Jo

Comfort Zone

2010-03-29T20:44:00.000-07:00

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

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

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

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

Heavy thoughts

2010-03-02T18:45:00.001-08:00

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.

Hiatus

2009-09-27T18:50:00.000-07:00

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

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

Doctors as patients, part 1

2009-05-18T05:12:00.000-07:00

It has often been said that the doctor's working in the hospital are the unhealthiest people within the whole hospital. I think I already made a reference to this in a previous post about doctors exercising. I think I can expand this thought and say that in general, doctors are horrible about taking care of their own health and make horrible patients.

I'm reminded of something that happened while I was in med school - one of the most respected surgeons at my hospital suddenly was diagnosed with lung cancer. He never smoked, it was just bad luck. He had been ignoring his symptoms for years and years, and even though he went through surgery and chemotherapy and his colleagues did everything possible to save him, he was dead within something like 4 months, which is very short, even for lung cancer.

I think there are a few reasons why doctors take such bad care of their own health. One is simply a time factor. When you work 80 hours a week, even if you only work 60 hours a week, it's hard to find time to go to a doctor or dentist appointment. Often, even the time you have off from work is spent catching up on the latest medical news or journal articles, which is necessary to stay current. Moreover, since most doctors have daytime working hours, it's nearly impossible to take time off during the day to make it to an appointment - you have to either cancel your own appointments, or arrange for coverage, both of which are costly, time-consuming and extremely inconvenient for you, your patients, and your colleagues.

Secondly, I think it's the medical culture. Even when doctors are deathly ill, they try to come into work unless it's a risk for their patients. This is partly because calling in sick means that you have to inconvenience your colleagues and your patients, and since doctors don't really get sick days, you have to make up the work at some later date, usually on a day off. Additionally, doctors like to be tough, and seem tough, and illness, even for doctors, is a sign of weakness. As a result, many doctors become trained to ignore their own symptoms, even when they are persistent or become serious.

Finally, many doctors feel that they can treat and diagnose themselves, and don't need to go in for an appointment, even though this is often not the case. By treating themselves, doctors again often ignore or miss important symptoms and miss out on getting valuable input or a second opinion from a colleague. Doctors tend to treat themselves very differently from their patients.

In the end, my point is that doctors need to take care of themselves as they tell their patients to do so. They need to go for their yearly checkups, screening tests, etc and not try to manage it all on their own, for their own sakes as well as to be good role models for their patients.

In a very different way, doctors can be bad patients even when they do seek medical advice... I think I'll leave that for another post...

Doctor Shortage

2009-05-17T05:31:00.000-07:00

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.

Bruce's Asia Travels Blog

2009-05-13T06:43:00.000-07:00

Bruce (my brother) is traveling in southeast Asia for about 2 months, and he'll be keeping a blog about it. I'm so jealous. :)

Sympathy vs. Empathy

2009-05-11T10:01:00.000-07:00

I remember in medical school being taught the difference between sympathy and empathy - a lot of people tend to use them as synonyms. In my line of work, when you empathize with someone, it means that you can feel what they are feeling. For example, if they have some type of cancer, and you've had that exact type of cancer, you can feel something similar to what they must be going through and you "empathize." If you feel sympathy for someone, then it's more that you understand, or try to understand as best you can, what the person is going through but you may not feel or have not felt that way yourself. In my opinion, it's very difficult to empathize with someone unless you've gone through a very similar process or situation that they're going through.

Having said all this, I highly empathize right now with all the 9 month pregnant ladies out there who like to deliver soon. :)

Doctors in training

2009-05-08T14:58:00.000-07:00

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.

Mira Loma High School and the Science Bowl

2009-05-05T01:08:00.000-07:00

I just have to post something unrelated. I went to Mira Loma High School, and (shockingly) I was pretty nerdy - I competed in all the science and math competitions, including Mathletes, Science Olympiad, Science Bowl, etc. There were a few others that I can't remember off the top of my head right now, but our crowning achievement was winning third place in the National Science Bowl competition under our chemistry teacher, Mr. Torgeson, wayyyy back in 1994. This won us a week-long all-expenses-paid trip to Hawaii. Needless to say, for a bunch of high school students, we were ecstatic!

Well, it seems we've been outdone, as this year's team took first place, getting them a trip to Australia! See the link below for the article in the Sacramento Bee:

http://sacbee.com/topstories/story/1833334.html

Congrats!! I'm glad to see the legacy continuing.

Keeping fit as an intern

2009-05-04T07:56:00.000-07:00

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

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

Kaiser and their electronic system

2009-05-01T08:28:00.000-07:00

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.

Doctoring Online

2009-04-30T07:53:00.000-07:00

This is a very interesting concept. It's a service that allows you to mostly connect with your doctor online through video chat, IM, and email after an initial face-to-face office visit. I think it's a great idea for simple problems that people have that can be diagnosed over the phone or email. I think it breaks apart when a patient comes in with more complex problems or health issues, making a good physical exam necessary. Then you need an actual doctor's appointment, just like with any other private practice.

Perspective on Costs

2009-04-23T23:33:00.000-07:00

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.

Personality

2009-04-21T11:35:00.000-07:00

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

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

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

Being a health care professional in bad economic times

2009-04-17T23:45:00.000-07:00

One good thing (of many, I think) of being a doctor during bad economic times - you pretty much are guaranteed a job. Especially in this day and age, with more and more people living longer and longer, people will always need doctors and nurses, and other health care professionals. In fact, there's an increasing demand for them. I'm sure salaries may go down, and people may have to work (even) longer hours and care for more patients in a shorter amount of time, but at least they're usually not at danger for losing their jobs. At the worst, people may have to relocate or take less-than-ideal jobs or situations in order to keep their incomes flowing in.

It's a reassuring thought this year considering 2,000,000 people have lost their jobs so far in the U.S.

Hospital Closings

2009-04-10T17:14:00.000-07:00

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.

Abusive, Arrogant Doctors

2009-03-17T08:00:00.000-07:00

This is an interesting article. It talks about how arrogant and abusive doctors can (not surprisingly) really affect the health care of a patient, not to mention affect the workplace and those around them. I've definitely run into plenty of them myself and experienced it firsthand, not to mention heard of other abuses plenty of times. It's a very unfortunate and inappropriate problem. As the article points out, I think the good thing is that there is awareness of the problem and steps are being taken at every hospital to minimize and eliminate it. Interestingly, many of these doctors happen to be surgeons - go figure.

I just also wanted to mention that I've been on the receiving end of this from not just doctors but also nurses, physicians' assistants, nurse practitioners, you name it. So although I will agree that it's much more prevalent in doctors than other medical staff, it is definitely not phenomena limited to MDs alone.

Difficult Decisions

2009-03-16T13:00:00.000-07:00

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.

Little Fish

2009-03-14T23:30:00.000-07:00

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.

Transfer of Care

2009-03-06T02:07:00.000-08:00

At almost all hospitals, interns and residents go through rotations that last about 4 weeks at a time. That means at the end of the four weeks, you transfer care to another team. Like I mentioned in the previous post, at Pennsylvania Hospital, we use a night float system. So what happens at the end of a rotation, one team signs out to night float with a paper signout describing all their patients (like a normal night) and the next morning, the new team picks up the paper signout with news about whatever happened overnight from the night float person. As the night float intern takes care of about 100 patients (or more) a night, they don't know any of these patients in detail unless they're pretty sick, so they don't really have any details to hand off to the new team in the morning. There is really no verbal communication between the new intern and the old intern regarding the patients. The best continuity comes from the resident of the team, who is on for about 4 days before the interns switch, so they know the patients at least to some small degree, although they often do not know the small details, or the really complex patients well.

As a result, the new intern is really dependent on the paper signout for active issues and things to do for the patients. In addition, if a patient has been admitted for a relatively long time (on the order of weeks to months), there should be an end-of-service note written by the previous intern for the new intern. Usually if all these things are done well, there are no problems.

However, I cannot believe how angry I was at the start of one of my months. I had 4 long-term patients, none of which had an end-of-service note. The paper signout I received from night float, who had been given this signout by the previous intern, was horrendous - it was lacking in detail, disorganized, and did not point out what the active issues were. It didn't feel appropriate to me to approach the other intern personally, but I did contact the chief resident and hopefully the importance of these notes will be emphasized. I also think instituting a verbal signout, in which one intern calls the other intern to verbally tell them about the patients and what's going on would be a great idea. It wouldn't take that long and I think it would go a long ways towards improving continuity of care.

Night Coverage

2009-03-01T18:14:00.000-08:00

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.

Proper Use of the Emergency Room

2009-02-22T19:44:00.000-08:00

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.

When things don't go as planned...

2009-02-19T06:38:00.000-08:00

Several months ago, I met a patient who had already been in and out of the hospital for months. He already had had many complications and was pretty sick. This guy had bladder cancer and had to have his bladder taken out. His ureters - the tubes that carry urine from your kidneys to your bladder - were instead fused to a part of his colon so that urine was diverted to his colon instead of his bladder. Immediately after the surgery, he had a heart attack, which is not common, but can happen because surgery takes such a big toll on your body, including your heart. He recovered well from this, and went home. Unfortunately, two days later he came back to the emergency room looking incredibly sick. It turns out that his wound had started to come apart, which is a potential complication of any surgery. His ureters were de-attaching from his colon, leaking urine into his abdomen, and he possibly had an infection within his abdomen. They had to open him back up and fix everything. In the end, it was all still leaking, so they had to place stents within his kidneys that led outside his body to drain the urine instead. He was discharged to rehab.

One week later, he was having his stents changed, and he suddenly became very very sick - he had a fever, the chills, and looked really sick. That's when I saw him. He had developed a very serious infection called sepsis where the infection is basically all throughout your blood. His blood pressure started becoming way too low and he had to eventually be transferred to the ICU where they could start him on special medications to keep your blood pressure up and your heart pumping. It turned out he had multiple types of bacteria growing in his urine, as well as fungus growing in his blood! That's pretty rare, but he had many potential sources of infection - not only did he have the normal sources that every else has (lungs that can develop pneumonia, urine that can develop urinary tract infections, and blood that with even just a blood draw can potentially develop bacteremia or sepsis), he had stents in his kidneys as well as an ostomy (his colon came to his skin and his stool came out through a bag) that were at high risk for infection. Moreover, he was a pretty sick guy, and he'd been in the hospital quite a lot over the last few months, so he was immunocompromised and at higher risk for infections, including hospital-acquired infections. Eventually, he was discharged about two weeks later to yet another rehab facility after being treated with multiple antibiotics.

Two weeks later he came back again. Actually, he had two emergency room visits in between as well. This time, he had developed serious bleeding from his gastrointestinal tract, requiring many blood and platelet transfusions. Over the next 6 weeks, he developed sepsis again and multiple infections, and also developed respiratory failure requiring intubation to help him breathe. Although after several weeks we were able to take the tube out and he could breathe on his own, he was still incredibly sick and his prognosis was very very poor. After many discussions and having dealt with this for nearly 6 months, his wife decided to make him DNR. After 6 more weeks in the hospital and the ICU, he eventually died.

I tell this story because sometimes, it can be amazing what a relatively simple procedure can lead to. I would not call a bladder removal a simple procedure, but I'm pretty sure this patient and his wife went into the operation with an optimistic attitude. He had bladder cancer, but it would be removed, and he would have to pee in a bag for the rest of his life. Traumatic, perhaps, but something you could live with. Instead, he had 6 months of increasing medical complications that eventually led to his death. I don't think the doctors did anything wrong at all, or could have done anything differently - sometimes it's just bad luck and unfortunately, patients and their families are often not prepared for things like this.

Smallwood

2009-02-10T20:56:00.000-08:00

From Smallwood Feb 7, 2009

That was a fun weekend.

A Universal Electronic Medical Record System

2009-02-04T05:54:00.000-08:00

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.

Zahav

2009-01-27T07:36:00.000-08:00

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. :)

Interviewing

2009-01-21T04:11:00.000-08:00

It's coming to the end of the interviewing season, thank goodness. :) For the last couple of months, with a break for the holidays, Pennsylvania hospital has been interviewing candidates for next year's intern class on Wednesdays, Thursdays and Fridays, about 10-20 4th year medical school candidates each day. It's somewhat interesting to see how a program recruits good candidates.

