Merry Christmas!!

Just remember, I get to open my presents about 16 hours earlier than my brothers...

:)

Merry Christmas!

Apologies for the blog delay-- been trying to work a few things out here in prep for heading back home. Apparently, I'm in need of a "career." Who knew?

In any event, the days have brightened up and here the solstice in December is the longest day of the year. Back home, my brother is dealing w/ mountains of snow in DC. In HI, my other brother is I'm sure doing just fine (sigh!).

The TED website really is fantastic and I wanted to share the following link:

http://www.ted.com/talks/ryan_lobo_through_the_lens_of_compassion.html

We'd heard all about General Buck-Naked while in Liberia, though I never met him (obviously).

These are a few pictures from around the 'Merican Thanksgiving table:

And here are a few of the DEM Christmas Party:

Time has gotten away from me and I need to head in for another shift. Things are a little tough @ the hospital now w/ staffing issues, so that's an excitement. I'll likely be off camping for the actual Holidays (nothing says "Christmas" like scraping a leech off your skin w/ the back of your knife...), but hope everyone enjoys them at home. There's a postal strike on in Aussie now, so I'll pretend that's why I haven't gotten your presents in the mail!!! :(

cheers, --aws

Royale with Cheese...

It's just the little differences, really. McDonald's is referred to as “Macca's,” Burger King as Hungry Jack's. The big things missing from my diet? Cherry coke zero, Diet Dr. Pepper and good sushi. No great loss, I hear some of you say, but do not underestimate these things. However, one awesome thing about the sushi/Japanese restaurants--

Yup, little plastic fish-shaped soy sauce capsules. They are awesome. And re-sealable.

In terms of the DEM (dept of Emergency Medicine, vs. ER or ED), there are also quite a few useful terms I've added to my vocabulary. My personal favorite is “acopia” (pronounced “a-cope-ia”), used to designate someone or someone's family member unable to deal with their issues (sometimes medical, often not) at home. It was apparently at one time an honest to God diagnosis that they would enter into the computer before a memo put an end to it-- formally at least. It's equivalent back home is my favorite (or, favourite) FTC for “failure to cope,” applied to patients in the same situation beyond the age-range of the more traditionally accepted “failure to thrive” diagnosis. Close seconds are the expressions “fronto-palmal” and “fronto-dorsal” to describe Pt “affective types”:

And the ever-popular “haema-chuk,” or what is spilled onto the floor when an upper GI bleed makes itself apparent. As an aside, to “root” for a team is an expression that has a very different meaning here and should probably not be used in polite company (though I'm curious to see what it would look like in practice...). To say you're a fan of a certain team in, Australian rules football, for example, you would say that you were a “supporter” of that team. “Root” is the unpleasant and impolite equivalent to “shag.” Similarly, “how are you doing?” is here “How are you going?” (how is “it” going does not exist), but I just can't get it in me to say, “I'm going well.” Saying so makes me feel like I'm making good time on some sort of river voyage. Not sure why.

Oh and a few other things. This sign is up in the utility room in the DEM. I tried to get it in focus, but it didn't come out right. It is a conversion chart for converting between kilogram and, wait for it, stone. That's right-- stone. As in, “He probably weighed about 13 to 14 stone.” I just have images in my head of a code in which someone is calling out drug dosages in “mgs/stone.”

For those of you who are fans of The Daily Show, you may recall their “Pantry of Shame,” which includes microwavable blueberry pancake-wrapped sausages on a stick and something called “Baconaise,” which is mayonnaise w/ bits of artificially flavored bacon already mixed in. Well, I saw this ad for Beconase, trade name of an inhaled nasal steroid, and couldn't help the mental

connection (much like the Ceylon industries bakery that produced the chocolate cookies mentioned in a previous Liberia post...).

I showed a co-worker here a section of my blog from back in Liberia that had my photo on it, and came in to sign out the next day with this as the computer wallpaper:
Apparently there's a website where you can upload your pictures and do things like this to them. With friends like these, who needs friends, right?

For those interested, I saw the group Tripod the other day on television. Like it sounds, three guys who do music and comedy. I noticed them while in Melbourne when I came upon an ad for their performance of “Dungeons and Dragons: the Opera.” I couldn't go because of my work schedule, but was really close to shelling out $300 for last minute plane fares... Anyway, they may be playing this upcoming Friday and I hope to swap shifts around to head out there. Some of the lyrics from the tv performance I saw follow. Imagine sort of a jazz quintet doing a little bossa nova number, the lyrics to which describe the lead singer's anxiety that as a bookish geeky technophile he likely does not have the skill set to compete under the new conditions created by the collapse of modern society...

“...when the polar icecaps melt and the oceans rise / just like in Waterworld, well / I'm pretty sure I don't have the upper body strength / for all that much rowing.”
“...And even if the post-apocalyptic dystopian wasteland of the future / isn't exactly like Mad Max, /
there'll probably be a healthy amount / of fending off marauders, / and I'm not very good / at
fending off marauders.”

Speaking of marauders, I awoke one morning to find this bad boy trying to die on my oven range:
He is a fine specimen of what I believe to be a “huntsman” spider, one of the rare varieties of Australian flora/fauna that are not imminently deadly to humans.

Interestingly, 10 of the 15 most dangerous snakes in the world live in Australia. Clearly, God does not want us here... :)

For the medicos out there, this is an interesting piece on the over-importance placed on medical care and documentation done for “medico-legal” reasons. I agree with his point, but the problem is as long as there's someone out there who's willing to say this or that to make a buck (which is always), it's going to be a long road to hoe.

http://journals.lww.com/em-news/Fulltext/2009/11001/The_First_Great_Lie.3.aspx

And this snippet is from the article referenced below which itself is extremely moving. But I enjoyed the emphasis this little bit puts on how our job changes our perspectives on things. Most people's jobs don't involve people dying every day, or pregnancy losses or broken relationships (“No, Miss. Regardless of what he told you, trichomonas is not something you 'just get' from having sex. Well, people who have sex with him could 'just get' it I suppose...”). I don't know-- for me personally it's led me to be a bit of a nervous Nellie when it comes to crossing cross-walks or having first aid kits and fire extinguishers in the car or not drinking on nights I'll be driving. But I also hope it's made me appreciate those moments I have with the people in my life, be more straight forward and up front about some things. Certainly this little bit is a reminder to be understanding of the people who've not had the same experiences you've had. The author is finishing describing the passengers/family involved in a collision in which one of the parents has died, and the other was driving intoxicated.

“The son has abdominal pain, which ultimately proves to be from a small bowel perforation. One laparotomy later and he's fine. (The most traumatic event of his life, possibly ever, and it warrants only 2 sentences. The ED has shifted my perspective so far that my own kids won't come to me for their minor [“trivial” to me] injuries. “Dad's only interested if there's an exit wound,” they say. This can't be good for me, my family, my patients.”

