco). Of course, this depends on the user as well, as there are genetic and environmental issues that are involved. Likewise, some withdrawal symptoms are mild, but some can even cause death, so clearly, the drugs are different. Does this translate into different levels of addiction? As an immediate answer, I think so... Clearly, if you can get addicted faster to a substance - that should mean it's more addictive. If your withdrawal symptoms are worse for a particular substance, probably you would do more desperate things to get the drug. For example, in the news you hear of crack addicts or heroin addicts robbing people, even the occasional murder to get the drug or get money to buy the drug. You don't hear that much for things like marijuana or mushrooms. Acid I have no idea. I guess I don't pay that much attention. I think this is very interesting because clearly some addictive things are legal - e.g. tobacco and alcohol. Legalizing some substances, like crack, cocaine, heroine, meth, seems like it would be impossible, and probably ethically wrong, because they are relatively easy to get addicted to and the withdrawal symptoms are horrible, not to mention the health issues of taking those drugs in the first place. However, if something is not that addictive, and symptoms of withdrawal are not that bad, does that mean that it's okay to be legal? Clearly the government thinks alcohol and tobacco are of a low enough addictiveness to be legal.

Finally, the last thing this made me think was that perhaps this definition was a bit restrictive. People have been known to engage in other behaviors that are harmful to themselves and are termed addiction - for example, an addiction to gambling or shopping. Although there are no withdrawal symptoms, people have a compulsion to do these things which are potentially (and usually) harmful to themselves. Myself - I have a potato chip addiction (especially ones with fake cheese). You could argue that maybe there is a biological basis for these people's behavior - maybe gambling gives them a natural rush, maybe a low-level state of excitement that they crave while gambling somewhat similar in nature to the adrenaline rush that adventure-seekers or sports-players seek. But that's a little murkier and far-fetched. I'm not saying impossible, but it's definitely in the realm of the unknown at this point.

I think this is a very interesting topic and deserves a lot more thought than I have time to give. Maybe when I'm retired.

Food and Personality

I think how and what someone eats is incredibly indicative of their character. In fact, in the past, I've used it as a way to decide whether or not I'll go on a second date with someone.

The trend I see is that the more adventurous someone is at the restaurant, the more adventurous the character. Someone who orders chicken all the time is not that adventurous. Somebody who decides to try the goat or the alligator (and they do not have to like it!) probably has a more adventurous personality.

I love to eat, and I love to try different foods - there's no way I could date or see anybody long term who didn't share those interests. For example, I could never date a vegetarian, or somebody who didn't like seafood or red meat or something. Even somebody who was allergic to nuts, or shellfish, or something like that - I would get so frustrated! But that's just me.

I guess I actually know plenty of adventurous people who place limits on their food - often that's health-related, or because they're concerned about the environment, or religious. Sometimes it's because of taste, which I think is fair. And those people are fine - I can like them just fine. But I could never date somebody like that. :)

Yummy Pies!!

Nothing much else happened today – I was on call, but there weren’t that manyt admissions. I was actually a little bored. I had to stay until 9pm, and I only admitted 2 new patients. And I missed Quizzo with everyone else (except Lisa and Phil, who were also on call) at the Bull & Bush. I actually did try to make it, because we got out right at 9pm, and Quizzo didn’t end until about 10pm. The night transport people at the hospital (which we use when it’s too dark to walk home) actually said that they would drive me there. But then we got on the road, and apparently a big football (soccer) game between Botswana and some other country – which is a big deal – had just ended and there was a ton of traffic! The driver was no longer willing to take me to the Bull & Bush, but even if he had been willing, it probably would have taken him half an hour to get me there, and then I would only have stayed for half an hour. So it wasn’t really worth it. We’ll make it to the Bull & Bush eventually – it’s a big place for ex-pats and foreigners to hang out.

