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.