JR Suchard. Unhappy Birthday. Annals of Emergency Medicine 54(4). October 2009, Page 627

Finish off with some pictures of the Gorge, where the kayak championships were held recently, and a view of the North Esk River as it comes in to the Central Business District of Launceston.

Nice to have a little appendicitis to finish out the day

The past few days have been a little rough for a few reasons. I have to admit I'm not a huge fan of being the doctor to people I know or co-workers. It almost never goes well because you know the person, and even when it does it makes the follow-up awkward or difficult. One of the things about DEM is that it is not kind to those who re-think and wonder if they've made mistakes. Because, let's be honest, they probably did. I like the passive voice that makes its way into medical documentation. It seems like an attempt to diffuse responsibility in poor outcomes (ie “the bowel was entered inadvertently during the procedure”) in the process destroys physicians' writing abilities. Eschew the passive, say Strunk and White! So, it is kind of nice when you have a clear-cut case that you manage well-- like an appendicitis-- probably even more so than a tough case that you finally figure out after a lot of work. Poetry in action...


"But then there are the other times, when everything goes perfectly. You don't think. You don't concentrate. Every move unfolds effortlessly. You take the needle. You stick the chest. You feel the needle travel -a distinct glide through the fat, a slight catch in the dense muscle, then the subtle pop through the vein wall - and you're in. At such moments, it is more than easy: it is beautiful." –Atul Gawande from Complications


Recently went down to the local fair (“show” here). I keep telling people Tassie is a little like WV, where I'm from, and the show more or less proved it. It was a pretty typical fair situation, with little portable rides and toss-and-win games. But what was a little extra awesome was the agricultural flavor to it. There was a dog show that breeders came from across a few different states in Tassie. Favorites included the huskies and the Tasmanian “labra-doodles” (hypo-allergenic & non-shedding, apparently; http://www.labradoodle.com.au/ for those interested). Also ideal were the “suspend your child from bungee cords over trampolines,” the wood chopping competitions, the chainsaw sculptures, and the horse jumping (English saddle). Some of the pictures are attached.



Also, with all the rain down here, it had to happen sooner or later....















In other news, recently found out that an Attending and friend from my residency passed away. In the words of another good friend via email, “in case you haven't heard, today the ground shook.” This doc was one of the first EMTs that graduated through the NY training system, then went on to be one of the pillars of the system where I trained. No graduate from our program was untouched by his personality, or failed to tighten up their sign-outs when he was the one coming one-- and that included the grads who had become Attendings! One day I was wearing striped socks and working alongside him. Another Attending approached and asked “Did you see the guy with the shoulder?” His response? “Ask Dr. Seuss over there.” I remember in particular an episode when I was running Fast Track cases by him. A schizophrenic patient was there for unrelated complaints, but he seemed a little disorganized and distracted, though not actively psychotic. Still with vestiges of my undergraduate empathetic self intact, the conversation went something like this: “This guy seems all right, but I don't know-- there's some things that are a little off, he's got some flight of ideas and loosening of associations...” “Christ, the guy's not suicidal or seeing monkeys or anything, send him out!” Thus was born the eponymous “Sensori-neural Simian Criterion for Patient Reliability,” which I've used ever since-- anyone seeing monkeys should probably not be discharged.

So, in honor of Dr. Gary Lombardi, I'll post a few of the thoughts I've had when thinking about the best of my profession. I'm sure Gary would make fun of me for it...

First and foremost, EPs have to be physicians. But their most important contribution or skill, unlike surgeons (surgery) or ophthalmologists (eye exam/Rx) for example, is communication. EPs are resuscitation specialists, certainly, but surgical resusc is also in the purview of surgeons, medical resusc in the realm of internists or intensivists. So, while the spectrum of the initial management of critically ill patients is certainly our emphasis, it is our personal skill at communicating during and about the care of the critically ill, or potentially ill, or not-so-ill-but-think-they-are that sets us apart as “good” doctors or not. As team leaders during a resusc, patient flow managers in a crowded department, providers of potentially critical patient assessments to consultants over the phone, re-assurers to patients being d/c'd, it is our ability to manage information and risk, in situations in which both can be incomplete or unknown that others count on. We are the improvisational obstetricians and the midnight therapists. We are the weekend dermatologists and the after-hours sonographers. We know which pills and why and will make sure you get them. We will get the iv, the pain medication, the tube, the turkey sandwich. We are emergency physicians, and you will do our best to get you our best.


-------

As an addendum, the following anecdote was emailed to a list of graduates of my program by one of the same. It's spot on. --aws

Gary Lombardi was an imposing individual, a bit hot-headed at times, and fiercely protective of his staff. One night, about 2:00AM or 3:00AM in the middle of a very busy shift, a gentleman was acting in a somewhat menacing and combative manner toward the staff. When Dr. Lombardi heard about it the veins on his temples throbbed and he started pacing about urgently. Finally he went over to the cube, threw the curtain open, glared at the gentleman lying there, and shouted, "Do you have a problem? Maybe you want to share that problem with me! What do you say? You want to share that problem with me?" The patient was stunned into silence.

Several minutes later one of the nursing staff tugged at his shirt. "That was the wrong one. It's the guy next to him, the one to the right of him." More pacing. Veins nearly popping now. He went over to the neighboring cube, threw its curtain open, glared at this new gentleman, and shouted, "Do you have a problem? Maybe you want to share that problem with me! What do you say? You want to share that problem with me?" He too was stunned into silence.

Then he leaned back a bit, glanced into the first cube, opened up the curtain about half way, stared at the first gentleman, the one whom he had mistakenly addressed that first time, and said, "And I'm keeping an eye on you too, buddy."

Oh, how I miss the Bronx! And Gary Lombardi. How I miss him!

For medical practitioners only...

So clearly this is terrible. And obviously me finding this even a little bit funny means I am a terrible person. But, I mean, _come ON_!!!

Emergency response pendant implicated in cases of strangulation, FDA warns.
MedPage Today (9/23, Petrochko) reported, "The Philips Lifeline brand of emergency response pendant may strangle its wearer if it becomes snagged, the FDA cautioned." This holds especially true for "patients who use wheelchairs, walkers, beds with guardrails, or other objects that could entangle the object." Already, "at least six occurrences of serious injury or death have occurred since 1998 when the device's cord became caught on something."


Sigh...

Merrily We Go Along...

Huh. Not much to tell recently. Working a lot because several of the other Registrars have asked to switch shifts w/ me to take exams and so on. I've been doing a few things, including my first solo Bier's block the other day. Getting the system down at work. To be honest it's still a little odd to me. “Bacteremic dialysis patient? Sure, give him some vanco and I'll follow it up in my office.” I guess you can handle it that way... And mental health services in Tassie are just beyond my understanding. Oh, the view from the hospital toward my house...