I did go to have lunch at the main mall with a bunch of people. We all went to Pie City, which sells all these different handheld pot pies. I had a chicken peri peri pie. Peri peri is their version of a hot sauce, and the pie was pretty spicy! But it was really good, and it’s pretty inexpensive – the pie, plus a drink ran less than P10. I will definitely be coming back for more pies. Although I may try the competing pie place next time – it’s called Pie Time. I think that’s sorta funny.

It was also pretty cool because I talked with Betsy a lot today – she’s getting an anthropology PhD from University of Chicago. I believe she’s on a Fulbright scholarship, and knows Setswana relatively well. So I had her teach me a bunch of stuff. We also had some good discussion about the health system in Botswana, and the different organizations, both international and home governmental, that provide health care, medications, and supplies. If I have time, I’ll definitely write more about it later, because it’s pretty interesting.

A Universal Electronic Medical Record System

I have an ongoing discussion with my husband about this - the need for a universal electronic medical record system. I don't think anyone really disputes the benefit we would have from such a system. The only thing I could think of is that it may be easier to access the system and there may be more breaches of individual privacy.

The potential benefits are enormous. I can't count the number of times patients come into the hospital or the emergency room with inadequate histories of their own medical care, or without a list of their medications. With a universal electronic system, there would be improved continuity of care, resulting (hopefully) in improved medical care. Not only would we have all their lab and imaging results at our fingertips, but we could get in touch with all the primary care doctors and specialists much more easily for additional information. This can be especially difficult to do if you are trying to contact a doctor at a different hospital or clinic after hours. Secondly, there would be a huge savings in health care costs. More often than not, laboratory and imaging tests are repeated unnecessarily because we don't have the results from another hospital or clinical setting or are unable to personally view imaging ourselves, such as chest x-rays or cat scans. This isn't good for the patient either, as multiple blood draws can introduce more infection or deplete already sick patients of their blood, and expose patients to more radiation than necessary.

Unfortunately, the costs to implement such a system are also enormous. The majority of hospitals still run on a paper system and of the hospitals that are on an electronic system, very few of them are 100% paperless. Moreover, these hospitals all run on separate systems. To get all hospitals on the same electronic system would be incredibly time-consuming, logistically a nightmare, and costly beyond belief. During the transition, there would probably be many records lost, confusion regarding how to access records or results and much worse and slower health care. The hospitals themselves probably all have their own systems in place already and would be reluctant to switch to yet another system, especially if they just spent all this time, effort and money to implement their own electronic system. Many hospitals would probably just want to make their system compatible with whatever universal system is being implemented, which is not ideal. And who would pay for this? The government?

Despite all the roadblocks, I still think it's a worthwhile investment, and hopefully the eventual benefits would outweigh the costs and the inconveniences and temporary lapses in health care.

George Carlin - anorexics and bulemics

Here's another one, much shorter than the first. It's about anorexics and bulemics. Man, that was a funny guy.

Blue Moon

I can't believe it. Blue Moon is a wheat beer, one I often order at bars and enjoy quite a bit. I just found out that it's not a microbrew, never even started as a microbrew, but in fact was created by one of the giant brewing companies. I'm sure had I known that before I started drinking it, I may have looked down on it a bit more.

But taste is taste - it's still a good beer.

Getting things done at PMH

It takes so long to get anything done here at Princess Marina Hospital – and people think HUP is bad sometimes. I’ve been asking for a portable chest x-ray for this guy with a pneumothorax since last weekend, and it still hasn’t been done. I can’t personally wheel him down to x-ray myself because, one, he’s on suction, and two, he’s on oxygen, and although we have one oxygen tank here in the ward, nobody has been able to find the valve that fits it. So I’ve personally gone to the radiology department every day, sometimes twice a day, and begged and pleaded for them to take their one portable x-ray machine down to the male medical wards, and take this guy’s chest x-ray. Half the time, the person who is in charge of portable x-rays isn’t there. Of course, all the people I talk to are radiology technicians, and they could all help me out, but none of them are officially in charge of the portable machine for the day. Then the other half of the time I finally find the person doing portables for the day, and he says, there was no request form (which is a crock – I’ve turned in like 5 request forms, some personally to the technicians), and I turn one in then and there because I’ve anticipated this, and he looks put out, and says, ok ok, I’ll do it this afternoon. I usually say something like, well can we do it now, because this patient is somewhat critical, and I can help you wheel things down and everything. And they always say no, they’ll do it this afternoon. Sigh.