Of course, the program reputation speaks for itself - either for good or for bad. Word of mouth goes a long way, and during the day, they give the candidates ample opportunity to speak to current residents and interns and ask them questions. I, for one, believe in being completely honest about everything, even if that puts the program in a bad light. Of course, I tend to look at things more positively than others, I think, so I may be putting a good spin on things unintentionally. I think it's a bad sign when a program doesn't give you time to spend with current residents and interns - what are they afraid of?

More interesting to me are the little things that candidates care about that draw them to or away from a program. #1 thing is the food. I can't tell you how many times the subject of food or how well candidates have been treated during the interview comes up or plays a role in their decisions. Logically, this should have nothing to do with someone's decision to join a program, or how good the program is, but if crappy food is served during the interview, candidates notice! It's worth noting that on the days that preliminary candidates come to interview (these candidates are internship candidates that, instead of staying in an internal medicine residency for 3 years, are in the program for one year and then go on to a specialty like radiology or opthalmology), the food is much better because good preliminary candidates are thought of as much more competitive and more difficult to draw to your program.

Other little things include paying for parking, taking you out that night with other residents, etc. If a program goes so far as to pay for other things, like hotel costs or travel costs, that's even more impressive to candidates. I think for most people this plays out during residency too - in the end, many people are concerned not just with the training they receive during residency, but their quality of life during residency which includes all these "little things."

Our litiginous society

2009-01-08T17:15:00.000-08:00

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

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

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

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

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

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

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

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

2008-12-30T10:02:00.000-08:00

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

Is this cynical? Maybe.

John P. Pryor

2008-12-27T10:24:00.000-08:00

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.

Christmas at the Hospital

2008-12-26T14:00:00.000-08:00

I think Christmas is probably my favorite holiday of the year. Despite having to spend it overnight at the hospital this year, for whatever reason, I was still in pretty good spirits. There was Christmas music playing on the radio, people are generally in pretty good moods (although there were definitely some sour faces at the hospital), and it's a relatively quiet night at the hospital - I think I got 6 hours of sleep on call, which is absolutely amazing! I played some poker with some other residents, we ordered some Chinese food (the only thing open on Christmas day), and just hung out.

However, it can also be a pretty tough time at the hospital. On December 24th we found out some crucial information about a patient. He was a 90-something year old guy who had had an amazing life, and earlier this year, became sick. By the time I took over his care, he had been sick 5-6 months, getting sicker and sicker, and nobody could figure out why. A lot of people thought that he might have cancer, but couldn't diagnose it after putting him through countless cat scans, MRI's, blood tests, biopsies, etc. We finally did some crucial bloodwork, and along with some suggestive imaging, made a clinical diagnosis of a specific type of cancer. We called his wife in on Christmas Eve (she had to drive in 2 hours) and had a family meeting with her and the patient. Horrible news, and a horrible prognosis so close to the holidays. The patient was getting sicker and sicker and likely only had a few weeks to live. He was much too sick for any kind of therapy for the cancer.

Amazingly, they took it pretty well - I think they were almost relieved to get this diagnosis, after having lived with the uncertainty for so long. Medically, they already knew that they didn't want him to go through any additional procedures or tests, and they didn't want him to go through any kind of CPR should his heart or lungs stop suddenly. They started making plans for him to go to inpatient hospice somewhere closer to home so that she could spend as much time as possible with him. After nearly a week of taking care of him, I had never seen him smile when his wife walked in. He said she was so beautiful, and she called him the most handsome man and couldn't stop stroking his hair. They were sad, of course, but they focused on the positive things - spending the remaining time together, recalling memories, appreciating what they'd had all these years... Despite how difficult everything was, it was, in a way, very heartwarming and it seemed about as good as it could get for Christmas at the hospital.

Medical errors

2008-12-18T11:24:00.000-08:00

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.

Dylan's triathlon with Team in Training, the Leukemia and Lymphoma Society

2008-12-17T08:26:00.000-08:00

My good friend Dylan Rivas started a blog about his training for the Lavaman triathlon with Team in Training, which is part of the Leukemia and Lymphoma Society.

A few friends have done this (I don't think I ever could) and I think it's a great idea - the triathlon is in Hawaii, which I'm sure is absolutely amazing for the participants. They raise a large sum of money, and 25% or less of what they raise goes towards the participant's flight, coaching, overhead, etc. The Leukemia and Lymphoma Society gets the remainder, which is a substantial amount. Moreover, it supports an active lifestyle, which not many fundraisers do!

Here's a haiku in his honor:

Go Dylan Rivas!
Many miles to bike, swim, run
Good luck and have fun

Respecting patient's wishes

2008-12-09T16:27:00.000-08:00

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.

The holidays

2008-12-07T08:37:00.001-08:00

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.

Extending coverage

2008-11-11T15:42:00.000-08:00

I am all for providing as many people with coverage as possible. I don't know many people that would say that they are against that, but I am even perhaps pro-universal coverage. It would come at great cost, and perhaps lower quality health care for the top 10% of the U.S. population, but for the other 90%, it would be a great improvement. However, one big problem we would face is the availability of health care.

It's a well-known and well-cited fact that places that have universal health care often have long long lines for care, to the point where people's treatments are suffering. Just as an extreme example, and because this is in the field I am going into, say there is a patient who needs cancer treatment. Cancer isn't something that waits around for you to treat it... if you need to wait 3-6 months before you can begin treatment because all the slots are filled up, it may be too late for you. What was at one point a localized curable cancer may have metastasized by then, making treatment far more difficult and prognosis likely much worse.

A more common scenario is probably one in which people may have to wait even for appointments or spots with primary care physicians - these are the most used and most needed (and arguably the most important) of all physicians for a patient and if health care is extended to a large percentage of the uncovered population, there will not be enough of these doctors. Massachusetts seems to be facing that problem now, as they have mandated that all residents have health care coverage.

Do I think this should stop us from trying to get health care for more U.S. citizens? Of course not... do I think we should take steps to anticipate and prevent this problem? Definitely. What we need to convince more people to go into primary care (whether those are doctors, nurses, etc), but that, ladies and gentlemen, is a whole different post.

West Philly Obama party

2008-11-06T15:00:00.001-08:00

I know this is mostly a medical blog, but Tuesday was a pretty great day for many different reasons, one of which was the presidential race. Impromptu street parties broke out in several areas in Philadelphia, one of which was in West Philadelphia - my neighborhood. It was absolutely amazing. Drummers and musicians came out to 47th and Baltimore and started playing for hours and hours. We didn't come across it until 1am, the musicians had already been going for several hours, and apparently it lasted until about 4am! People were chatting and dancing in the street, which was nearly blocked off. When cars or trains did manage to make it through, everyone was hi-fiving passengers and each other. "O-ba-ma" and "Yes we can" and "U-S-A" cheers broke out throughout the night to the drum beats. I saw so many people I know from the community there, and it was a really really great feeling. My cell phone couldn't take any good pictures, but somebody managed to capture it on video:

ABATE Philadelphia Biker Toy Run to CHOP

2008-11-02T11:16:00.000-08:00

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:

Night Float

2008-10-17T18:43:00.000-07:00

What can I say - I've been on it this month and it sucks. Let me count all the reasons why:

1. You're taking care of 12 interns (plus or minus some medical students) worth of patients at night, which is up to 120 patients. All the little (and big) crap that interns normally get called about during the day gets funneled through to night float. Depending on the intern, sometimes they don't do a very good job of taking care of issues before they leave for the day, so then you have to deal with it at night.

2. You're exhausted. At Pennsylvania Hospital, we work from about 5pm until 7:30am for an average of 3.5 days a week. If you say that's about 15 hours a day, that averages 52 hours a week, which isn't bad, but the timing is horrible. Usually we work 3-4 days in a row. For those days, I usually get home around 8 or 8:30am, shower, maybe get something to eat. I finally get to sleep around 9 or 9:30am, and then get some bad sleep before getting up at 4pm again to go to work - even if I sleep the whole time (usually I waken quite a few times, sometimes for more food), that's barely 7 hours of sleep, and it's never good sleep.

3. You feel very isolated and you never seen anyone. You're completely time-shifted and if you live or have a significant other, you often leave for work before they get home, and you often get home after they've already left for work. So if you work a number days in a row, you might not see them for quite a while. Moreover, you work during the nights half the time, and the other half the time, you're exhausted or recovering from working multiple days in a row, so you never see your friends since they all get together during the evenings. You don't even see your colleagues much - you see most of them for signout when you get there and before you leave. You really only see a couple of people throughout the night, many of whom are also busy. So you spend much of the time alone - it's very isolating.

4. Nighttime is generally a bad time for patients - for whatever reason, if patients start to deteriorate, they often do it at night, so you deal with a lot more critical issues and patients whose hearts may stop beating or who stop breathing. There are many fewer doctors and nurses around at night, so you have less help and have to make many more crucial decisions on your own, which can be daunting at times.

5. The food is horrible. I basically eat cafeteria food around the clock when I'm working, so I usually get cafeteria food only for 3 or 4 days in a row. It's horrible. Although one saving grace is the pancakes on the weekends. Sometimes residents will order out, but unless they take care of it, I often don't have time. Plus that costs a lot of money, so I don't want to do that too often.

One more week to go.

Scrubs

2008-09-24T08:16:00.000-07:00

An interesting article in the New York Times sent to me by my mother-in-law:

In case it won't let you read it, here it is:

Should hospital scrubs be worn in public places?

That’s one of the questions asked by my Well column this week, which looks at the role clothing may play in the spread of germs by health workers. The issue of scrubs on the subway and other public places has been raised often by readers of the Well blog.

“I cringe every time I see a medical professional on the subway in their scrubs, which is a regular occurrence,” writes reader A.K.

“What drives me crazy is the sight of someone wearing scrubs while shopping for groceries, going to the post office, picking up their kids from day care, and so on,” writes Jenny, a nurse. “Someone wearing scrubs has been around germs all day. That person is too lazy to keep their patients’ problems away from you, and now they’re handling the apples and cereal boxes that you or someone you love may handle next.”

As my story explains, there’s no evidence that wearing soiled scrubs out of the hospital poses a threat to the public, but part of the problem is that the issue of physician attire and germs hasn’t been well studied. To read more, read the full Well column here, and then post your comments below.

I think the best part of the article are the comments below it from readers - not surprisingly, I agree and sympathize with the doctors. If you work in an operating room, or somewhere that requires clean clothes for the patients' sake (for example if they are all immunocompromised), even if you wear scrubs to work, you have to change into new clean scrubs at the hospital, which you take off before you leave. Otherwise, scrubs are no different from other clothes (for example a suit) that you wear to the hospital. It's really just a public perception that they are dirty - people wearing nice clothes touch the same patients, do the same procedures, go into the same areas of the hospital as people wearing scrubs. From my own perspective, if something happens to a patient and we have to do something emergent, or there's some blood spilled during a procedure, it is easier to clean scrubs than it is to clean a suit or a nice blouse, not to mention that scrubs are often much more comfortable and allow me to do procedures without restriction or care about my clothes. Although not relevant to the safety issue, I also agree with some of the other comments saying that many non-medical personnel wear scrubs too just because it's convenient, and these people often include janitors, technicians, medical students, researchers, etc. In the end, I guess what would be needed to settle this point is a study looking at people wearing scrubs in the public compared to other medical and non-medical people wearing regular clothes and seeing if there are any differences in "germs", and moreover, even if there were differences in amounts or types of germs, if this actually made any difference in terms of infection rates of people they came into contact with. I doubt anyone is willing to spend thousands of dollars to find something like this out.

Steps involved in medical care

2008-09-23T19:43:00.000-07:00

I'm at a conference right now, and one of the keynote speakers said something that inspired this post - he said "Think how many health care professionals it takes to take care of someone when they're sick." It's hundreds. Let's just go through an example, one I'm relatively familiar with.