Let's see-- what else? The Daily Show is back on the web; every few days I watch an episode of Battlestar Galactica on mail-order DVDs. Finished a book a friend gave me about an emotionally distant physician who can't make a romantic commitment and then contracts TB (yeah, some people are hysterical). Made it to lesson 7 on “Introducing Guitar: Book 1,” which is just beyond “Mary had a little lamb,” though here the tune is called "Merrily We Go Along." The cold/swine flu/pneumonia complex has gone, and I'm now no longer short of breath walking to and from work, so I'll start exercising again (goal: 9:00 min mile for ½ marathon...). The ants have been subdued and a study schedule posted. Plans have been made for my first trip to Melbourne for a medical procedures seminar. Now, time to get a car to see about doing some hiking here in Tassie-- already marked some trails.

Attached are a few pictures of the environment. Many houses have this elaborate trim which is apparently typical of Victorian architecture (and knowing is half the battle). What I love is the one for sale sign that mentions the benefits of "Inner City Living." That's awesome.

All's well so far. There are definitely some frustrations at work, battles that should've been fought, etc. But all in all it's not too bad. Now that I'm feeling a bit better, it's time to do some exploring.

For those who don't know, a little wisdom from Queen and Bowie...

'Cause love's such an old fashioned word

And love dares you to care for

The people on the edge of the night

And love dares you to change our way of

Caring about ourselves

This is our last dance

This is our last dance

This is ourselves

Under pressure

Cheers,
--aws

Down time

So, still under the weather in Launceston. Not so good. Being sick sort takes the wind not only from your lungs, but also from your sails... The good part is that sleeping all day is easier in Lonnie than in NYC. No one's jack-hammering or refurbishing next door, so that's good.

As a result of not feeling all that well, been spending a lot of time on the internet at my favorite sites. For those interested, I've copied the links of a few of my favorite TED talks below. Don't know TED? Seriously, check it out. It's part of why having an internet make sense!

Also, in keeping w/ my first post ("Questions of Travel"), I've copied Robert Service's "The Men That Don't Fit In" below as well.

In terms of work, I guess I really do like the procedures and so on better than the rest. We (finally!) had an intubation the other day and I was so happy! Unfortunately, because the closest required specialist a 2-hour ambu ride away, it may have been simply a prolongation of the inevitable. Still, it kind of balanced out some terrific misses I've been making recently. Sigh. Anyway, hope all's well.

--aws

There's a race of men that don't fit in,

A race that can't stay still;

So they break the hearts of kith and kin,

And they roam the world at will.

They range the field and they rove the flood,

And they climb the mountain's crest;

Theirs is the curse of the gypsy blood,

And they don't know how to rest.

If they just went straight they might go far;

They are strong and brave and true;

But they're always tired of the things that are,

And they want the strange and new.

They say: "Could I find my proper groove,

What a deep mark I would make!"

So they chop and change, and each fresh move

Is only a fresh mistake.

And each forgets, as he strips and runs

With a brilliant, fitful pace,

It's the steady, quiet, plodding ones

Who win in the lifelong race.

And each forgets that his youth has fled,

Forgets that his prime is past,

Till he stands one day, with a hope that's dead,

In the glare of the truth at last.

He has failed, he has failed; he has missed his chance;

He has just done things by half.

Life's been a jolly good joke on him,

And now is the time to laugh.

Ha, ha! He is one of the Legion Lost;

He was never meant to win;

He's a rolling stone, and it's bred in the bone;

He's a man who won't fit in.

http://www.ted.com/talks/ken_robinson_says_schools_kill_creativity.html

http://www.ted.com/talks/dan_gilbert_asks_why_are_we_happy.html

http://www.ted.com/talks/barry_schwartz_on_our_loss_of_wisdom.html

http://www.ted.com/talks/benjamin_zander_on_music_and_passion.html

http://www.ted.com/talks/malcolm_gladwell_on_spaghetti_sauce.html

http://vimeo.com/moogaloop.swf?clip_id=2539741

http://www.glumbert.com/media/everydaynormalguy (ribald lyrics)

http://www.ted.com/talks/vusi_mahlasela_sings_thula_mama.html

http://plagiarist.com/poetry/

and of course http://www.theonion.com/ and http://www.thedailyshow.com/

For those of you interested in the saga of my pants

Reproduced below. I'm not sure if I feel worse being robbed of a good pair of pants or of the recognition that I am, in fact, hysterical....

Email to North Face's parent company, VFC something or other--

Funny story, actually: I was abroad doing some medical work when on a rare day off I went to the beach. I was wearing my North Face Paramount convertible pants at the time, converted as shorts. Suffice to say, I was mugged. To my dismay, the attackers made off with a few items including, for reasons unclear to me, the right leg of the pants (the left, I guess, they didn't feel they could sell?). Luckily, my phone was kept safe in the front right hip zippered pocket (which can now legititmately be advertised as a theft deterrant) and all ended well. Except that I am currently in the position of having a very nice pair of shorts and one left gaiter. I would obviously much prefer to have the whole thing intact. How would I go about obtaining a replacement R sided leg for a 34-inch inseam Dune beige Paramount convertible pant? I bought the item in the US, but have since moved on from Africa to Australia, so I'm not sure how to provide proof of purchase (it was originally through REI...). I'm not sure if there is even a supply of the pant legs laying about somewhere. I'd love to have the set whole again, though, as they are my favorite pants for work in the Emergency Department as well as play (why I was wearing them at the time of the incident, in fact...). Looking forward to a response. Cheers, --andrew s.

Response(s)--

Hi Bernie, Pls kindly review the case with customer below. thanks! Best Regards,Jessica

Good Evening, Andrew

Thank you for contacting us in regards to your The North Face product.
Unfortunately, we do not supply spare part to replace the missing right foot of the convertible pant.

Below stores are some places where they still stock this convertible pant for purchases:
Paddy Pallin, Anaconda, and The North Face retail store on Pitt street, Sydney.

Hope this info will assist.

Kind Regards
Bernardus

Bernie, turns out, has the title of "After Sales Manager." If nothing else, I feel gratified knowing that responding to my email gave him something to do with his day...

Cheers,

--aws

Oh, PS-- On a separate note, in looking into this, I found out that REI discontinued their line of Granite-style(?) canvass pants. These were, without question, the pants that have made me happiest thus far in my adult life, and my current pair are torn and mildly blood-stained. Shattering.

View of the Launceston dryer/living room combo-- shorts and accessory gaiter; the lonely Granite pants (my study area in background...)

Thousands dead in Launceston...

Ugh.