Finally today, we took him off suction, and he was doing ok. He’d been off suction before, but never was stable for long enough for me to wheel him down to x-ray. And I also managed to find the valve for the oxygen tank – it leaks, but at least the patient can get some oxygen. So I pushed him quickly down to x-ray, and we took the film, and hurried and wheeled him back before anything bad happened to him. Thank goodness he didn’t crash or anything. I was patting myself on the back for going to all this effort to get a simple x-ray when I took a look at it. He’s now got bilateral pneumothoraces, and probably has a bronchopulmonary fistula – that’s a direct connection between the inside of your lung, and your chest cavity. Even in the states, that’s very very bad, and many patients don’t do so well. He’s probably not going to survive, which really sucks. I totally thought he was going to pull through.

Being on elective

I feel like I'm drowning in free time. They let the preliminary students basically do whatever they want for their elective months (we get three months a year) and I'm choosing to finish up my research with the radiation oncology department at Penn. Not only do I really like the research, but my hours are soooo much better than when I'm doing a floor month. It's pretty much 9 to 5, it's closer to home, and the time I have to work is more flexible. For example, if I have to take an hour during the day to go to a doctor's appointment, I can do that! Also, all my weekends are free, which means I can make some of those weddings and ultimate tournaments this month.

I think it's going to be a great month and a little hard to go back.

The rest of Africa in one blog entry

So I never had time to blog about the safari Pete and I went on in Botswana (including Victoria Falls) and also my travels in Namibia with Bruce and his friend Mike, but here are some links to pics on kodakgallery.com:

3 albums (Joanne alone, Joanne and Pete on Safari, Namibia with Bruce and Michael)

As expected, it was an amazing experience. Our group consisted of Gunther, this 70ish year old German guy, Linda and Roger, Marcus and Lilian, and our guide Richard. The safari started out with a lot of safari drives in a huge 4x4 truck that held all of us - Richard, who's been doing this for 20+ years and is one of the best, was an amazing driver. Although there was a slight mixup and we were forgotten for the first half of the first day (and we missed Victoria Falls), we eventually caught up with the rest of the group and got taken to this awesome lodge. The next morning we set off! I'm not going to describe it in detail, but it was the same stuff I think everybody does on these safaris... game drives, river cruises, game walks, and mokoro canoe trips (people pole you around on traditional mokoro canoes). Highlights included an awesome game walk by a real San-person, almost getting chased by a huge bull elephant, coming scarily close to a hippo pod in the mokoro canoes, seeing two leopard sisters playing together, all the sunsets over the desert, the Okavango Delta, and everything else. With my brother in Namibia, we had an awesome game dinner, went on the most awesome hike I've ever been on in the Namib-Nauklauf park, climbed up the red sand dunes of Sossusvlei for a sunrise, and quadbiking and sandboarding near Swakopmund in the deserts of Namibia.

Amazing and unforgettable.

Medical errors

They happen... just like they do in other parts of life. It's horrible and unfortunate, but it's a fact. They're also unavoidable. We can (and should) do everything we can to minimize them, but no matter what, they're going to happen occasionally, or hopefully, rarely.

I haven't had to deal with this issue until relatively recently, and I consider myself very very fortunate. It's going to be purposefully vague, but I'll tell a story now because I think it has some valuable lessons to be learned from it.

I was taking care of a patient who was admitted for lung problems, and we were giving her all the appropriate treatment and doing the right studies for her for the first few days. Then the 3rd or 4th day, a nurse went in and gave the patient the wrong medications. Someone from the family was with the patient 24 hours a day, and they didn't notice at first, but then the nurse went in and threw a medication away into the trash without saying why. The family thought this was odd (as would anybody) and they looked at it, and it happened to have a different patient's name on it. In this case, the different medications probably did not cause any harm to the patient, however, giving the wrong medication was definitely an error. It was horrible and should never have happened but I feel that what happened afterward was worse.