A woman - let's call her Mrs. Smith - finds a lump in her breast one day. So the first thing she does is go to her family practitioner (health care professional, or HCP #1). At the doctor's office, she's greeted by a receptionist (I won't count this person as a HCP) and a nurse takes her vitals or her visit information (HCP #2). The doctor feels the same lump during that visit, gets concerned and sends her for some bloodwork and a mammography. Mrs. Smith has to go get the bloodwork done at an outside lab because of her insurance and there a tech or perhaps another nurse (HCP #3) does it for her. At least one technician (HCP #4) performs the labs and sends the results back to the primary care provider. For her mammography, Mrs. Smith probably has to go to a different hospital or radiology center for her mammography. There, one or two techs (HCP #5) do the mammography, then they send the results to a radiologist (HCP #6) whom Mrs. Smith may or may not ever meet! Unfortunately, the radiologist sees a suspicious lump in the mammograph and sends his findings to Mrs. Smith's family practitioner. She goes back to see him (her second visit, at the very least) and of course, he's very concerned and sends her to an oncologist (HCP #7).

At the oncologist's office, she meets more receptionists and nurses (HCP #8) who take her info first, and then she meets the oncologist (HCP #9). The oncologist feels the same lump, looks at the mammography findings and says she needs a biopsy. The first biopsy they usually do is relatively simple. The oncologist inserts a needle into the mass, sometimes under ultrasound guidance (sometimes requiring another tech or radiologist) and gets some tissue, which gets sent to a pathologist (HCP #10). Often, the first biopsy isn't good enough and they need to do the biopsy a different way, or get someone else (another HCP) to do it. Let's say in this case, the biopsy sample was good enough and the pathologist says it's cancer. The pathology lab has some other techs and pathologists (HCP #11) who do additional studies on the biopsy sample to characterize what type of breast cancer she has. On Mrs. Smith's second visit to the oncologist, he tells her the bad news, and tells her she will have to have it removed by surgery, and because of the characteristics of her cancer, she will also need radiation and chemotherapy. The oncologist has now become her center of health care, and he sends her to a surgeon (HCP #12).

Again, at the surgeon's office, she meets another nurse who takes her vitals signs and her initial information (HCP #13). The surgeon says yes, we need to do surgery and after some more bloodwork and probably some cat scans or additional imaging, she's ready. Mrs. Smith gets admitted to the hospital the night before the surgery, and meets at least two nurses who take care of her while she's there (HCP #14 and #15). There are also techs who take her vital signs and may administer medication (HCP #16 and #17) as well as a tech who normally does blood draws (HCP #18) for routine labs in the hospital. Because she's in a hospital, a different lab and a different tech runs her bloodwork and interprets them (HCP #19), and she may have a different radiologist (HCP #20) interpreting her imaging studies. There is also at least one pharmacist (HCP #21) involved in giving her the correct medications at the correct times. Moreover, there are healthcare-specific social workers (HCP #22) checking her medical charts and information and making sure things are overall being done correctly. The next day, she's wheeled off to the O.R. (operating room). Before anything is started, she meets the surgeon again as well as the anesthesiologist (HCP #23). In the operating room, there is of course, the surgeon and the anesthesiologist, but there is also a scrub nurse (HCP #24), a nurse in the room (HCP #25) helping get extra supplies, answering phones, etc., and at least one resident or physicians assistant (HCP #26) helping the attending surgeon. After getting out of the O.R. the patient usually goes to a PACU, or basically a recovery room, where there are at least one or two other nurses that help her (HCP #27). From there, Mrs. Smith would probably go to the medical ward where other nurses and techs take care of her (HCP #28, #29, and #30) and the surgeon and his team (probably his resident or assistant) visits her to make sure she's okay after surgery. Hopefully there are no complications and she leaves the hospital within a day or two to go back home. Meanwhile the hospital pathologist (HCP #31) examines her breast tissue under the microscope, and a lab technician or another pathologist does further biochemical work to characterize her cancer (HCP #32).

After she's recovered from her surgery, it's time for her to start radiation therapy! So now her primary care provider refers to a radiation oncologist, at who's office she is again first greeted by a nurse (HCP #33 and #34). They get her set up with a planning cat scan, which is done by a tech on a second appointment (HCP #35). The radiation oncologist plans her therapy on a computer, which is assisted by a dosimetrist (HCP #36) and a physicist (HCP #37). Radiation therapy usually takes many many weeks of daily Monday through Friday treatment, over which time Mrs. Smith will meet many technicians, nurses and other doctors (HCP #38, #39, #40).

Finally, it's time for chemotherapy. Although this may again take a number of weeks, this is done through her oncologist's office, where she already has probably met the nurses and assistants that will be involved in her care. Depending on the type of chemotherapy Mrs. Smith receives, she may meet some new HCP's in a chemotherapy room or who help her to administer the chemotherapy at the office or at home.

As you may have noticed, even though I probably grossly underestimated the numbers of HCPs that helped Mrs. Smith out, in the story itself, that's a total of 40 health care professionals who have all helped Mrs. Smith during her medical problem! This story doesn't even take into account residents, medical students, nursing students, medical transporters, and other health care professionals who often play a large role in a patient's care and may more than double the number of HCPs who help her! Moreover, this story was relatively straightforward, and the patient didn't experience any complications, such as infection, adverse effects from chemotherapy or radiation, biopsy problems or anything else, which would of course result in more diagnostic procedures and treatments, as well as exposure to more HCPs. In addition, Mrs. Smith may have other medical problems and comorbidities not mentioned in the story which require the attention of even more HCPs.

The entire reason for this story is that I think it is amazing how many health care professionals are involved and how many steps are required for providing basic care for what has become a relatively commonplace problem. With this consideration, it seems like it would be a miracle if everything went smoothly, nothing went wrong, and the patient was satisfied with absolutely everyone that helped her out. It seems healthcare is so complex in the modern world that there will always be room for improvement despite continual modifications, and from the standpoint of a health care professional, I hope that patients realize all our efforts to streamline the process and make their own healthcare easier for them to go through.

LuBang! horah video

2008-09-14T10:03:00.000-07:00

Well, it took long enough to upload, but here is the ever-anticipated Lubang horah video. I think the highlights are the parents.

God and medicine

2008-09-09T18:57:00.000-07:00

I'm not particularly religious, but I know many patients and doctors are. Although I don't believe in the same thing they do, I feel that I have plenty of respect for their beliefs and don't usually have a problem with it. However, I have a small pet peeve about something I hear a lot of patients say. It's not a big deal, really it isn't, but I dislike it when there's a test or therapy patients don't want to take and they say "it's in God's hands." I completely respect patients' wishes (and sometimes agree with them) when they don't want to take something or do something - it's their right. However, I have a problem with them using God as an excuse. I'd rather them tell me they just don't want to do it, even if it's against all logic, than use what I call the God excuse.

For one thing, it's contradictory. The very fact that they came in to the emergency room or the hospital means that they do not completely believe that "it's in God's hands." Why go to a doctor at all? The very act of going to seek medical help means you believe that you can change what happens to your health and that maybe you believe that it's not all "in God's hands." If you truly believed that, you would just stay at home to live, die, suffer at will.

But it's not a big deal. For whatever the reason, whether it be religious or not, we respect what the patients want.

Medical Time Suck

2008-09-04T15:41:00.001-07:00

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.

Attitude

2008-08-29T16:25:00.000-07:00

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

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

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

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

-- Charles Swindoll

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

Dialysis

2008-08-27T20:56:00.000-07:00

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

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

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

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

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

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

Doctors and arrogance

2008-08-26T16:22:00.000-07:00

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

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

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

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

Drug Dinners

2008-08-08T06:32:00.001-07:00

In med school, one of the last things we had to do was take a one-week long ethics course, which included several lectures about pharmaceutical companies and reps. One of the more interesting things they did was to take the survey of the graduating medical students right there during the lecture. We all had a wireless handheld device and when they asked us a question, we would enter our answer in a completely private and anonymous way, and the computer would tally our responses live and show the results on the big screen for everyone to see. One of their questions was "Do you think the majority of students in this room can be influenced by drug reps and pharmaceutical companies in the future?" Something like 60-70% of students said "yes." The next question was "Do you think you yourself could be influenced by drug reps and pharmaceutical companies in the future?" This time only 30% of students said "yes."

I think this one little survey told us a lot about how drug companies work and why their tactics work on doctors.

The medical school also had an ex-pharm rep come and talk to us about the tactics they use. Most doctors and medical students I know believe that they can't be influenced by things like free food or dinners, much less free pads of paper or pens or clipboards (or anything else) that is given to them by drug reps, or at the very least, that the influence is minimal. But the drug reps and pharma companies wouldn't be doing this if it wasn't working, right? And that's basically what the ex-drug rep told us. Pens and pads of paper alone, labeled of course with the drug logo of choice, will change prescription practices 20%. I may have that figure slightly off, but that is the figure she quoted. This doesn't even take into account other types of gifts, free samples for patients, free dinners they offer, filling up gas tanks, honorariums for speaking, travel costs for conferences, etc. I can't find it online, but apparently the pharmaceutical companies have amassed actual data regarding how well these tactics work. Amazing.

On an unrelated note, the ex-drug rep also told us that they used to hire pharmacists as pharmaceutical representatives. However, now they've started to hire people without scientific backgrounds for several reasons. For one, if there was an argument about the validity of a certain drug between the rep and the doctors, and the doctors were backed by evidence, the pharmacists would eventually come around to agree with the doctors. Secondly, it seems that a pharmacist background isn't really necessary to sell these drugs or to make their tactics work. This New York Times article seems to say it pretty well.

I think it's great that the University of Pennsylvania Health System (UPHS), which includes my hospital - Pennsylvania Hospital - has banned all drug-rep-related activities within the hospital. I think some of the outpatient practices and satellite clinics (especially private ones) have some immunity to this rule, but overall this is a good move and hopefully will set some precedent for other hospitals and practices.

All this being said, I am a poor resident and I went to my first drug dinner the other week, and it was delicious. :) To be completely honest, the speaker gave a 30-minute presentation and all I remember is that the drug was a new one for hypertension. I do remember I had a crab cake appetizer, some vegetable dumplings, seared salmon, and steak for dinner. I guess that tells you my priorities...

Being on elective

2008-08-06T05:12:00.000-07:00

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.

Dinner last night

2008-08-03T06:41:00.000-07:00

was really good. I don't have time to cook anymore, so when I do, I really enjoy it. Yesterday we set up an interactive appetizer: spring rolls. I showed people how to soften the wrapper. Then we had an assortment of ingredients you could put in. Bean threads, bean sprouts, thai basil and thai mint were the basis, usually with some hoi-sin sauce. Then you could put any number of additional things - we had enoki mushrooms sauteed with a lot of garlic, green onions, jalapeno peppers, different hot sauces, fish sauce, or dumpling sauce. There may have been more, but it was a pretty good spread.

For dinner, we had three dishes. Chinese broccoli sauteed with oyster sauce, honey walnut shrimp and chicken with cashews. I think everything was a big hit. There were 2 and a half pounds of chicken, and 2 and a half pounds of shrimp. By the end of the night, the shrimp were totally gone, and considering we had 8 people, I think that's pretty impressive. We all stuffed our faces.

Eating in the hospital

2008-07-29T08:50:00.000-07:00

There aren't too many options for eating when you're working 10-12 hours a day and rushing around all day. To be honest, especially at the beginning, when I'm carrying a lot of patients, I'm so involved and busy I think my adrenaline is going all day, and I don't have much of an appetite! Even when we're at a meeting and there's food in front of me, sometimes I don't feel like eating. If you know me, you know that's unheard of - first of all, I usually have a huge huge appetite. Secondly, if there's free food, I'm there. But I power through - I make myself eat. :)

Even when there's time, and I'm hungry, one of the problems is that the only option we have is the cafeteria. Sure, you can order in or have something delivered, or take a quick 5-10 minute walk to somewhere to get some food, but all that takes more time and also costs more. The issue really is that it takes more time and that it's difficult to leave. You really have to be in the hospital at all times in case something happens to one of your patients, or to answer pages or put orders into the computer. I guess people can also bring food, but that's rare - you hardly have energy to make dinner for yourself after coming home from a 12-hour shift, much less lunch for the next day. A few people with significant others sometimes can do it. And you can do it sporadically, but it's far from common. So you are really limited to the cafeteria, and sometimes you don't even have time to go the cafeteria!