I hate taking antibiotics-- they are for the weak. What kind of hypocrite would I be if I told my patients there's no need for antibiotics and then took them at the drop of a hat? Besides, I absolutely believe that the end of humanity will come in the form of wars over water and resistant bacteria (or flu...?). So, it was with a great amount of soul-searching that I finally started a course of macrolides the other day. I'd been sick for almost 16 days (initially just a little swine flu...) and getting worse. Finally I was asked to stop coming to work because I was making the patients feel bad for me. Luckily, I have a few days off to convalesce. To be fair, I guess I would've diagnosed me with sinusitis or pneumonia (no chest xray, but I guess it's pretty bad when you can hear localized rales in yourself?) if I'd come in. The big thing was I was sleeping all day whenever I was off. Eight-to-ten hour shifts and I'm asleep from one to the next! What kind of New York (medical) Resident am I? Getting a little better, and no longer an infectious risk to patients (don't work for a few more days). But unfortunately I haven't felt like doing anything except laying around at home, not accomplishing any thing (car, salary packaging, running/gym...).

And I'm assuming that's when they knew it was time to strike...

Yup, completely frickin' overrun. Don't worry, after making the video I had the stamina to dispose of the bodies, so that's nice. But the live once are still crawling over the computer and in the Gatorade. I only just was feeling like walking down to the store to pick up the traps, which so far do not appear to be all that useful. I've heard it said that by mass (not just number) there are more ants on the planet than people. Well, that's certainly the case in my apartment.

So funny little anecdote: I was working with an Irish-derived locums the other day, and the ICU team comes down to talk to us about the case. We're around the PACS and talking about the case when the Aussie ICU guy says "Whoa, I didn't realize I'd have to bring a translator!" The team started laughing and I didn't get it until I realized that here, the Irish guy and I are the ones with the accents...

For the ED docs reading-- just a tiny example of how we do things differently here. 88 yo woman feeling unwell for a few days. Found to be in new afib, cheap pneumonia on chest XR, and very cheap troponin leak. You guessed it-- ED ROMI, po abx as an outpatient, start metoprolol/aspirin, and check in w/ GP in 2 days to see if afib persists and discuss A/C. WHAT?!?!? I guess that's one way to handle it... The big differences are not ones in medicine, just practice. It's a little like having the rug pulled out from under you. ED is all about disposition and what/where to do/send next. Since that's a little gone for me, I feel like I'm starting residency all over again. I keep getting frustrated that I'm sometimes allowing the fact that I don't know a lot of things (not necessarily about medicine, though sometimes that, but also management here) erode my confidence about things I do know. Common practice on how to handle persistent neck pain in a low risk MVC w/ (-) imaging? Tony once accused me of using “the Shannon Criteria” for clearing a collar. The SC for c-spine pain was basically “I don't buy it.” Here, I've been reluctant to use that criteria, but what do I say when the consult does? I guess it takes the burden of responsibility off of me, but 1) not really (still my patient and I the treating doctor) and 2) it makes the consult think I'm wasting their time. And, due to erosion of confidence, make me think I'm wasting it, too. Sigh-- so that's frustrating.

But, now that breathing is improved and hemoptysis ceased, I'll be on my feet again to run the Burnie 10 km and learn guitar (oh that's right-- you heard me...). There's always a positive. To quote myself from the other night, “Hey, if a patient's going to smack you in the face with a urinal, just be glad it was pre- and not post-.” Medicine is so glamorous and sexy.... Until the next time. --aws

Ever Forward...

Hi there,

So, interesting few weeks. The Registrar position in Aus EDs is kind of like the Jacobi 4th year “pre-attending” position in that you run your side of the ED and check in with the Attending (here “Consultant” or “Specialist,” sometimes both) whenever there's a problem. The primary difference in Lonnie is that my “side” is the department, and the Consultant is usually at home at night. If considering coming out here, make sure you're scheduled/billed as a Consultant... Here's a picture of my schedule for the month (shift days in yellow)...

While so far no overnights alone for me (5 in a row coming up), I'm headed in that direction. Mostly it's just seeing patients, assisting with difficult cases (and certainly getting assistance), and hearing cases presented by RMOs (Resident Medical Officers) and Interns. The hang ups continue to be the fact that many lab values are in unfamiliar units (a glucose of 7 is ok, apparently) and that I'm reading my own films during the day. I still call folks over every now and again to get a second opinion, but my little follow up book is now a few pages full of films to see if I'm any good at calling pediatric,.. sorry, p_a_ediatric pneumonia. No diphenhydramine in the country-- the anti-histamine of choice is promethazine (phenergan). Also, roxithromycin is the available po macrolide (no resp. quinolones like moxi, which is odd. I'll have to double check that). Ticarcillin as opposed to piperacillin, and no etomidate. I'm using a lot of propofol for simple reductions and so on. Speaking of which, doing quite a bit more from a “procedure” standpoint than I'm used to doing. The other day during a “Fast Track” shift, I saw 2 thumb dislocations (one was a morphine/fentanyl/midazolam after nitrous and local lignocaine (what I call lidocaine) flail), one tibial fracture, one distal fibula frx I had to _cast_ and one acute kidney rejection, to name a few. It's been interesting. The use of Bier's blocks is also a new one to me, so I'm still working that out. I've done three cardioversions (one w/ amio) and one Peds arrest. No bedside sonogram, and to get one after hours and weekends we have to call in the radiographer and the radiologist. There's a lot of “can this wait till morning?” and “Have the r/o ectopic (granted, low prob, but that's why we get the tests) return tomorrow for her sono” which I'm not as familiar with. Also, had my first "swine flu" pneumonia/ARDS case the other day. So far she's doing well (we've had ~ 3 inpatient deaths so far). An additional flu clinic has been set up for people w/ "flu-like" symptoms (the commonly heard rejoinder to many of these complaints is "stop your s-whining!" [sound it out...]).

So I'm glad I picked this place in terms of the pathology not disappointing. It's busy enough to challenge some management issues, there's no buffer of "senior residents" to take away onerous procedures, I'm doing almost all my own psych and Ortho stuff (yay latter, boo former) and arranging a lot of outpatient cardiac work ups, which I'm trying to get comfortable with. No real trauma so far (rare year in which penetrating trauma cases reach double digits...) but for the most part that's fine-- those cases are really only "find the hole and plug it" anyway.

To a person so far all the patients, even the “problem” patients, have been very polite once you get past it. I actually had a guy thank me for convincing him not to sign out AMA and get evaluated. “Thank you.” Who knew?

Obviously I still have a lot to figure out about this place and Medicine in general. Everyday I have 2 or 3 things I absolutely need to get home and read about (few for several on that count). So that's cool. I'm still a little hesitant about stuff I shouldn't be (ie stuff that two months ago I was not having difficulty managing), and my conversations with others are a little tentative. Much like a wobbly, new-born colt trying to find his legs, I'd say. But I'm getting used to it. Having a few instincts confirmed as I go along, which is nice. So far, I think things look like they'll be fine, and I enjoy walking to work in the morning.

Still finding places to run. The area is like the bastard child of Parkersburg and Vienna crammed together, w/ the topography of North Hills, so even hour long runs are gruesome right now (hey, just spent 2 months in Africa w/o any exercise!) You can see my street in the pics here, w/ the hospital in the upper right distance (~ 15 min) of one.