The family had to call in a different nurse passing by to see what happened, who then called me. When I talked to the patient's official nurse, the one who gave the wrong medications, she denied certain aspects of it and lied (whether knowingly or unknowingly) about certain things - I only found out the truth later. Moreover, she never explained what happened or what she did to the family or any other doctors, and she never apologized.

No matter what happens, no matter how serious, you ALWAYS NEED TO TELL THE TRUTH. Although I feel particularly strongly about it in this case, I feel that this should be something people adhere to in general when dealing with patients.

Secondly, I believe in apologies, which we did (on behalf of the nurse) profusely to the patient and her family. There's actually some debate about this, although perhaps less so now than several years ago. At one point, I believe lawyers may have actually advised medical staff against apologizing to patients, whether or not some sort of mistake was made. The thought was that if you apologized you would be admitting guilt, which then would make a court case much more difficult. I don't necessarily agree, but I could see a situation in which medical staff apologized for something that was not anybody's fault, and the patient took it the wrong way. However, now people are saying that apologizing, while that may seem like admitting guilt, often deters patients and their families from suing the hospital or the staff. Personally, I think if you or somebody that works for you did something wrong, and it was without a doubt an error, you should apologize. You are guilty in a way, and if apologizing is a way of admitting that, then so be it.

In this case, the family even said that had the nurse come in and explained what had happened and apologized, they would still have been upset, and rightly so, but they would not have been so angry as they were when we started talking to them. Unfortunately, at least at the beginning, the family was threatening to sue... however as time went on and everyone calmed down a bit, they didn't seem as litigation-minded. Actually, since no harm came to the patient from the error, they likely would not have won a court case anyways. Hopefully patients (and their families) realize that health care workers are, for the most part, all trying to do their best, and unfortunately, sometimes mistakes are made and all we can do is try to prevent them and correct them as best as possible.

Accumulation of Wealth

This came up in a previous post. How come we have sooo much crap?

Not only did I already own a lot of crap, but when I moved in with my fiance, we doubled our crap and neither of us is willing to give up much. When I moved here, I brought my clothes, my car, and some pots and pans. I went to Ikea the very next day and bought a mattress, a TV and a chair. That's what I had for 3-4 months, and that worked pretty well! Now we have 2 TV's, 2 DVD players, 2 stereo systems, a futon (we actually sold our two couches - only because they didn't fit), three tables, one desk, one desk chair, three easy chairs, one rocking chair, 6 wooden chairs for the dinner and breakfast tables, 4 huge bookcases and 2 smaller ones, 3 chests of drawers, 3 air conditioners in various conditions, pots and pans galore, one bed and mattress, a huge number of towels, a couple hundred books, countless wall hangings/posters/art, and probably some other furniture and stuff I can't remember. It's crazy!

And now that we're getting married, people keep pushing us to get more stuff - my people, I mean the culture. Not everyone is going to want to give us cash for getting married, so we had to register for all this stuff we don't need and may have to move from apartment to apartment. And going to the store, all the salespeople are pushing us to register for tons and tons of stuff - even things we don't need. And somehow sometimes it works and I feel like we need it. And then they say "well you just throw out the old stuff." I think that's also a load of crap. But we really don't need it and our stuff doesn't have to be the best out there in the market.

I think I'm just saying I don't like this material culture even though I am 100% a part of it and play into it.

Hospital Closings

There are all these rumors flying around that Methodist Hospital in South Philly is closing. This is in addition to Northeastern Hospital in NE Philadelphia already closing! If Methodist Hospital closes, that will really put other hospitals in a difficult position. If the other city hospitals are anything like Pennsylvania Hospital, they're already overfilled with patients currently. How are they going to handle the load and stress of another hospital closing? It's a very sad state of affairs when hospitals have to close because they're losing money.