Even when you're able to make it to the cafeteria, the selections are horrible, limited, and repetitive. And the cafeteria closes down around 7:45pm, so if you are working a late shift, you have to make sure to get in early for dinner. For lunch, we don't have 5-10 minutes to wait for hot entrees to be made often (like cheesesteaks or grilled cheese sandwiches), so we often go for the quick already-prepared foods. Soup is always a good option, and inexpensive, but they go through the same soups every week so those get a little tiring. Sushi is also a good option (although it's not like it's great sushi), but it's expensive. The salad bar is actually pretty good, but it's not cheap and you can't eat salad everyday either. The hot entrees are also not cheap, are often terrible, but are very fast items to get besides soup and sushi. Other fast options include ready-made sandwiches (horrible), burgers, fries and onion rings, chicken wings, mozzarella sticks, and some other fried foods. The options are even more limited for dinner. Because of all these things, doctors usually end up eating horribly if they eat at all. There's a joke that doctor's are the least healthy people in the hospital.

It'll be nice when I can cook more again.

A good blog

2008-07-23T08:26:00.000-07:00

This is a great blog:

Stuff white people like

ha

2008-07-16T19:22:00.000-07:00

Look at this site about what a proctologist is... more specifically, look at the girl they put on there! That's a proctologist? Ha. Or you might get they funny looking guy with the stare. Interesting way of depicting proctologists. :)

A lesson well-learned

2008-07-12T09:52:00.000-07:00

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.

Medicare sucks

2008-07-08T20:30:00.000-07:00

There are a lot of changes going on in health care. One is that pretty soon in Pennsylvania, it will be mandatory for hospitals to report hospital-related infections. Now, I believe this is a very good step overall. For one, it's important for hospitals to keep track of something like that, and to take steps to lower the numbers. It is probably impossible to completely eliminate it, but it's crucial to reduce it as much as possible. Although hospitals should already be taking measures to do so, I think mandatory reporting will go a long ways toward speeding hospitals along. Secondly, I think it's good that patients will be able to access this information and see the rates of hospital-related infections at different institutions. This may help them make health care decisions, which in turn, will pressure these institutions to lower their rates of hospital-related infections.

However, I also see some potential problems. For one, I have heard that Medicare is going to stop paying for hospital-related complications and infections. Now while I believe that many hospitals will be able to reduce these by quite a lot, hospital-related infections will never be completely eliminated. Let me give an example.

A patient comes in because he had a heart attack. He's on the older side, also has hypertension, and congestive heart failure. The heart attack really does a number on his heart and it starts failing. He can't pump his blood well, fluid builds up in his lungs, he can't breathe, and he gets sent to the ICU and gets intubated - that's getting a tube thrust down your pharynx so that you can breathe with the help of a machine. This is a life-saving intervention. Without it, this patient would have died. However, several days after intubation, the patient develops a rip-roaring pneumonia. He gets treated with antibiotics and gets better. Eventually, the patient's heart gets better, he gets extubated (the breathing machine is removed), has open-heart surgery and lives another happy 20 years.

A relatively high percentage of patients that are intubated develop pneumonia. While this is serious, it can be treated with antibiotics. Medicare is saying that they will not pay for the antibiotics, because this type of pneumonia is a hospital-related infection - even though this infection was the result of a life-saving intervention! This is not the only example of something like this - there are many others.

Who is going to pay for the cost then? The patients? No - they never have enough money. So it will go to the hospitals. They will have to eat the costs and make up for them by billing more for just about everything else. Would it be ethically okay for the hospital and doctors and nurses to say, well, this patient will probably develop pneumonia if we intubate him, and we won't get paid for that, so nevermind. Let's just let him die. Of course that would not be ethically acceptable, and of course that won't happen.

I think it's ridiculous and sustainable for neither the insurance companies nor the hospitals.

Paul Levy, the president and CEO of Beth Israel Hospital in Boston posted about this topic and I think he also brought up some very good issues.

The neverending bag of patients

2008-07-07T19:45:00.001-07:00

I have had a lot of patients on my list everyday - nearly the max an intern can carry. Today I discharged four patients. That's a lot. But it didn't matter - I admitted another four in the afternoon into night, and there will probably be another one I get there in the morning.

Sigh.

Frustrations with giving medical care

2008-06-26T18:48:00.001-07:00

I'm sure there are a many frustrating things during intern year, and I'm sure I will blog about quite a few of them. Here's one.

There are so many patients in the hospital who fight with you about their care. You're trying to do something for them which will make them better, and they don't want to go through with it. And I'm not talking about interventions that are risky, or have lots of side effects, or ones that we're not sure about or ones that don't matter that much. Sometimes they're life-saving interventions! Here's my example from intern year:

I had a patient who had a horrible infection - she needed IV antibiotics. She wasn't about to die just yet, but if she didn't get the IV antibiotics soon, she would get horribly sick. And we know this because we see it happen all the time. Sometimes we don't even know people have infections in the hospital yet until they're horribly sick - we got lucky and managed to catch this patient before they got to this point. She tried to refuse the IV antibiotics! She said vitamins or herbs might do just as well. Ridiculous. She also had made some really bad medical decisions that had got her in this situation in the first place. I spent close to an hour talking her into, first, letting us put an IV in her arm, and then second, getting the IV antibiotics. What if I had said, fine, don't get the IV then. She would have gotten seriously sick! But of course, I spend more than an hour arguing for her, and she got the IV and the IV antibiotics, which probably saved her life.

The problem is that it's very difficult for doctors to say something like oh well, it's your call, go ahead and die to a patient. First of all, they genuinely believe in the therapy and believe that they're right. Secondly, if they didn't try their absolute hardest to argue with the patient for their own good, doctors would be held liable. It's very frustrating, but I think we're stuck with it.

Blue Moon

2008-06-26T15:07:00.000-07:00

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.

George Carlin - anorexics and bulemics

2008-06-23T17:51:00.000-07:00

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

George Carlin video about swear words

2008-06-23T17:46:00.000-07:00

Well, George Carlin died of heart failure today so of course this news is everywhere. I just watched this video for the first time. It's his famous bit about swear words. I'm not going to say much about him because I honestly didn't know him that well or watch him that much, but this is HILARIOUS.

First Call - to Code or not to Code?

2008-06-21T18:09:00.000-07:00

I had my first overnight call as an intern. It wasn't too bad. Pennsylvania Hospital is actually pretty nice to their interns. Typically, interns stop admitting around 1 or 2 am if they're on overnight call. Which means they probably get 3 or 4 hours of sleep, which is great! Of course, I spent about 2 hours with my resident doing a paracentesis (sticking a big needle in somebody's abdomen - you usually do it when fluid is building up abnormally in a patient's abdomen, making it all poofy. Yes that's a medical term. Poofy.) and trying to get IV access and blood drawn from a very difficult patient. So I didn't even start admitting until around midnight, and I felt bad, so I ended up doing 4 admissions, which lasted until about 4:30am. Plus there was a code - which is the thing I actually want to talk about that happened that night. I ended up getting only about an hour of sleep.

So the code was interesting - a resident and I are doing admissions in the ED, and suddenly a code call goes out across the hospital-wide PA system. "CRT... CRT... " and it told us the location. Apparently that means somebody was going through cardiac arrest. I found out later that this patient had been doing fine after his surgery and was being monitored by telemetry. That's where they attached a lot of electrodes to a patient's chest, it monitors their heart, and somebody in a centralized location watches a lot of monitors 24-7 to make sure all those hearts are working properly. This person noticed that at 1am, this patient's heart suddenly stopped working for some unknown reason and called the code. When my resident and I got in there, there were 4-5 people already there working on the patient and giving CPR. It turns out giving CPR (which at its most basic is simply chest compressions and giving breaths) is the most important thing in bringing someone back from the dead and giving them the best chance of survival afterwards. Somebody had already gotten IV access, and he was being pumped full of fluids, they were attaching a monitor to his chest. His heart was in ventricular fibrillation, which is a type of arrhythmia, that if left untreated, usually leads to death. They shocked him, and he immediately went into PEA, or pulseless electrical activity, which means the electrodes were sensing electrical activity by the heart, but it wasn't actually pumping, and the patient was pulseless. At this point, shocking doesn't help anymore, and you basically continue CPR and start giving all these different types of medications meant to jump-start your heart.

The rule of thumb is that you don't continue to code a person past 10 or 15 minutes because (1) the chance of survival is way too low after that period of time and (2) even if you bring them back to life, they've been "dead" for too long, and their functionality is horrible. There's a good chance they'll code and die again before they leave the hospital. However, in reality, codes often go on for 20-40 minutes, especially in patients where it is unexpected. Time goes super fast in a code, and people are reluctant to give up. This code had gone on for about 17 minutes... people were starting to give up, they'd loss IV access (I actually managed to put a new one in on the foot that lasted about 2 seconds). And then all of a sudden, someone says "I've got a pulse." Crazy. This guy was dead for 17-18 minutes, and then all of a sudden his heart starts working again. And the monitor shows that his rhythm, although not idea, is a workable rhythm, and he's "alive" again, and somewhat stable. All this activity starts up again and he eventually gets intubated (a breathing tube shoved down his throat) and transferred to the ICU. I don't know what happened to him after that - I guess if you follow statistics, there was a good chance he coded again and died.

Afterwards, I finally found out the rest of his story. This patient has esophageal cancer, one of the worst cancers to have. The treatment is surgery - they take out your whole esophagus, which is an extremely hard surgery to live through. Then afterwards, many patients have to go through chemotherapy and radiation, which is definitely no joke either. And after all of that, there's a good chance of it coming back anyways! So even if this patient lived and was stabilized, first of all, he would probably have little to no brain function since he got very little oxygen to his brain for 17 minutes. He'd be a zombie, on life support, for the rest of his life. Even if a miracle happened and he woke up, he'd die of his esophageal cancer pretty soon, or have to go through chemotherapy or radiation, which might kill him too.

So my question is... should he really have been coded? If I were the patient, I would not have wanted that. But not many people think of these things when they're going in for surgery anymore. In many countries, they trust the doctors to make these decisions, but in this country, and in the era of litigation, that's just not possible. Because of this, we waste millions of dollars on codes and life support and everything else. But more importantly, it leads to horrible situations that families have to deal with.

Faith in American patients

2008-06-18T16:15:00.000-07:00

Today may have restored my faith in American patients. Way back when, I posted about how much better African patients were than American patients. Today was my first day of internship and I was prepared. I was prepared for the gripes from the patients: "My cable TV isn't working!" "I asked for mashed potatoes for dinner, not broccoli!" "I refuse to take that medicine!" "I demand a private room!" And of course, I was not expecting any gratitude or help with the patient care from the families. I was not even expecting the patients or their families to know anything about their own illnesses. I expected a lot of drug addicts, HIV patients, gun-shot wound patients, people with no family support, rudeness, impatience, an air of presumption and expecting things they should expect.

I was surprised. Three of my patients or their families expressed extreme gratitude for my help. Some of them were pretty demanding, but in the end they were grateful for all that I did. A fourth patient started out pretty surly and unfriendly. To be fair, he's been in the hospital for close to 3 weeks, and he's not that much better yet. But after talking to him and joking around with him for a few minutes, he warmed up, and even thanked me at the end for talking to him.

I think in the end, you get what you put into the patients. They may be very demanding (especially compared to Botswana patients), but if you really care and try to help out, they'll see that in you and be appreciative. If you don't care about them, of course they're going to realize that and see that in you. Maybe American patients aren't so bad after all. Or maybe it's my first day and I'm still being naive. :)

The first day of internship

2008-06-18T16:06:00.001-07:00

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

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

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

The Making of the Lubangs

2008-06-15T23:31:00.000-07:00

I just got married!

We had a crazy 3 weeks, starting with my graduation. You'd think this would be a bigger deal since I spent 9 years trying to get this diploma, but it got a bit eclipsed with the wedding. But it was still a good time - my parents came into town, as did Pete's mom. We had a nice dinner that night, and the next night, my parents through a big banquet dinner for me and my friends. It was so nice of everyone to come!