Swung by the gym the other day and everyone is in better shape than me, so that's just great. Working on that as well. In fact, my list of Tas goals (posted on the fridge) include a 9:30 min mile for 1/2 marathon distance, getting in shape, improving posture, finishing some review material & Board Prep, and normalizing my TSH. We'll see about that last!

Thanks for all the emails and Skyp-ing. Look forward to those every day!

Until the next,

a few weeks in...

It's cold here-- about 4 C in the am and 14 at a high. But it is also their depth of winter, so it's not going to get any colder. I've got the power and hot water set up finally, but the heating is still not working. Got a bank account, cell phone, internet (finally) and will start working on bathmats, window insulation, drivers license, etc. (right now driving without, which is interesting on the left...).Had a meeting with the ED director yesterday am (I'm writing this at my 09:00 on Fri am) and saw some of the ED. No one wears scrubs- the nurses' uniforms are like school uniforms (slacks, button shirts, sweaters/vests) and the docs wear their normal clothes. I'm thinking I'll have to break in the whole scrub top thing...

Tasmania is about the size of Scotland or Sri Lanka, ½ the size of Lake Superior, a bit smaller than Ireland, and has a population of around 1 million people. It's about 5-10 years behind the times, depending on who you ask. Launceston or “Lonnie” is the second-largest city in Tas, just behind the capital to the south, Hobart. There's an interesting history there, if you're inclinde to read up on it. Suffice to say that there continues to be a bit of a rivalry btwn the two centers. Lonnie has an immediate “greater” population of about 100K, which is less than Hobart. However, the north of Tasmania, an area served by the Launceston General Hospital, is home to the bulk of the population, spread out as it is, so the hospital can get a bit busy. With the flu season, confirmed to be at least partially H1N1, the past and current months are shaping up to be the busiest in the LGH ED (about 122 visits in a day, up from a prior max of 102).

One of the biggest set backs is that The Daily Show full episodes are not available in Tassie/Lonnie via the wireless... The countryside is quite amazing. The climate is temperate and forests still take up most of the island, so there's an opportunity for some “bushwalking” or hiking/camping. So far I'm walking pretty much everywhere in the city, as things are that close. Between Hobart, the capital, and Lonnie is mostly grazing (yes, sheep) country. In the city, the air is cold, and scented with woodsmoke, still a major source of heating for many in the city. The overall impression is that of Scout camp-- walking outside in the morning surrounded by the crisp fog and hint of woodsmoke, it's easy to recall mornings in Camp Katoga headed up to the Trading Post. The other memory this place evokes in me is that of the northern desert/forest of Argentina (I forget what the area was called, but it was north of my friend Augustina's home in Tucuman...) They say that smell is the sense most tied to memory... Finally, the pastoral/rural picturesque architecture and overcast skies makes me think of old BBC-America shows that my mother watched on Saturday mornings-- usually involving a “pepper-pot” old English lady solving murders.

The medicine is interesting. Just little “Royale with cheese” differences. Brand names for drugs are obviously all different. The formulary is a little different as well (roxithromycin is the macrolide of choice), and practice is very different. For example, I don't think I've ever sent home an 86 yo with chest pain after two (-) sets in the States. And I've certainly never done a Bier block on a 79 yo for her Colles frx! But, there you have it. So far I've had a woman come in in rapid afib, degenerating to sick-sinus with long episodes of asystole (you read that correctly) that increased in symptomatology and length, and a woman who showed up in shock with cyanosis, mottling, cold extermities, and perfectly intact mental status and vital signs. Still not sure about that one... apparently no brown snakes in Tassie (60% of the mainland's fatalities) and no useful history from her or her family...

People are very nice so far. By now writing the blog after my second week here (1st working week), I've met a few folks and have gotten the place and the other stuff pretty well set up, but not yet out about town very much. I've put up a clothesline inside the living room, which makes me look pretty classy... There's a 10 k race (how far is that, anyway?) in October I thinking about dying on, and apparently a mixed-martial arts club in town. We'll see... :)

I've included an email I wrote to a friend of mine asking about my ED work experience over here as it may give another POV.

Hey ---,
I'm trying to continue blogging what's up here in Tassie, so if that'll be helpful it'll be at www.doctoroffortune.blogspot.com
To try to answer your question, though, it's been good so far. I've been working for about a week as a Registrar, which is basically equivalent to a Fellow. I was told this is because I'm not Board Certified, but I'm not sure about all that. The Consultant/Specialists (“Attendings”) in Emerg where I am, and in most places it sounds like, tend to not overnight in the hospitals. They get called in for major things. So far, haven't been on overnight by myself, so not sure how that will work. The drugs are a little different, the abbreviations very much so (GORD for gastro-oesophageal reflux), and the follow-up practices different as well. The other day I was corrected for ordering an afterhours sono on a Pt to r/o ectopic in a preg vag bleeder. It was felt it could wait until morning, as she was hemodynamically stable and not peritoneal. They would've had to call in the consultant radiologist and apparently that's not easily done (“that HCT can wait until the morning-- we'll just observe the intox 82 yo potential head trauma until then...”). So that's taking some getting used to. Obviously no separate Peds ED...

I guess the bigger city trauma centers are more like what we're used to, but I don't imagine they're in much need for locums. Lifestyle is fine, though taking some getting used to. The environment and social scene where I am is a bit like where I grew up, so it's something I understand if not entirely enjoy-- things close down pretty early. But it works for me for now, hanging out, reading, getting back into some extra-curriculars I'd let go. Pleasant enough co-workers, though I do get the feeling that people say “no worries” when actually there's room for improvement if they would just tell me where!

So, hope that's helpful. Moving overseas was expensive and kind of a pain in terms of getting banks, post, internet, new phone, buying new electronics done. But the whole thing's been interesting, which is all I'd hoped for. Let me know if you have other specific questions, and I'll be happy to try to point you in the right direction...

On to Tasmania

Hey there. I'm getting back to the blog-- sorry if it's been a while. I got back in the States without a problem on July 5th. Spent about a week packing up the rest of my stuff, moved it down to storage at my lil' bro's (thanks Jon/Kelly!), and went to FL to hang with the 'rents. Now, headed out to Tasmania. I'll be spending a year there at Launceston General Hospital as a "Senior Registrar," which is like a Senior Resident/Fellow equivalent position in the US. Because I'm not Board Certified, they wouldn't accept me as a "Consultant" (ie Attending/Specialist). It's kind of a silly quirk, especially considering I just learned that an affiliate of my old program is now advertising a position that pays two-and-a-half times what I'll be making in Australia!! Whatever-- it's the experience. That's what I'm telling my creditors...