Respecting patient's wishes

I haven’t been in this business very long, but I have already seen many cases in which a patient’s wishes were not respected. What I write next may be surprising – it’s never the doctors or nurses or medical staff. It’s the family. This especially happens with very old or demented patients, or very young patients. The patient often wants one thing and the family, or at least their closest relative or spokesperson, wants something else.

One case I remember particularly well. This was an 80-something year old gentleman who had lung cancer, diagnosed perhaps a year ago. He had it surgically removed (which is not a small surgery by any means) and was doing relatively well for the better part of a year. However, more recently, he started changing. Whereas he used to be able to walk well, talk normally and knew where he was at all times, he occasionally became unsteady and unable to walk, he started slurring his words, and sometimes became confused about where he was, what day it was, or who he was with. After admitting him to the hospital, we found out he had lung cancer that had spread to his brain. At this point, there were three options for him: do nothing, give him radiation, or operate on him. Doing nothing would obviously lead to death the fastest way possible. Giving radiation is usually not curative, but can buy patients time at the expense of different possible side effects of brain irradiation. Surgery was the only option that really provides any hope of a cure, although the chances are incredibly slim, and for someone who is that old and sick already, there’s also a high risk of never recovering from the surgery.

We (the doctors) talked to the patient and his family extensively. It seemed the patient was learning towards doing nothing, or at the most, going through radiation. However, after many days, the patient’s family was able to convince him to go through surgery. Now, I’m not saying this was a bad choice – I have not yet had to be in this situation, and I’m sure it can be incredibly difficult. It sounded like this patient had been an incredible father, brother, uncle, etc and his family all wanted him to live many more years and have a wonderful life. His daughter, who was the main spokesperson, was a nurse and was a major player in convincing her father to have the surgery. I can’t say I would not do the same, although I hope not.

The patient had the brain surgery, with plans for eventual chemo or radiation after recovering, and slowly, over the next 4 weeks, deteriorated more and more. Before going through surgery, the patient had told the doctors (and I thought the family as well) that in no way did he ever want a feeding tube, or if his heart should stop beating or his lungs stop breathing, did he want CPR with shocks, chest compressions, or a tube shoved down his throat to help him breathe. However, it seems that once he became unable to make his own decisions after the surgery, his family decided that they wanted everything possible done for him.

The patient became unable to swallow on his own without choking and eventually, a feeding tube had to be put down his throat so that he could be fed. Even then, he started regurgitating food from his stomach into his lungs and developed a lung infection. His body became weaker and weaker and he could no longer go through physical therapy. His mind also deteriorated as became less able to talk or recognize his family members. I realize that this is a very difficult process, but the family members, including his nurse daughter, seemed unable to process the fact that he was going downhill and it seemed very unlikely that he was going to recover from this. They asked for the feeding tube to be put in (a risk in itself), which after it was inserted, could not be used much anyways because of his risk of lung infection. They wanted everything (CPR, intubation, chest compressions, shocks) to be done for their father, although in his debilitated state it was unlikely to succeed, and they wanted him to go through physical therapy whether or not he was in any condition to go through it.

It was not until 3-4 weeks of counseling the family almost every day or every other day that they finally realized that he may not recover and decided that they didn’t necessarily want him to go through CPR should his heart or lungs fail, although they were still pushing the feeding tube and physical therapy. Purely coincidentally, the patient died several days later. However, if we hadn't gone through those weeks of counseling and reasoning with the family, that patient's heart would have stopped, and we would have gone through 45 minutes of trying to bring that patient back to life, breaking ribs during CPR, trying to ram a throat down his throat, sticking every possible vein and artery with different needles to try and get IV's in or blood drawn, etc etc. All against the patient's wishes.