That next week we spent getting ready for our wedding, which takes way more time than you might think. I can't even remember what I was doing anymore, but every day was super busy doing super important wedding stuff. Plus we were picking people up from train stations and airports and my brother his girlfriend, and my sister and her boyfriend were staying with us.

The wedding itself was so much fun for us! We started with photos to get them out of the way, and then it was on to the ceremony. My brother Bruce was our officiant, with Karen, my sister, as my maid of honor, and Ben, Pete's brother, was his best man. We had Ben's two twin sons, Jacob and Aaron, as our ring bearers. During the rehearsal they were so cute, in their tuxes carrying the ring pillows. I wish I could have seen it myself, but I hear during the actual ceremony, they did great! And of course, there are probably a bazillion pictures documenting their cuteness. :)

Bruce did an awe job as the officiant. I'm lucky he let me read a draft of his talk the day before, because when I read it I was bawling, and that probably would not have been the best thing to do during the ceremony. He made it very personalized for Pete and I, which was great. You know those parts of ceremonies where you almost fall asleep? Well completely objectively-speaking, there were none of those parts during our ceremony. I for one, did not fall asleep. :) Tons of people came up to us afterwards though and told us what a wonderful job Bruce did. There were even a few requests for Bruce at other weddings!

Afterwards came the cocktail hour. We holed ourselves up in our private room for 30 minutes or so then stepped outside for some socializing. The private room was great - family members came in to see us, we played with the twins for a bit, and we even had our own food! I didn't have many of them, but people said the appetizers were great. We had a table with lox and whitefish and bagel fixings, a table of cheeses, olives, and crackers, as well as an assortment of butlered hors d'ouvres brought around to guests: shrimp tempura, wild mushroom phyllo, scallops wrapped in bacon, coconut chicken, beef tenderloin with eggplant, asparagus with goat cheese, peking duck rolls, and crab cakes. And, of course, it was open bar.

Time went so fast! Before we knew it, it was time to go into the reception hall. Bruce went in and was announced first, followed by my parents (Phillip and Catherine Jang) and Pete's mom (Carol Lubetsky). Then we were announced as Mr. and Mrs. Lubang! It was such an amazing feeling to go into that room with everyone cheering and applauding. After our entrance, we went right into our first dance. I know this is what everyone wants to see, so here, courtesy of Jen (my sister-in-law, Ben's wife, and mother of Jacob and Aaron), is a video of our first dance on youtube. We had it choreographed to Let's Get it Started, by the Black Eyed Peas.

The first dance led right into the hora, which was the best idea ever because all the energy from that was transferred into the hora. I've never been lifted or pumped in a chair before, but it's great!! I can't believe they even got my parents up there. And everyone said my dad looked so good in his yarmulke. :) After that, there we had toasts from Ben, Catherine (and Phillip) and Carol. And then we started dinner! Even though we didn't get to eat too much of it, everyone told us the food was so good! I think it was just as good as when we tried it at the tasting dinner. Just because food is my thing, this is what the guests were served:

Appetizers:
Butternut squash soup (delicious!!!)
Caesar salad

Main entree: Guests had a choice of
(1) sweet potato-encrusted NY strip steak grilled medium rare with roasted potatoes and julienned vegetables,
(2) chicken olympia (seared European chicken breast topped with sauteed spinach, roasted red peppers, and feta cheese in a lemon-thyme sauce) with garlic mashed potatoes and julienned vegetables, or
(3) a vegetarian option that I -believe- consisted of tortellini. I guess this shows how much we cared about the vegetarian entree... :)
Kids got something like chicken fingers and fries.

Dessert: wedding cake! (with coffee or tea) The wedding cake was a layer of vanilla and a layer of chocolate, separated by a coffee ganache and a raspberry layer. The wedding cake was awesome - we got it from Dough Main Bakery. Pete keeps talking about how he wants to order another cake from them. :)

The rest of the wedding was fantastic! We had a father-daughter and mother-son dance, which ended up with all of us dancing together. We did cake cutting and a few more pictures. We talked to so many people, although not nearly as many as I wanted to. At some point we tried to make it around to all the tables, but we probably didn't even get to half of them! I felt really bad about not talking to some people, so I figured it out... the entire reception was 5 hours, but we spent half of the cocktail hour alone, then there were the different dances. Also cake cutting, toasts, etc. - so there were really only about 3 hours to socialize. If you divide that by the number of guests, each guest would only get a little more than a minute! So if I talk to someone for 5 minutes, I shaft 3 to 4 other people! So no wonder I didn't get to talk to everyone - I'm justified by math. And yes, this is pretty nerdy. :)

It was a wonderful day and I think it set the tone for a wonderful life.

The beginning of intern year

2008-06-13T08:35:00.000-07:00

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

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

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

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

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

The absurdity of the airline industry

2008-06-12T14:13:00.000-07:00

I've been traveling a lot over the last year and I've had to spend a lot of time in airports. Of course, everyone has gripes about traveling. But lately I feel it's been getting absurd. Take a story that my mom told me.

My parents had to be in Boston for a wedding, so I arranged all their travel plans for them - their flights, the rental car, hotel, etc. My parents aren't poor, so instead of going for the cheapest flight, which is usually a red-eye or leaves at an insane hour, I book a reasonable return flight for them going from Boston to Sacramento, which leaves at something like 9am in the morning, has an hour and a half layover, and makes it to Sacramento around 2pm. About a month later, I get an email notice from this un-named airline (but which rhymes with Smelta) telling me that their flight has been changed. Not only does the flight now leave at 7am, but now there are -two- layovers, one of which is 30 minutes long (yeah right, my parents would never make that), and now they don't get home until 6pm at night (9pm EST). This is important because they need rest. My dad is asleep usually by 9pm, and moreover, they were picking up more family at the Sacramento airport the next day from China, Taiwan, and Hong Kong to show them a good time in ol' Sacramento. Anyways, so I call, raise hell, and eventually they rebook my parents - they still have to leave at 7am, but now they only have one layover (45 minutes, still tight), and get back to Sacramento around 1pm.

So the day of their return flight, my mom calls me around 11am. Of course, I'm assuming that it's during their layover, but noooo. My parents made it to the airport around 5:45am - a good hour and 15 minutes before their flight takes off. I would have thought that at 7am, probably the first flight of the morning, this would have been plenty of time. Unbeknownst to them, Smelta apparently has around 7 or 8 flights leaving all at 7am from Logan International. The lines were horrendous and since everyone was in the same boat, they were not letting anybody skip ahead to make flights. My parents finally make it past security with a couple minutes to spare and my mom makes a run for it - my dad was a little slower since he had to put shoes back on and he's old, so he has to sit for that, and tie his shoes and everything. My mom actually makes it to the gate, it was still open, and they were letting in 4 more people. She pleads with the woman and says her husband is coming up right behind her. The gate woman says sorry, it's too late, and closes the doors. Literally a minute later my dad comes running up as well, and she wouldn't open the door for them even though the other people had just gone through and probably were still in line on the bridgeway to get it their seats. It was 7:01am.

How ridiculous is that? Do you know how many times I've been kept waiting by airlines? Not even for weather reasons. For cleaning reasons, mechanical reasons, reasons not explained to us, the customers. These delays have over my lifetime probably cost me days and days of time. If I said, oops, sorry, you were a minute late, I'm not paying - how do you think they would take that? Probably not well.

the genetics of race

2008-05-16T05:43:00.000-07:00

When I was in high school, I got into a debate at school. I said that if different races were separated long enough to evolve different skin colors, then other things could have evolved differently too. For example, blacks are stereotypically thought of as good athletes. Asians are thought of as good at math. I know this is really oversimplifying it, but it's certainly possible that over time, blacks developed a "strong muscle" gene (or set of genes) or maybe a "hand-eye coordination gene" and Asians developed a "math" gene (or set of genes). I'm not saying that's what happened... it's just what is possible.

I was watching a TV show (I think it was Without a Trace) and although I'm sure nobody really picked up on it, there was this one part that I think really made this statement. In this episode, there was this white kid who disappeared, partly because he was having an identity crisis. His mother was white and the father who raised him with his mother was white, and the kid looked white, but his father was black, and he just found that out. In one of the flashback scenes, they show the kid when he really young, and he's talking to his adopted father, saying that he doesn't "feel right". I'm not getting the words completely right, but he basically says that he feels different from his father and all the other (white) kids - they don't like the same things, act the same way, or even look the same. And after the flashback, the father says about his adopted son, "he always knew" (that he was different).

Now at first glance, this doesn't seem to mean much. But actually, what's it's saying is that even though there was no difference in skin color for this kid, there were other characteristics - facial or other body features, personality, attitudes, etc. - that made him feel different. And then he finds out he's half-black. The point is that this one scene in the show is suggesting that there may be other differences to race than skin color (whether genetic or otherwise). It's interesting to me that this was brought up, albeit in a very subtle way, on TV, while in reality, it's something that society as a whole isn't really ready to talk about yet.

Free pens and pizza for doctors

2008-05-13T11:50:00.000-07:00

A couple of years ago, my hospital banned any sort of pharmaceutical advertising, including free pens, lunches, dinners, prescription pads, drug samples, anything. This was a huge deal. Half the resident lunches were paid for by pharma, and they always coincided with mandatory meetings and conferences, so residents could eat while the attended and knock out two birds with one stone. I certainly understand. For one, without the free lunches at these meetings, residents often don't have time to get lunch! They don't even take the time to go the cafeteria and grab something to go. Even from an outsider's perspective, I think this is understandable - why feed yourself when you could work more on your patients and provide better care? Perhaps even save a life? Secondly, residents do not make a lot of money. They make about $40-45K a year ($30K after taxes), and many of them have $200K in debt after medical school. They haven't saved anything for retirement yet, and some of them have kids and families to support, so the loans are often just gathering interest during residency. So actually, these free meals were a source of income for the residents! Sure you can bring food and eat cheaply (and be much more healthy too) but the average resident does not have time to do this. The alternative is eating at the cafeteria or elsewhere, where an average meal probably costs $5-7. However, if you eat a free lunch off of the drug company (which usually is just pizza or ordered in chinese food or sandwiches), you save that money. You may even have enough left over for dinner if you're working late, which you usually are. Taken over a week, that's $20-$30 you save. Taken over a year, that's $1000-1500 you save, which for a resident, is a lot of money.

Despite these reasons, I've always been hugely for this. I've always thought these free pens and everything else could easily influence (hopefully subconsciously) doctors' prescriptions of these drugs. For example, say you want to prescribe a proton pump inhibitor to a patient, and in your line of sight is your clipboard, with "Protonix" all over it. You might not even realize that you saw it, but the next thing that happens is that you prescribe Protonix for your patient, and they're on that for life... not a bad way for the company to get a patient for 30 or 40 years, huh? And it's even worse with the free samples. I completely understand that free samples are how a lot of poorer people get their medications, and I think that's certainly a benefit. However, if you have a sample of drug X, and it works for a certain patient, even after they stop giving out free samples, that patient is probably going to stick with it, even though it might be 10 times as expensive as drug Y. It's also a huge source of medication confusion - so many patients I've seen have switched from medication to medication, for, say, their hypertension. And it's basically because they switch to whatever is being given out for free for that particular month. That is bad medicine, and bad for the patient.

Of course, we never knew if this was true or not. These are just theories. But why would pharma keep doing this if it didn't work, right? I'm sure they've done their research, and I've actually heard statistics from some ex-drug reps about it. So it's real. And hospitals and practices should ban pharma from advertising in their space. Of course, that's just my opinion, and there are plenty of differing views on this.

Here's an interesting recent article by Art Caplan, a pretty well known medical ethicist.

Food and Personality

2008-05-11T17:23:00.000-07:00

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. :)

Tonight's Menu

2008-05-09T18:11:00.000-07:00

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

Korean food in Philly

2008-04-29T18:59:00.000-07:00

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.

When to have children? or When to have fun?

2008-04-28T12:18:00.000-07:00

I've had this discussion with a few different friends on separate occasions lately, so it must be on our minds. When is the best time to have children? I don't know if this is right or wrong, but it quickly becomes a question of assuming you want to have children, when do you want to have fun?