So, in any event, feel free to stop by if you're visiting Austral-Asia any time in the next year... I've uploaded a few pictures of my theoretical apartment, which is just a few kilos walk (Yay metric system!) from the hospital. As a result of the cost and time lost in heading back and forth between the States and Aus, I think I'll postpone taking the Board Exam for a year. Apparently I can do this and still not have to start counting my CME activities for certification. We'll see. It'll be nice to have that money and vacation time to hang out in New Zealand, Japan, Thailand-- whereever-- if I can have it. It probably also makes sense in terms of not really having studied for the stupid thing...

Anyway, so let me know if you have suggestions about what needs to be seen/done in Aus, where I need to head to next, etc. I hope to keep updating the blog, but if I don't it's either because my life has gotten way too interesting or waaaay to boring... Cheers,

--aws

Monrovia 5-0, or how I became a Liberian Crime Statistic

I thought I'd include the above pictures in this, my last entry about Liberia. The left is a jello mold that was discovered by Rachel and myself while looking for a pan to cook lentils in. We found it, and she said, "Why would they make a jello mold of President Tolbert?" It is of course Harry Potter, but I understand the mistake, given the uncanny resemblance. So, Harry is pictured with three leaders of Liberia for comparison (I'd think Doe before I thought Tolbert...) for Rachel's benefit.

The right picture is of our competition-- the medicine man (or manor?) is apparently a big herbalist who can cure more sicknes ses. I'm not one to argue. But it does highlight the reliance on "country medicine"-- which is herbs, etc. that are eaten or applied to improve illness prior to coming to the JFK ("just for killing") hospital. So, by the time they get there, the question is raised as to whether the liver damage is from the original illness or the country medicine used to cure it...?

So anyway. The last 48 hours in-country were... interesting.

The last week there I had been asked to review some material for the Ministry of Health's supervisor training. It was actually a bit of a bigger project than I'd realized, but was able to complete some changes to their training manual in time for a brief talk on emergency care that Thursday morning (I mention this in the video of the medical side in the ER during my discussion with Deborah). It was suggested after that morning that I go do something fun in Monrovia, given that I'd spent a lot of time in the hospital while I was there. So I thought I'd go see one of the beaches that I'd been told should be relatively safe.
You see, some of the beaches in Monrovia, especially around the hospital, aren't all that secure and are known for their criminal activity. Kind of like alleys in the States, you really don't have any business being there, especially at night, especially alone. (Of course some private beaches that are patrolled are fine).
But, let's face it, I'd gotten kind of bored and was looking for something to do besides work. So, in the early afternoon of my penultimate day, I headed out to one of the beaches that was recommended as relatively safe. I wandered around the beach for a bit and was heading back when I was approached by a group of guys. There were about 6-8 of them, and they initially asked me a few questions in order to surround me. They started yelling and grabbing my arms, while two of them waved around broken bottles and one a pair of kitchen scissors (you know, the kind with the orange handles that your mom has laying around somewhere). They gave me a few cuts to make sure I wasn't going to try anything ("uhm, there are 7 of you-- I think you win today...") and took my wallet/money and my digital camera. Through the course of the encounter, it became pretty clear these guys weren't really all that dangerous, so I followed them a little bit and asked them to drop my wallet and id, which they did. It was kind of like in the Big Leibowski-- "Are these men going to hurt us, Walter?" "No, Donnie; these men are cowards."
After all that I called for the driver from the hospital to come get me. (My phone was in one of those "change" pockets that are sometimes in jeans or "travel pants" in the hip pockets..) So Mr. Moore, one of the drivers from the hospital, and one of the hospital's plain-clothes security guys (Frances I'm pretty sure) came. We eventually located the guys who took my money (they were still in the area apparently playing craps with a bunch of US bills. Yeah, not all that subtle).

We drove back to the police station to pick some of them up and took them back to the beach. I was in this way part of my very first Liberian stake-out. Which quickly became my very first Liberian foot-chase, as the guys' lookout recognized one of the plain-clothes cops and sounded the alarm. Everyone scattered and myself and the driver in the van went around to try to cut off escape routes while the police and hospital security guys (as well as Mr. Moore, who-- as those of you who've met him might have guessed-- loved every minute of it) chased them through the little alleyways.
Eventually we rounded up about 5 guys (the 6-7 on the beach became 12 or so when we found them again) and took them to the main police station. I identified the ones I could and filled out a statement. During this, of course, they were in the room, tied together with the tails of their t-shirts. "White Man-- look at my face! It wasn't me!"
Got back to the hospital, and fortunately since I know a good ER doc got taken care of. The next day, I was told my camera had been found. Apparently there are only a few people in that area of Monrovia who can fence a digital camera, so both were followed and the one arrested. Obviously this effort wouldn't have been put into things if I weren't part of the hospital where the administration is so connected to the President, so I'm grateful for that. So in any event I survived the experience and did a little more work that last morning before packing out. An interesting aside, when I got to Brussels I checked the photos on my camera. They include the following picture of the guys who stole the camera from me. I guess they took a few shots of themselves for posterity... ;)

Video diary overload!

Hi there! Got the ol' camera back so thought I'd post a few of my close-to-last-day videos!
This first should be a quick look at the breezeway/classroom where we'd talk some to the Nurses in the morning. It's also a hall of the hospital that we'd use to walk to and from the main patient care area of the hospital and the dormitory.

This next one is a quick trip through the Trauma side of the ER. Nothing too exciting going on.


This is a quick look at the medical side, and a discussion with Deborah, one of the Head RNs

Here is a video of a trip up to the floors


Finally, this video shows a quick look at the medical wards and ICU, w/ Drs Toomey and Borbor




I tried to whip-pan (yeah, that's right-- it's an industry term) so that no one could be identified... Skills of an artist, or cinematographer. Trogdor. :)

Hysteria, Lazarus, and No mo' Flomos -- medical stuff

I had thought this text had uploaded, but I guess not... hmmm.

So some of the more interesting stories I'll try to list here.

One thing I was impressed by was the number of “hysterical reactions” or pseudoseizures that came in to the ER. I suppose I shouldn't be. I mean, I'm hesitant to diagnose depression in the Bronx (“Hey man, it's not your attitude/outlook or brain chemistry-- I agree with you, your life sucks.”) where at least you're not getting dysentery or malaria 3-4 times a year and your poverty does not preclude getting a ride thanks to public transportation. So why shouldn't there be a relatively high burden of psychiatric disease in a recently post-conflict poverty stricken nation? About once a day a girl/young woman would come in, not speaking, or unconscious, or staring. They'd usually get a dose of quinine before I was able to resuscitate them with an advanced ER procedure known as a “sternal rub.” (yes, think of it like a noogie-- except in the center of the chest. Really annoying and likely to cause you to come out of your psychologically induced coma). I can't argue with the quinine, though. Top diagnoses for acting screwy, depending on age, were cerebral malaria, HIV, hypertensive encephalopathy, and hypoglycemia.