I tell this story for several reasons. For one, it highlights how someone’s illness is often a whole family’s problem, not just a single patient’s. You often have to not only treat the patient, but their entire family, and that can involve a lot of talking, explaining, and counseling, no matter how much many doctor’s may detest it or try to avoid it. It’s what you would want if your father were the one that were ill. Secondly, it demonstrates how important it is for someone to have that conversation with their family or to have a living will. If you don’t want CPR, or a feeding tube or anything like that, it’s important to explain it to your sons, daughters, other close relatives ahead of time so that they understand, because to be honest, if you tell the doctor, who then try to tell the family, they may not believe the doctor or understand. If you can get this in writing in a living will, it’s even better – then the family has proof of your wishes, and also less power (I believe) in changing how you want to die. I think this is especially important if you’re elderly or sick, but realistically, I think everyone should at the very least, talk about it with those close to them. It can certainly save a lot of heartache and problems later on.

ABATE Philadelphia Biker Toy Run to CHOP

One of my favorite events in the city is the annual ABATE (a motorcyclist rights group in Delaware) sponsored toy run to CHOP. Once a year in November (it happens to be today), thousands of bikers come together to donate toys to the Children's Hospital of Philadelphia.

They clog up the highways and streets for miles and miles around the city, and the city dispatches cops to help manage the traffic. Any and all bikers are invited to join in, so although you see the occasional recreational biker or motorcycle-owner in the long line of donors, most of them seem to be real "bikers." There are a lot of negative preconceptions about bikers, and it really warms my heart to see some of them, whom I'm sure have very little themselves, donate their time and money to help some sick kids. Nothing beats seeing a big huge bad-ass biker riding his Harley with a huge stuffed bear on his handlebars - it makes me feel like there's still a lot of good, and a lot of people that want to do good, in this world.

Although this video is not of great quality, and lasts quite a long time - you get the idea:

The Riverwalk Mall

Nothing too crazy happened at the hospital – I did two LP’s and a blood draw. Got both LP’s, the first one was after a few tries. This patient is a 30 year-old with HIV and altered mental status and we have no idea what’s wrong with him. The head CT was normal, so we decided to do an LP (lumbar puncture), but he’s out of it, so he kept moving and it was pretty hard to get. Even Boipelo tried and she couldn’t do it, and then I tried one more time and finally got it – it was a very traumatic (bloody) tap, but at least I got some CSF. I’m sure it’s a matter of being obstinate, but I’m still pretty proud that Boipelo couldn’t do it and I got it. The other guy was someone that needs to be tapped every day. This week, sometimes Boipelo has done it, and sometimes I do it – he likes me better. The first time I ever tried it (on Tuesday), I hit it on the first try, and Boipelo apparently took a bunch of tries on Wednesday. And today, I sorta had a first try, but I didn’t put the needle very far in. And the 2^nd time, I got it easily. So he says he likes it when I do it. But I don’t know how long I can keep it up. I guess we’ll see – I have to keep doing it until his intracranial pressure (the LP opening pressure) goes down. And this was the first day that it was lower than the day before, so I hope that this means he’s getting better – he has Crytococcal meningitis. We may have to put in some sort of shunt because we can’t keep tapping him every day. Boipelo says to not get my hopes up about him because she has seen pressures that got lower, then went back up the next day, but I don’t care! I’m getting my hopes up! He’s on Amphotericin right now, which is an awful drug. We have to give him 4L IV fluids (IVFs) every day because this drug seriously dehydrates you.

And tonight, we finally got out a little earlier! Like 6pm! It’s the earliest so far. This is my and Phil’s easy week – only on call Monday and that’s it. Our teams are on call Saturday but as Penn students we don’t have to come in on weekends. Next week will be super hard though. We pick up all the patients on Monday that our teams admitted over the weekend, and then we’re on call Wednesday and Friday.

Anyways, so because we got out early, we all went to the Riverwalk Mall (one of 3 malls in Gabs) and there’s a big grocery store there! Sort of like an American supermarket! And the mall is indoors, and has clothes shops, a food court, something like a Walmart – very similar to an American mall but with Botswana flavor. So I bought some groceries, and then we went to the Italian restaurant there called Primi’s. There were a lot of Americans there – apparently it’s a very nice restaurant by Botswana standards. I got a big pasta entrée (more than enough to take home) and a glass of wine for like P80, or $14. Not too shabby.