A lot of my friends are having children, plan to have children, or may have children in their 30's. Maybe even 40's. I think that's relatively late.... but that means you get to play when you're younger! Sure you can argue that there may be genetic risks the older you get, but let's take that out of the equation by saying you can adopt. And you can do that whenever you want - even when you're 50! The good thing about having fun when you're younger is that you have more energy, and you're usually more accepting and experimental and willing to try new things - these characteristics are perfect for travel and having fun! The problem with having fun when you're younger is that you have no money. And this is supposedly the time when you should be saving for retirement, yada yada yada. Another drawback is that if you have children relatively late, when you retire, you may still have kids in college, or even high school! I don't know about everyone else, but I'd rather have the kids out of the house and out of school by then, or taken care of in some way so that I can travel all over and enjoy retirement. I'll know how much money I have left and how I want to spend it.

Now if you decide to have kids early, you can start saving early for their school, which may not only include college (or post-college stuff), but also include grade school and high school depending on where you live and if the public schools are okay or not. Not to mention day care for the younger kids! And when you retire, they're all taken care of and you can have your fun. And presumably you have plenty of money for that fun. The downside is of course, you don't have as much energy for the fun stuff (i.e. traveling) and because of that, you would probably do different things. Like, I doubt that when I'm 65 I'll go bungee jumping - not impossible, but I probably wouldn't do it.

After thinking through my options, I think I would rather have kids earlier rather than later - it'd be nice to have a lot of energy for the kids too, much less traveling and other fun stuff. But I guess it's too late for me to have kids early in life, so I'll settle for having fun now and having kids later. :)

Nerdy comics

2008-02-28T14:59:00.000-08:00

This site is awesome. I've spent the last hour looking at the comics. Fits my inner nerdiness.

http://xkcd.com/304/

Patient Rights

2008-02-27T13:46:00.000-08:00

Informed consent. It's a long history, but informed consent came about when patients started asking for more autonomy in their patient care and the term "patient rights" came into being. I'm all for patient rights and autonomy and it's definitely the right direction for patients to go towards. Of course, there has to be a limit to what a doctor can or has to do, and this article does an excellent summary of listing and explaining common myths about informed consent:

http://archinte.ama-assn.org/cgi/content/abstract/156/22/2521

Let me summarize.

Myth 1: A signed consent form is informed consent. Just because somebody signs a piece of paper saying they understand all the risks and potential complications of a procedure doesn't mean that they understood everything you tried to tell them, or everything that's on that piece of paper. Some of those consent forms are pages and pages long and full of jargon, so that could actually confuse someone more than it helps.

Myth 2: Informed consent is a medical miranda warning. There's more to informed consent then tell patients all the risks of a particular procedure or action. You also need to tell patients about options, potential outcomes, etc.

Myth 3: Informed consent requires that physicians operate a medical cafeteria. For a given problem, there might be 20 different ways of going about treating it or solving it. A doctor doesn't actually need to present all 20 ways - in fact, this usually confuses the patient! The doctor only needs to (and should) present a couple of the methods (usually what the doctor thinks is best) to the patient and information about the different methods. And physicians can still give advice - the goal is just to not be paternalistic. In fact, patients often ask for advice ("what would you do if you were me") in addition to the information and welcome it. Doctors don't have to just sit back and let the patient choose out of all the options with only factual information.

Myth 4: Patients must be told everything about the treatment. This is certainly not legally required, and if doctors did this, it could take hours. Ethically and legally, a doctor should tell a patient everything a "normal" patient would want to know, and then of course, ask if the patient has any questions. A doctor cannot and should not be sued or deemed a bad doctor because he failed to disclose an aspect of the treatment that is very rare or that the common patient wouldn't care to know at the beginning.

Myth 5: Patients need full disclosure about treatment only if they consent. Theoretically, patients need to know about important things before they consent if they are trying to choose between options.

Myth 6: Patients cannot give informed consent because they cannot understand complex medical information. While a patient might not be able to remember or recall everything that was explained in the office, during that office visit, they will probably understand everything well enough to make a decision. Secondly, things need to be simplified in a way that patients can understand things. If a patient is incapacitated or incompetent in a way that makes them unable to make decisions for themselves, then there needs to be a surrogate decision maker.

Myth 7: Patients must be given information whether they want it or not. It is certainly within a patient's right to not participate in decisions affecting their health care - they may leave it up to a family member, or even their doctor. The doctor shouldn't force a patient to listen to them if the patient truly wants to give up this right.

Myth 8: Information may be withheld if it will cause the patient to refuse treatment. In no instance is it right to withhold health information from the patient about him or herself.

I think this article is great, because often doctors feel they have to tell the patient too much, or there are doctors not telling patients enough. Conversely, there are patients who expect things that doctors aren't obligated to give. Of course if they ask, it is usually given, but just because a doctor doesn't give it, doesn't mean they're a bad doctor. The article basically explains to both doctors and patients what is expected of them during an office visit, and that's been a relatively murky issue for quite a while - at least in my mind.

Accumulation of Wealth

2008-02-18T22:04:00.000-08:00

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.

The theory of addiction

2008-02-13T04:45:00.000-08:00

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.

Escalation

2008-02-01T17:03:00.000-08:00

So it's interesting... when I first moved to Philly, I must have had nothing to do. I mean, sure I was probably kept busy for a bit, getting situated, moving things into my new apartment, and starting med school. Actually, I remember it took me quite a while to get more furniture... For a while, all I had was a mattress, a TV, and a chair that sat in front of the TV. I eventually found what I was looking for either on the street, or at Ikea but it definitely took me 3 or 4 months. I even had people over dinner - I made them sit on boxes and on the floor!

ANYWAYS, the point of this blog is that everything in my life seems to have escalated. I had barely any social life back then. I moved, and I knew nobody in Philly. I probably went out once a week, and med school-related events, and went to watch football games with pseudo-friends, some of whom I would become really good friends with, and some whom I have no desire ever to be friendly with again. Maybe I was studying (although most who know me would probably laugh), but I think I found other ways to occupy my time, and for the life of me, I can't think of what that was back then. Now my social life is so busy, it's a little crazy. Not only do I have friends from med school and ultimate frisbee now, which keeps me busy enough, but I have a significant other to interact and live with, and since his whole family lives on the east coast, and his whole friend base is also here, we have some sort of family function about every 2 weeks, which can often take up an entire weekend! And we're also big hosters and cookers - we love hosting people for parties, dinners, you name it. So we're definitely busy.

Other things have escalated too... I came with what fit into a very small two-door car. Basically my clothes, a TV, some pots and pans. Now we have a two-bedroom apartment, plenty of storage, and we are crammed with stuff. Granted we moved in together so there's two people's stuff crammed into one apartment, but I think more than half of it is mine! And we have tons of stuff in storage space too that we don't even use but don't want to throw away. It's ridiculous.

Maybe moving to a new city will be good - it'll be scary but it's a new beginning, and that's pretty exciting. :)

Family

2007-12-30T15:45:00.000-08:00

Around this time of year I suppose tons of people are thinking about family, and usually with family. I'm really lucky to have a great one, and just as lucky to be marrying into another great one.

Here's my family back in Sacramento:

And here is the family I'm marrying into - with twins in the family it is pretty much impossible to get everyone together at the same time for a group shot, but here are a few pictures of them separately:

I am super lucky to have two such wonderful families... but sometimes I wish I could be close in distance to both at the same time. I'm on the east coast right now, and there's a good chance I will be staying here for quite a long time, and my mom, dad, brother and sister are all still in California - I definitely miss them.

And get this - this Christmas was the first time they met! Not everyone - that would have been pretty difficult, but Carol (Pete's mom) came over to California to meet my family. It went pretty much as expected, which was wonderfully.

Everyone got along very well, and we had a great Christmas. In fact, I'm still humming Christmas songs, much to Pete's chagrin, I'm sure. :)

The rest of Africa in one blog entry

2007-11-28T11:54:00.000-08:00

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.

Chinese food!

2007-09-19T22:30:00.000-07:00

I’ve been dying for Chinese food! So finally tonight, I forced everyone to come with me for Chinese food at J Ma Oriental at the Riverwalk Mall! They all ordered very American dishes (like beef with broccoli, chicken stir fried with vegetables, etc.) and I guess we were planning to eat everything individually. But they came out with all the dishes so irregularly that it became family style. I ordered eggplant and minced pork, which was by far the best dish, and everyone ate mine! But that’s okay – we all ate until we were ridiculously full. We also had these good dumplings in soup, that came with this straw fungus/mushroom thing (which my mom puts in Chinese jai) in the soup.

Prisoners as Patients

2007-09-18T23:00:00.000-07:00

We were on call today and miraculously got no patients!!!! It’s the first time ever! I was pretty excited. :)

I’d like to mention a special subset of patients we have at Princess Marina – the prisoners. There is a prison near Gabs (which we actually saw on the way to the Kalahari) that often sends prisoners to us for medical treatment. There is a small clinic within the prison but I think they can only treat patients to a very limited degree – so for very sick prisoners, they send them to PMH, shackled at the ankles, along with at least one prison guard.

You never really find out what these prisoners were jailed for. Boipelo and Maggie (another MO) told us that it’s mostly small things, like theft, but occasionally there are murders (usually crimes of passion, or as they say, “passion killings”) and rapes. Sometimes if a prisoner comes with two prison guards, I think that they must have committed some more offensive crime. But we treat them all the same. They stay shackled with these old-fashioned metal chain shackles, and anywhere they go, a prison guard goes with them. Some of them are relatively healthy and walk around everywhere, while others are incredibly sick and stay in bed all the time – it’s interesting because they stay shackled no matter what, even if they’re too sick to move!

Most of the prisoners are pretty sick by the time by the time they come to PMH. I think the prison clinic does everything it can to help them and then sends them to the hospital only when absolutely necessary. There probably is a huge incentive to fake illness – PMH is like a vacation for these guys. They get mattresses, decent food, and they can even have visitors at PMH!

A high percentage of the prisoners are foreigners, especially Zimbabwean. It’s actually a big problem because foreigners don’t get the same medical treatment that Motswana prisoners do. Because they aren’t citizens, they can’t get CTs without paying (and it’s expensive!), and they can’t get free HIV or TB medications. One patient I had was diagnosed with HIV in prison a few months ago, and is starting to get these complications from AIDS. These are mostly due to opportunistic infections, like Cryptococcus, or TB, and if you get them, it’s a sign that your CD4 count is pretty low and you need to start HIV medications as soon as possible. If this patient could just start taking HIV medications, then it would be ok, his immune system would recover enough for him to fight off the infections on his own. But since he’s a foreigner, he can’t get the free medications from Botswana, and obviously he’s in jail, so he can’t make any money to pay for them. If he was out of jail, he might be able to make enough money, either here or in Zimbabwe, to pay for medications, but here he’s just out of luck. It’s a horrible situation – I don’t know how much jail time he has left to serve, but he might die in there just because he can’t get the HIV medications.

The San-people resettlement villages

2007-09-16T23:30:00.000-07:00

On the way back from the CKGR (Central Kalahari Game Reserve), Jo took us to see a resettlement village of the San-people. The San-people were removed from the Kalahari Desert years ago – maybe not physically, but many of them were told to move and intimated out of the Kalahari and relocated to these settlements where the government provides them with free water and maize, education, roads, and a variety of other free services. So now, the San-people live on 3 main settlements in Botswana, but they really have nothing to do! The government tried to teach them to farm, but historically they are a nomadic group, and there wasn’t much motivation for them to learn farming or keep up with it once the government left. There are no jobs for them, but even if there were jobs, popular opinion is that they probably wouldn’t be interested in taking them. The government provides everything for them – food, water, shelter, so there’s not really a reason for them to work or go to school.

There even seems to be a degree of resentment among the other Motswana – they say that the government gives everything free to them, and if they want to go to college, they’ll pay for them and everything, but they don’t even take advantage of these things! Instead, they sit around all day, and they make this drink called Chibuku. The San-people get free water, sorghum and maize, so they use some of it to make this very strong alcoholic drink. They mix it together, dump in some termite mound for yeast (the more termite mound, the stronger the drink!) and it only takes a day or two to brew. They’re often drunk by noon or 1pm because they just sit around and drink all day and hang out. We visited one of these Chibuku establishments (a bar) and actually got a carton. It’s not bad – a little sour and mealy, but it’s ok. It was definitely very strong. Jo said that after you drink two cartons, you’re drunk. It was only about 11 am and many of them were well on their way to being drunk. It was a little sad.