So, they'll tell you in Liberia that the language is English. Not quite. Most people do speak a kind of “pigeon” English. I think it's equivalent to the way some Dominicans speak Spanish. Letters/sounds left off here or there, different idioms, etc. So it's not always easy. We actually started on a phrase book for the people after us. “Tryin' small small” means “getting somewhat better.” “Running stomach” means “diarrhea.” “O'Ga!” means “My Goodness, this is really painful.” And, interestingly, “Fell off” means “passed out” or “became unresponsive” or “felt weak.” (“Fell out” is sometimes used in the Bronx-- any others people know about?). So, when I came across this young man who “fell off” and has been “weak” since, I initially didn't think much of it. Get a malaria smear, give fluids, dextrose, etc. However, sometimes, “fell off” means something much more literal and in keeping with how I use the phrase. Sometimes, “fell off” means “this guy fell off the roof he was working on, landed on his head, and hasn't really been able to move his arms or legs since, so we brought him here in a wheelbarrow with his neck hanging over the back of it.” Overcoming this linguistic barrier I feel, was, in retrospect, key to his eventual care and disposition...
I decided to start calling him Lazarus. After ~ 6 weeks on the floors, getting intermittent physical therapy, he's able to stand on his own again (Partial cord syndromes, his diagnosis, have a good prognosis a few months out). He was so happy to see me when I went up on the wards that he got up and sat down several times to show me. He may not be playing soccer again anytime soon, but he's walking, so things could've been worse.

I always enjoyed Michael Jackson as much as the next person (Rock with You, Don't Stop Till You Get Enough, and Billie Jean are overplayed, The Way You Make Me Feel and Smooth Criminal underplayed), but certainly didn't get all bent out of shape when he died. (It was ridiculous, BBC and Al Jazeera- London desk were covering news, while “the Situation Room” was on Michael Jackson all-day all the time for what seemed like a week. Yay America and your declining world relevance!) Liberia, like most of the world, however, felt differently. There were two days there when everyone felt a little sadder, was a little quieter (not easy, in Liberia) in mourning for the King of Pop. In particular, one young man came in to the ER the day after the announcement. Seems that upon hearing of the death of the King, he let out his best “Dangerous”-era “O!/Hoh!” and dislocated his jaw. So, after I finished laughing at him, myself and the medical student grabbed and yanked. Not so successful, and well past the end of my shift, so I gave him some muscle relaxants and figured I'd try again in the am. Apparently, he'd relocated during the night and was able to be discharged by the overnight team. I guess it wasn't a bad dislocation. Not a Bad, Bad, really really Bad, one anyway.

I feel I should break up the text here with a picture I only got at the end of my stay, as it was from the OR. Often surgery is the diagnostic modality of choice here, so there is a certain significance to claiming that an abdomen is "surgical," especially for kids. In any event, they had thought this tyke had a typhoid fever perforation, but on opening the peritoneum, turns out it wasn't the case. Here you can see the surgeon taking out the worms (ascaris) from the small hole in the small intestine before repairing the hole and putting the kid on antibiotics and anti-helminths. Enjoy!

Early on in my stay, I was given the Liberian name “Flomo.” For almost 5 weeks, I tried to get people to tell me why I was given this name. Louie was called something that apparently means “owner of a town,” and as far as I could tell, both Marcia and Rachel were called “Kebbe,” which is a name from Lofa county. Lofa is one of the biggest counties and quite a few people who moved to monrovia after/during the war for protection are from there. It is common knowledge among hospital staff and I assume Liberians in general that Lofa women have the biggest backsides. I'm not sure how this is appropriate, because if either Marcia or Rachel attempted to tie their children to their backs with their Lappas, the way most Liberian women do, their kids would slide off to the ground. Sorry if I'm telling you something about yourselves that you didn't know Drs., but it's true.
In any event, I too, it was decided, needed a name indicating I was from Lofa County. (and yes, the children would slide off my skinny Irish ass as well, though I don't think that entered into the decision making process). So, I was called “Flomo.” The name had shown up a few times as either a first or a family name, so I was a little familiar with it, even though I was told it didn't have a “meaning” per se. But, over the course of my time there, I noticed something-- Flomos died. Like, a lot. Chances are, if you were named Flomo (first or last) and you made it to the JFK ER, you were not getting out. I mentioned this a few times to the nurses, and thought maybe a different name would be better. They all loved it. To the point where they would say in the morning “Hey, it's Dr. Flomo! Do you think he'll leave today?” One time I felt particularly uncomfortable when a nurse in triage (full of people, mind you, any number of whom could've been named “Flomo” to varying degrees), explained to another nurse that “Dr Shannon doesn't like to be called Flomo because Flomos always die.” Ha ha-- not so funny if you are overhearing this conversation and just registered your uncle, Flomo Flomo from Lofa county. And if you were Flomo and triaged to bed 19, just frickin' forget about it. Bed 19 was not kind to Flomos. Or to anyone else, for that matter. Come to think of it, Beds 19, 10, 8, 6 and 5 were just not good beds to be in. So, I instituted a “No Mo' Flomo” policy in the ER, which the nurses also loved. I would not be called “Flomo” on days I wasn't feeling well, and all Flomos under my care had to have rock-stable vital signs before I would see them-- even if this meant lying to me.

--aws

Radio Silence- pictures of ME!

I apologize for being negligent on the blogging front. TRUST me, though. Some interesting things have been happening, and I've had an action packed last week and few days. Suffice to say, I hope the scar lasts so I can pretend I'm a bad-ass... I'll post a few things in the next few days. BUT, I'm on my way home to from Brussels now, and will be back in contact shortly. A few teasers... Myself and Dr. Fowler enjoying the official hospital Jollof (or Jollah-- I saw it spelled a few different ways) rice in the cafeteria, and Joseph, Dr. Borbor and the ward nurses checking out a sonogram on one of our ICU patients. Hmmm, with the Brussels internet, maybe I'll risk posting a video before the plane leaves... Oh, no, can't-- long story as to why not, involving the Liberian National Police, my undercover operation, and the aforementioned scar. Oh, apparently the flight is oversold and they're looking for people to stay in Brussels tonight... This is God testing me after the events of the past 3 days-- Lord, no worries. I have learned that discretion is the better part of valor...
--andrew

The Death of Peanut

I don't know when I started referring to Preemies as "Peanut." It might have been from an Attending at Hopkins, but I think it was probably from Dr. Atherly-John at Jacobi. In any event, I've added it to my medical lexicon ("munchkin" refers to infant-post infant-early toddler, and "rugrat" refers to anything that's likely to pull things off the dinner table up through early adolescent) to described the half-baked "petri-dishes with asthma" that get me sick every Peds ED rotation. Yeah, I'll be a great father.