So how did all this happen? The government made up some excuse about the roads not being good enough in the desert, so the San-people had to move (not that the San-people used roads anyways, or not that the government couldn’t have build the same roads that they built for the San-people’s resettlement out in the Kalahari). The rumor is that the real reason the government relocated the San-people is diamonds, which were discovered in the Kalahari. Some of the San-people have won the rights to move back to the Kalahari, but now the government is saying only those 200 or so whose names were on the legal suit are allowed to move back. So they had to sue again, saying (rightfully so) that they represented all of the San-people. They eventually won, but by that time, the government had been providing so much free stuff now to them that only the older people want to move back. The young ones just want to stay on the resettlement grounds and stay drunk. It’s a very sad story.

Camping in the Kalahari!

2007-09-16T05:40:00.000-07:00

We went camping in the Kalahari this weekend! Joanne, Amy, Jeremy and I went with Johannes (Jo), a guide that works with Tim. It took us 3-4 hours to get there, we had lunch at the campsite, and set up our lion-proof tents. We were staying in Khutse game reserve, which is connected, or adjacent to, the huge Central Kalahari Game Reserve (CKGR) – the largest game reserve in Africa.

We had a huge lunch – quiche, salad, other things – and then went on our first game drive. We saw a few funny things, but no huge game. We did see this huge flock of vultures near the air strip – very impressive. Of course, we saw many springbok and steembok, some oryx gazelle, these cute ground squirrels that ran fast everywhere and use their tail to shade themselves. And we saw a ton of birds – the lilac-crested roller, hornbills, some weavers, and the kgori (or kori) bustard (which we were saying bastard the entire time) – apparently it’s largest flying bird in the world. We also collected some firewood and saw a beautiful sunset! Here are just a few pictures of the things we saw:

Vultures

Ground squirrel

hornbill

kgori bustard

After we got back, Jo made dinner. It’s funny – there were 3 Jo’s on this trip so it was very confusing when Jeremy or Amy tried to talk to one of us. They would say Jo, and three heads would turn. Dinner was delicious – we had steak, garlic bread, and green beans with pap. And we also had chocolate cake for dessert. We sat around the campfire for a while, and eventually crawled into our tents. I slept with Amy, Jeremy slept alone, and Jo(anne) slept with Jo(hannes). J We were a little afraid of lions – they often go right into the campsite at night although they stay away from humans for the most part. So I didn’t make it out to the drop toilets all night because I was so worried! I think that was a good decision because apparently campsite 5, which was right next to us, had a lion visit them!

We went on another relatively uneventful game drive the next morning after breakfast, and Jo took us to a relocated village of the San-people (they’re also called bushmen, which is derogative, or Basarwa, also derogative since it literally translates to “stick-people”). I thought it was the most interesting part of the trip, but it’s a pretty sad story. I’ll talk more about it in the next blog entry. After visiting the San-village, we stopped at the Khutse Lodge, which is right on the border of the Khutse Game Reserve, for a light lunch of sandwiches and salad. We were there for a couple of hourse, so we went swimming in their pool to cool off, and then drove home. Even though we didn’t see any big game, it was still a great experience, and I’m totally glad I went. It was so quiet and beautiful out there. I think it was a good preview of what our safari will be like…

My team at PMH

2007-09-14T23:30:00.000-07:00

We were on call tonight and got a lot of patients. We have a new MO – Mpho Mpape. She’s not very good. But she’s pretty good at doing scut. She disappeared for like 3 hours in the middle of the day. But I guess then she stayed late (only until about 5) doing stuff.

There was a little tiff at the end of the night – Boipelo came on for call at 9pm and found a chart on the female side that said the patient was in the ward at 7:30pm and she got all mad because she had not been admitted yet. She got upset at Amy, the resident who was on call on the female side, and also at Shabnam, the Indian MO who is on call until 9pm. But both of them said they had not seen any new admissions! It’s interesting – the MO’s are very strict when it comes to whom new admissions are clocked by and which team new patients are assigned to. It makes sense – they don’t want to do any more work than absolutely necessary. In this case it turns out that Amy had already clocked this new admission but the nurses lost the admission note and so put the file back into the new patient box. So Amy was able to find the lost admission note and put it back in, but people were still aggravated at each other.

In general, I think my team is great, even though it’s the smallest one. We have as much work as every other team, but for some reason we don't get any new students, residents, or interns! At least so far it has been manageable. Boipelo (our MO) has always been there, although she’s taking the next two weeks off for vacation, starting Monday, and is being replaced by Mpape. She’s actually on call tonight. Not all the MO’s are that good, but she’s pretty good, even though she definitely has an attitude and is pretty cynical. She also works pretty hard. The work ethic is pretty interesting around here. Most of the Motswana MO’s and some of the doctors work relatively slowly, compared to the doctors in the U.S. It’s just a different pace – they tend to take 1 hour lunches (at least) and they don’t rush to try to get everything done. If by 4:00 pm there are some things that are left to do, they just leave anyways. They just try to get to the most important stuff early in the day. This I understand, but not necessarily agree with. There is just so much to do that sometimes one person just can’t get to it all. I do get frustrated on occasion, because there doesn’t seem to be a need for 1-2 hour lunches when you can be working on patients!

I think especially on the teams that have Penn people, the MO’s have a lot less work to do because the Penn people are “extra”. And on call nights when Penn people are on call, the MO’s tend to take off early or disappear, because we are also “extra” help on those nights. It can be really frustrating – often, an MO will just disappear for hours at a time because they feel there’s someone else there to do the work! Some of them are really starting to take advantage of us, and the MO’s are starting to fight to be on teams that have Penn people so they don’t have to work so hard. It’s annoying, because although we are there for patient care, Penn people rotate in and out, and we don’t always know the correct way to do something, or what resources are available to us. And more importantly, we can’t speak Setswana, so we need those Motswana doctors and MO’s to help us translate! It’ll be interesting to see how this plays out in the future because I don’t see it getting better unless there’s some kind of intervention.

Each team also has a specialist, who is equivalent to an attending in the states – they make the big decisions and do a lot of teaching. For my team, the specialist keeps on changing. The first two weeks it was Dr. Stefanski, the next two weeks it was Sarah, and now it’s Shanthi. They all do quite a bit of teaching, and are all very good (not all the specialists are good) but I think I liked Sarah the best because she knows how the hospital works and helps us out with the work after rounding. Shanthi will probably be like that too, but she’s relatively new, and is still learning the system.

Below is a picture of my most recent team – it’s Boipelo, Sarah, and I.

Decompressing

2007-09-13T00:29:00.000-07:00

It was a busy day today and we barely had time for lunch because we had 10-11 admissions overnight that were done for us by the MO on call. There were 3 of us working though, so we made it through but were running around all day.

We needed to decompress, so a few of us (Sarah, Amy, Joanne, Jeremy and I) went to the Bull N Bush for dinner, which is a nice chain. It’s a pretty busy bar and club too on Friday nights, but I never went when it was really active. I had a great burger with mushroom sauce here, and we took these funny pictures with a cross-dressing cow statue. In general, I think I’m starting to get tired and worn down a bit – when we got home, Jeremy and I started Skyping each other even though we were in the same room and I thought it was the most hilarious thing ever. And we only had one beer at dinner! :)

Food at Princess Marina Hospital

2007-09-12T22:30:00.000-07:00

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

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

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

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

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

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

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

Children of Men

2007-09-11T23:31:00.000-07:00

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

Arranging travel plans at Game City

2007-09-11T17:00:00.000-07:00

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.

Food and Jazz

2007-09-08T23:30:00.000-07:00

It was a day to eat! We went to this place called Sanitas for brunch, which does pretty well in providing good American-style brunches. It’s actually a tea garden and horticultural center, where you can buy lots of different plants and gardening supplies. In the winter,

Botswana

is very dry and brown, so the lushness and greenness of this place is a welcome change, although it probably requires ridiculous amounts of water to keep it that way. At any rate, after eating, it was fun to stroll around and look at all the different things in this large outdoor store. And we also got gelato from their counter, even though we stuffed ourselves during brunch. :)

During the day I tossed a Frisbee around with Amy and Phil. Amy actually was quite good – she said she used to throw a Frisbee in summer camp. It was pretty fun until one of us threw it into the bushes near our apartments. All the bushes have these super sharp thorns, and two of them actually pierced the Frisbee! We used pliers and still couldn’t get them out! Eventually we were able to cut off the ends and file them down so there was no longer any protrusion from the Frisbee, but the little bits of wood were still embedded in the Frisbee. Crazy.

Then for dinner, a few of us went out for Ethiopian food. It was this place located at the Riverwalk mall that Dr. Gluckman recommended to us. They had a buffet which consisted of chicken with egg, beef, lentils, some other vegetable, and of course, plenty of that spongy bread, injera. Unfortunately I wasn’t very impressed – I think I like the Ethiopian food in West Philly better! It wasn’t as spicy as I’m used to it being, and the bread wasn’t sour like it normally is! I think the Ethiopian food in West Philly is actually more authentic, since there are a ton of Ethiopians in that area. I’m willing to bet that the Ethiopian food here has been tamed down a bit for the Motswana.

After dinner, a few of us (Lisa, Amy, Joanne and I) went and joined Kristy, Kiona and Phil at Botswana Craft for a jazz concert. The band playing was called Punah, and I guess they are known to quite a lot of people, but are not really super famous. It was a ton of fun – after a while, we joined in the dancing with the locals who whole-heartedly welcomed us. There was dancing in groups (like in the states), dancing in a circle (I think there were specific steps to this, but we certainly didn’t know them), and dancing in sync with specific movements, like the Macarena (which I could sorta do after watching and miming the other dancers for a while). Most of the dancers ranged from 20-40 years old, with the young men being pretty entertaining to watch. However, there were these two old men (probably in their 60s) dancing and they were hilarious! Their moves were very… original. One of them had very jerky and deliberate movements, like those men in the parks painted in silver who pretend to be statues and move robotically when you put money in their can. Joanne took some video, and I’ve got to get a copy of it. :)

The band Punah was also very good – I definitely enjoyed their music. Kristy bought their new CD and unfortunately it came damaged, but I burned what I could onto my computer. Funnily enough, several days later I was walking through the Main Mall, where there are tons of street vendors out at lunchtime, including ones that cell CDs and DVDs. I heard music being pumped out from one tent, and I said, “that’s Punah!” and the vendor was surprised and said, “Yeah, that’s Punah!” And he asked if I wanted to buy it but I said I already had it. Even though it wasn’t a huge crowd that night at the jazz concert, I guess their music is relatively well-known.

Water in Gabs

2007-09-07T23:00:00.000-07:00

We went to the yacht club today after work, and enjoyed a gorgeous sunset. I went with Amy, Michael, and Michael's fiancee (whose name escapes me at the moment). It's set over the Gaborone dam, and people can take boats out on the small lake. The yacht club itself is pretty nice - the clientele is almost entirely made up of ex-pats. They serve plenty of alcohol, and some food that they mostly warm in a microwave or grill. Apparently it gets quite crowded on friday and saturday nights usually, but tonight was unusually calm.

This dam provides most of the water for Gaborone and the surrounding area. Right now, the lake is super super low, which you can see by the water line. Last year, Gaborone (and the rest of southern Botswana) experienced a severe drought - they had a ridiculously low amount of rain. I think it was 2.5 cm or something like that for the entire summer. And the couple of years before that was not great either. I think the last time they had great rain was 4-5 years ago. And before that good year, there was a drought for a period of years as well. So it's been relatively dry for southern Botswana for the last decade or so.

As a result, a lot of people have stopped farming and are trying to eke out a living doing other things, usually in urban centers. Cattle look really skinny because there's nothing to eat, and livestock of all sorts are not doing well. It rained for about 5 minutes during our braai last weekend, and everyone was jumping for joy. Rain and water is so important that the word for rain, "pula," is also the word they use for money. That's also what you say when you raise your glass in a toast, like "Cheers!"

Hopefully this year Botswana will get lots of pula!

The supply chain in Botswana

2007-09-06T23:00:00.000-07:00

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.

Tele-dermatology at PMH!

2007-09-05T20:00:00.000-07:00

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

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

The Patient from Zim

2007-09-03T23:00:00.000-07:00

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

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

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

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

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

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

Mokolodi Game Reserve

2007-09-02T20:30:00.000-07:00

Today we went to Mokolodi game reserve, which is just 20-30 minutes away, still really a part of Gaborone. It’s not nearly as wild as Tau, but it was still pretty fun. It’s probably about 1.5 times the size of center city in Philadelphia, and it’s a little more zoo-like than Tau. The animals are still wild, but they are tamer, and there aren’t as many predators. They don’t have any lions, and they only have 4 elephants. On our game drive, we of course saw tons of game, but our guide was not nearly as good as Hein from a week ago. She tended to blaze past the animals and recite memorized bits of trivia about the animals. I didn’t get the sense that she knew a whole lot about the animals other then the stuff the game reserve probably gave them to memorize. Nevertheless, it was pretty cool.

We saw tons of kudu and other deer-like animals, likely springbok and steembok. We also saw this baby rhino with its mother, which I took a million pictures of. I think Aaron and Jacob (Pete’s nephews) will love this picture – I can’t wait to email it to them! We also came upon this giraffe just by the side of the trail munching on a tree. This was very cool, since I’d never seen a giraffe so up close before. We also got to see their 4 elephants – they had one male and 3 females. The male one was definitely bigger than the rest, but was chained, and they had a staff of about 3 people watching over the elephants, I guess to make sure everything stayed okay as people came by in the safari vehicles to gawk at them. It was a little sad, actually. Although it was super impressive – they came within an arms reach away, and they (rather angrily, I thought) started ripping to shreds this massive tree right next to us. They were reaching above our heads to the branches and pulling them down! It was amazing! And we got close-up views of their tusks and their mouths, and just how strong their tusks and legs can be. Pretty scary, actually.

Finally, one of the highlights of the trip was that I got to pet a cheetah! There were two male cheetahs that were in this large fenced enclosure. Apparently their mother died when they were very young, and the only way they were able to survive was being bottle fed by humans. So they got used to humans at a young age – although they’re still somewhat wild. So now, they feed them every day at 2pm, and around 3 or 4pm, they’ll bring a small group of tourists in to their fenced enclosure to pet them! I wasn’t going to do it at first. It was an extra P100 to pet the cheetah, and I was just going to watch other people do it. But in the end I figured, eh, it’s an extra $16 and I don’t want to walk away from this regretting not going to pet the cheetah, even if it is super touristy. :) However, I think Phil put it in a pretty funny way: “why would I pay an extra $16 to go get my hand bitten off?” I thought that was hilarious, but maybe you had to be there.

So it wasn’t quite as I expected. For some reason I had in my head the idea that we would be petting the cheetah through a fence, or that there would be a trainer there holding them or calming them or something while we petted the cheetah. Not so. Our guide unlocked a gate to let us into the first fenced enclosure (sort of like a foyer), and then unlocked another gate to let us into the second fenced enclosure, which was large, and was where the cheetahs were. The cheetahs were prowling around, and eventually lay down in the shade of some bush. We went over to them, and the guide said to go up one by one, and avoid petting the paws and the tail. She went up first and petted the cheetah, and then we all did it. One cheetah was feeling feisty I guess and didn’t want to be petted, so we petted the other one.

There were these two Indian guys on our safari who I swear deserved to be eaten. They were so intent on taking pictures and everything that they seemed to forget that this was a CHEETAH. They were kinda like that the entire trip – almost jumping out of the jeep to take pictures, and being totally touristy. I mean, I know I’m also a tourist, but they were a little obnoxious. Anyways, during the cheetah petting, we were mostly petting one cheetah because the other one was a little grumpy. The two Indian guys kept on almost stepping on that cheetah’s tail because they were too busy taking pictures of them petting the other one. And the one that we were petting, they petted it too hard or something, because it took a swipe at one of the Indian guys. I’m sure it was just a little annoyed and doing the equivalent of batting a fly away (if he had really wanted to hurt the guy or attack him, I’m sure the cheetah would have), but the Indian guy didn’t seem to realize it! He dodged backwards, but then went back for more petting! Then the cheetah reared its head, and looked at the guy, who finally seemed to get the picture.

Anyways, it was a fun trip overall. We hung out in the Mokolodi restaurant for a while afterwards, drinking some beer. It’s supposed to be one of the best, or maybe the best, restaurant in Gabs. I think they changed chefs recently though, so I’m not sure how it’s supposed to be now. I know that some of the Caucasian doctors go there for special dinners. They also apparently have more exotic things on the menu, such as kudu, and their steaks are supposed to be amazing. I wanted to eat there for dinner, but I think some of the other people either didn’t want to eat out or wanted to go home. It’s expensive by Gabs standards, but definitely not by American standards – it’s probably about P80-120 for an entrée (which is about $15-$20), and drinks are relatively inexpensive. But that’s okay. I’ll try kudu eventually.

Speaking of kudu, while we were sitting out there on the restaurant terrace, they had set out some grass for animals to come and eat, and we saw a few warthogs and a lot of kudu. This family of kudu seemed to come up – one male and several females. Then we saw another male kudu a hundred feet behind, who seemed a little hesistant to come forward, probably because of the first male already there feeding. Eventually he came up, and we thought they were going to fight! They lowered their heads and met horns softly several times, but didn’t end up fighting or anything. I think it was a way of greeting each other or making sure everything is okay. It was pretty impressive and I got a few good shots of them greeting each other with their horns.

The hospital crowd

2007-09-01T17:00:00.000-07:00

So more about the patients and the hospital… Working at the hospital has definitely been an interesting experience! The patients here are so different from the patients in the

U.S.

There are usually 8-10 patients in a cubicle, with about 5 cubicles in each ward. Often, a small office gets turned into a 6th or 7th cubicle to cram another 5 patients into. Sometimes patients don't even have a bed, they have a mattress on the floor, sometimes in the hallway, if it's too crowded. The ER never closes because the hospital is too full, you just squeeze more patients in. There is absolutely no privacy - you're lucky if you get a curtain to draw around a single patient. You do procedures at their bedside, often with other patients looking on. The picture below is one of the better cubicles (the "high-intensity" cubicle for sick patients - which is right in front of the nurses station should a patient need immediate attention) on a very uncrowded day. There are no patients on the floors and there are a good number of curtains up.

So the patients are crowded together, usually not more than a foot from each other, they have no TV, no books, nothing, and visiting hours are only from 6-7:30am, 1-2pm, and 4-5pm and 6-7:30pm every day. And surprisingly, the hospital and the nurses are very strict about the hours. So right at 1pm, all these friends and family stream in, and right at 2pm, they leave. They're actually sort of necessary because the hospital is so understaffed that often the family helps bathe the patients or feed them if the patients can't feed themselves. The patients come in pretty sick too, because they often don't want to go to the hospital until their symptoms are super bad. Despite all this stuff, the patients rarely, if ever, complain. They just sit there everyday and wait patiently for us to come see them, and to get better. It's such a change from the

U.S.

patients, who have such a sense of entitlement, and demand every little thing, even things like mashed potatoes for dinner or something.

Patients rarely sue anybody here, and they put up with a lot more crap than do patients in the U.S. I guess that’s necessary because I think mismanagement of a case is pretty common. I think there are a variety of reasons for it – number one being the fact that the hospital is way understaffed. There are not enough doctors, nurses, social workers, physiotherapists, anything you could possibly think of. I also believe (and this is almost definitely egocentric) that the doctors and nurses here are not as well-trained, and so there is some medical mismanagement because of that. The Penn people are very good, but the other doctors sometimes are just here to do their job and make money (not that it’s a huge amount) – they don’t put in the effort to learn, teach, or really help patients get better. I’ve seen so many patients come in with congestive heart failure get put in fluids, or people with focal brain tumors that are obvious on physical exam, get diagnosed with meningitis. It’s a little embarrassing sometimes. Of course, when you get 10 admissions in a night, and are covering 100 other patients, sometimes it’s difficult to do an appropriate workup of a patient. But still, the lack of knowledge can be appalling.

There’s this one M.O. (a doctor who has only finished internship only) the other day who was getting grilled about a patient during intake as she was presenting. The patient had right upper quadrant abdominal pain, and she gave her differential diagnosis as pneumonia. Horrible. When the chief of the hospital asked her what else it could possible be, she could only answer pneumonia… so then he asked her what organs might possibly be in the right upper quadrant. She said spleen. And that’s all she could come with. And this is a doctor! Awful.

The nurses here are also very different. They don't do much here - they don't do IV's, blood draws, put in foley catheters, etc., so you have to do it all yourself. Believe it or not, I actually miss the nurses at HUP. :) I guess some things are still the same – some nurses and good, some are nice, some are moody, some refuse to do anything. There’s a whole variety.

The diseases we see here are different too - we see a ton of HIV and advanced AIDS-related illnesses here: TB (which can be anywhere), cryptococcus (which can be anywhere), PCP pneumonia, different cancers. I'd say about 75% of my patients are HIV positive, which allows a lot of this other stuff (TB, PCP, cancers) to happen. Botswana actually has a free HIV medication program (which is a whole separate topic for a different day) for all of its citizens. Even so, many of the patients refuse to take their medications and instead take traditional medications. They’ve caught patients throwing their medications down the toilet or in the trash before. And sometimes these traditional medications – we have no idea what they are – cause kidney failure or liver failure! I guess that’s the most frustrating thing about these patients, even though they are super nice and appreciative, and their families are by and large amazing in terms of support.

In general, there are so many patients you just can't take care of all of them - some stuff just has to slip through the cracks and you have to let it go. You're already working twice as hard as many of the

Botswana

doctors and at some point you have to go home, but that means some patient is probably going to die. Luckily I didn't have anyone die on me for my first two weeks, but it's really just luck - almost every team has an average of one patient die every day or two. I will probably have a patient die on me this weekend because there’s less care during the weekend. There’s usually two people covering all 100 patients, and they are really only required to see the sickest ones. It’s also difficult if they admit 10-30 patients over the weekend to see the other sick patients already on the ward – they are just so busy! However, other people just don't take as good care of your patients than you do when you're actually at the hospital. And any signout you give to the covering doctor doesn't usually get done, but it depends a little on who you sign out to and who’s covering the weekend. I guess these things are just things you have to let go because you can’t be at the hospital all the time.

Getting things done at PMH

2007-08-31T14:39:00.000-07:00

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.

The patient wards at Princess Marina Hospital

2007-08-30T20:30:00.000-07:00

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.

Dialysis

2007-08-29T23:00:00.000-07:00

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. :)

TB patients

2007-08-28T21:00:00.000-07:00

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

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

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

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

Back to work again....

2007-08-27T19:00:00.000-07:00

It was time to go to work again, which was a bummer after such a nice weekend. Plus my team had a ton of patients after last week. Up to 20 patients were on our list, and my team is just Boipelo and I! I believe all the other teams have at least 3 members to do all the work, if not more. And we had to round twice because Dr. Stefanski didn’t know he was still covering for Sara. So Dr. Gluckman sorta rounded with us, then Dr. Stefanski rounded with us again when he got back late morning – we didn’t really finish rounds until 3:30!!! And we had very little time left to do all our work. It was a little frustrating. But Phil helped me out by drawing bloods quite a bit at the end. I guess it was his way of paying back all the help I gave them earlier. Hopefully those will go through and I’ll get results because the computer system for ordering labs was down… I had to manually fill out requisition forms, and those don’t always work. :(

When I got home, I got motivated and made a beef stew with carrots and onions. I didn’t use potatoes because I like to put it over rice. But I usually thicken it with corn starch, which I didn’t have, so I used flour – that worked pretty well, but I got impatient and didn’t put enough flour, so it’s more like really thick soup than stew. But it’s still good. The flavor is great, but some of the meat is pretty tough. But some of it’s soft. So it’s still good. :)