Anyway, Peanut came in at about week 2 of life. That said, he was born at about 36 weeks, so he really was just out of the gate. He was premature due to oligohydramnios and placental insufficiency caused by maternal malaria. Apparently on pathologic examination the placenta is just full of the little parasites (the which, my marine biologist brother tells me, are more closely related to algae than any other organism...) such that there's actually an increased echotexture on sonogram. Anyway, like any maternal infection without prenatal care, it's not good for baby. So peanut was born 2 weeks ago, and was brought in with a fever to 102 F. He was ridiculously fragile, and had the build of one of the anole lizards we kept as pets when I was a kid and the skin of your 92 year old grandmother. But for all that, looked great. Dehydrated? Sure, a little. But pooping, peeing, breathing, eating. How much more of a repertoire are you asking of this little guy? His breathing was fast, but symmetric and clear, and his airway was fine. The belly was beautiful, all things considered. So I started Peanut on fluids, anti-malarials, antibiotics, and for the love of God keep breastfeeding. So, Peanut was chillin', decked out is his over-sized onesie and toboggan hat (these little puppies must come standard issue from baby/mother boot camp because they are everywhere).
Interesting aside. There was one patient that I was flipping through the Nurses' notes on and came across an awesome phrase. She wrote that “the patient was observed chilling in bed.” Awesome. I immediately had images of a large pair of over-sized sunglasses that make people like Lindsay Lohan look like an owl, a reclining beach chair and an umbrella drink. I surmised that if this were true, we could probably discharge the patient. Turns out, of course, the nurse was referring to the patient as having rigors or “chills,” which can sometimes happen as a result of fever or bacterial infection. Not as much of a vacation scene, but the image was certainly one of those moments that gets you through the day.
In any event, in spite of all the deck stacking against him, Peanut was doing fine. He'd had no fever in 2 days, was eating and so on, and continued to look like a peanut-sized rose. Day three in the late morning I was called over to the crib by the med student, because the mother had gotten her attention. There was Peanut, all wrapped up and fragile and tough and cute. And not breathing. And pulseless. When a kid goes down, chances are it's respiratory in nature. They haven't had a lifetime to abuse their hearts and their respiratory (and neuro-respiratory!) status is relatively tenuous, so it's think lungs before you think heart w/ them (though there has been some recent evidence disputing that).
In a room full of sick kids and their mothers, with a child who never really had a chance and his mother. I gave him two quick breaths, and sent the student for a bag and his chart. The morning note from the other MD was dated about an hour and a half earlier. Things had been fine: Afebrile, good response to interventions, feeding and voiding well. Continue current management. I pulled the slack of the swaddled blanket over Peanut's onesie, toboggan and face, and I told his mother that her child was dead. She borrowed my cell phone to call the family. I wrote the note, with time of death about 13:10. It is common practice to put tetracycline eye ointment in a neonate's eyes after delivery, to treat any potential infections acquired during transit through the birth canal. I thought about how it was entirely possible that since that time, the little boy's eyes had never been opened except when I looked into them when I first met him, and then again on the day he died. There were more patients to see.

video diary 2

So hopefully the above video works out. I'll try to do more of them as I can.

Nothing earth-shattering to report. Things still go. A little more time outside of the hospital than I've become used to because our program director, an ER doc working out of CT and a relation to the President, came into town and now we have access to a car pretty readily. So that's been interesting. Worked on the medical department's grand round presentation for Monday (tomorrow) which is a case of hypokalemic periodic paralysis. They couldn't get a K level, but the EKG looked like hypokalemia, so that's how they made their diagnosis.
Here, surrounded by people who have the books but not the scanners, I realize that I should've done a lot more reading in residency. I guess I knew my program would be more "running around doing" than "sitting around thinking," and that's why I went with it, but dang. I must've become mentally challenged at some point because I can't remember a single I supposedly learned. What have I been doing these past 4 years?!?!? Maybe studying for the Boards will help solidify some of that...
The medical students are looking for me to teach them and I'm a bit at a loss. I want to spend my nights reading the Rosen's that's been left in the dormitory common room...

Take care!

--aws

coughing up a diagnosis... (medical stuff)

ok, so this was awesome. I walk into the ER yesterday and start discharging Pts like a fiend (filled up immediately after, and today was even worse chaos). There was one lady who was seen by the O/N doc, a semi-private who sometimes takes call to fill gaps (though one day didn't show up at all!) and dx'd w/ enteric fever/typhoid. I go in to see the lady, stacked Monte style three abreast in one little room. She looks ok for an elderly Liberian woman and says she feels ok to go (not as useful an indicator of being ready to go as you might think...). Anyway, I write up her d/c stuff for standard abdominal pain meds, including anti-helminthics. I realize I forgot to do her abdominal exam, (it wasn't documented from the prior doc either) so I go back in and have her lie down and start pushing on her belly. I'm starting to think "you know, she's a little distended..." when all of a sudden she complains of "water" in her chest, and looks like she's about to vomit. We sit her up and give her a pan just in time to catch this diagnosis:


Round worm (ascaris) is an intestinal helminth/parasite. Her burden of disease must've been pretty extensive-- they live in the intestine, so by the time they're coming out your mouth you have quite a collection going on. So yeah, totally awesome.

--aws

more medical stuff

A few more medical pictures.

Below is a kid s/p Road Traffic Accident (RTA) with a broken L humerus and dislocated elbow. These were overlooked initially, though in the rush to pay attention to his R shoulder laceration that bisected the deltoid and exposed the rotator cuff, but left the joint capsule intact. Because he couldn't afford surgery and was above 5 yo (for free/reduced cost care), we closed him in the ED after an attempt to reconnect segments of his delt. Days later, he's adducting that arm ok, but a tissue defect remains...









Interesting sono here-- this woman had so much ascites that her pelvic organs (uterus, tubes & ovaries) are outlined beautifully floating in the fluid in her stomach (this is normally not the case!). Just had to take a picture of the sono screen.


Hmmm, oh, here are a couple TB cases. The first is a woman coughing up blood and with R chest pain for a while. There's a small density with some central clearing on the upper right close to the lung periphery. Not much else causes a "cavitary lesion." There's also a guy who was cachectic (ie skeletal) and had had cough for several months. His nodular infiltrate is pretty good for advanced TB, and he was begun on meds.











So a few others will wait. Got called out of conference to do a pericardial centesis on the floor (so, how many of these have you done, Doctor?) and continue to see a lot of "end-stage NOS" A woman came in the other day with complaints of no urine output for a week and on sono had the worst bilateral obstructing hydronephrosis I'd ever seen (retroperitoneal fibrosis due to TB?), and another woman presented with hepatosplenomegaly and enormous kidneys (medical renal disease --> HIV nephropathy? HELP!!!). So it's been interesting. But, for the most part the kids bounce back, so that's good. Oh, one last bit. Remember, when you're working in an international setting, even when the patients do bring in their medicines, it's not always helpful...


All good things,
--aws