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

It's nice to be wanted...

Some pictures: To the left, the picture of club beer and Louis' feet. Taken during a Robertsport excursion (the location of "Sliding Liberia"). The likely apocryphal story is that during the 13-20 or so years of intermittent fighting the Club Beer brewery was the only institution in the country in continual operation. It's nice to find something people can agree on...



The center pic is one of the beach view from the tent we stayed in at Nana's Lodge. In the distance under the tree you can just make out one of the young Liberian fisherman checking out the ocean. Wonderful composition, Andrew. Why yes, it is. Thanks for noticing.

And finally, our Pepsi tends to be from Dubai, and our Coke from Lebanon (pictured) or Algiers...

I'll have to get a picture of it for you, Lee, but if you feel like something is amiss during your time in Liberia, perhaps it's because your chocolate biscuits are being manufactured by... CYLONS!! Yup, the Ceylon distributing company of Singapore-- biscuits so human-like you won't be able to tell the difference.

So I was taken out to my first Liberian night club last night. The other one was closed for renovations, so we went out to Deja vu, which is a music pounding neon-lit bar/dance floor. It was about a $5 cover (which is not a little here) and there was an issue with paying with one of the old 10s. Apparently now they only take “big-head money” (the new bills). I'm assuming this is because they weren't as accustomed to $US prior to the change up? More likely the “new” (it's been what, 10 years?) bills are the standard and the old ones are different, and therefore unacceptable in some ill-defined way. Ie if you're not sure, someone who is doing something different is probably trying to “juke” you in some way...

Anyway, it was nice on the inside-- comparable to a standard American club. Not smoky, not crowded, and packed with provocatively dressed Liberians. A little background-- we'd just gone out to a little bar after a late dinner & were listening to some live music. One of the nurses, myself, one of the other HEARTT docs, & a Liberian friend. Interestingly, we met a guy there who was with the UN Security Sector Reform mission. I think he put it well-- people are nice, but they're still in survival mode. Everything is about what can someone else do for them. In particular, white males. And that's understandable, given recent history. It's all about the hustle. Apparently the “Bath and Leisure Center,” a Chinese-run establishment (and yes, it's what it sounds like) and other NGO-based comfort/service industries just follow the UN wherever it goes. So there's this interesting dynamic between aid groups and this aid and aid-worker based economy in these post-conflict areas. I'm told an interesting book on this kind of thing written by some former Doctors without Borders folks (I think) is titled “Emergency Sex.”

So, we decided to go to this after club. And the nurse decided to go home. Leaving me, Rachel and Ben, a Liberian telecom business man. And it was like I was thrown to the wolves. Wolves who wanted money. About 30 seconds after getting a drink and separating from my friends by ~ 10 yards, I was approached by a girl who started talking to me. She said her name and had a pretty well-thought out/detailed back-story. Living in Europe, back visiting for a few days, first time at the bar, etc... It was kind of an interesting sociological experience.

Throughout the evening, I heard a lot of plausible if improbable back-stories from girls with names of questionable veracity such as “Venus” and “Promise” (though, to be fair, two patients of mine in the ED over the past few weeks have been named “Baby-girl”). Apparently it's pretty common practice for girls, even those with regular jobs or students, to kind of look for foreigners to attach themselves to while they're in-country in the hopes of money for school, some meals/drinks, etc. You get what you can and you don't know what that is until you try, I guess. I think it's an offshoot of the same kind of situation as the “Older-white-male-former-aide-worker/ex-pat-and-the-younger-local-girl” phenomenon that skeeves me out a bit. My brother Lee said it's the same in Thailand. Everything and everyone is for sale, and there are no moral implications to buying a stick of gum, a bottle of water, a mosquito net, a shoe-shine or a “something else shine.”

On the one hand, hey, everybody gets something out of that situation. People are operating at different levels in Maslow's “Hierarchy of Needs,” and will do what they can to satisfy the impulses for food, shelter, security, sex, etc. (I think self-actualization is the last one on the list-- anyone get there yet? Please write back and tell us what it's like). And a girl I dated once worked as an exotic dancer to get through school, so I've heard about this from a few view points. Exploitation and opportunity. The broader implication for women in society versus the very real implications of not having enough to eat. The physician's responsibility to do the most/best for an individual patient versus the public health perspective of what is or is not cost-prohibitive to a society's health care system... There's a well-known tendency is psychology of people to have different interpretations of a given situation depending on which role they play in it. "The Fundamental Attributional Error" is the tendency to assign to someone in a situation ("disorganized patient presentation and late for rounds) personal attributes as the reason for their behavior ("he's lazy and unprepared"), though when in the same situation themselves to assign outside agents ("traffic, alarm clock broke, the patient can't give a good history," etc) as primary.

So certainly it's difficult to judge people for doing what they can to make the best of their situation. But there is a certain amount to be said for recognizing the enormous informal power differential between the two people in that ex-pat/local relationship and acting accordingly, and I think that though morality may be relative, you should stick with the set of morals you've picked for yourself and go with it.

For those interested in the particulars rather than the abstracts of that evening, let's just say that I did not avail myself of the opportunity to support a local business project or pay any school fees or stimulate the informal business sector. Nor did I take advantage of a potential opportunity to reinforce on a micro level the over-arching behavioral change model messages regarding safe-sex practices. The neo-liberal guilt I am currently suffering as a result of these failings is, I assure you, more than punishment enough.

Though there was one very entertaining cat-fight-- “That girl's a prostitute!” “Who are you to say I am a prostitute? You are a prostitute!” (scuffle, scuffle; Security Guard bodily picking up and carrying one small Liberian girl to the exit) "Um, I guess I'll have another Jameson & soda...?"

till the next time...

On meeting the President and ED VIPs

I'm not a huge fan of the concept of VIPs in the ED. As far as I'm concerned, the only categorization should be based on severity/stability (“sick” vs. “not sick”). Perhaps this makes me too much of a socialist? But it's also true that any time as a health professional you're asked to see someone as a favor, you run a significant risk of the interpersonal/social situation informing and overwhelming the clinical aspects. One will almost always end up doing too much or two little when emotionally involved. And besides, I think the motto of the Osler firms (the medical service at Hopkins) was “aequinamitas,” or “equanimity” pretty much sums it up. It's the characteristic of a physician to maintain composure and remain un-impassioned or prejudiced no matter what or whom came to him/her. I'm glad you're powerful/influential, but if you're not sick or in pain you have to wait. One of the errors providers make is to think that patients or their families are being “annoying” when they keep pestering you about their case. It's like the survival mode-- if you don't speak up, you could be forgotten. If you don't push yourself to the front of the line, someone else will and you'll get left behind. It's understandable, especially when people don't understand what part of their care is important and what part isn't (Ok, guilty on this one-- I really don't care that there's some blood backing up in your iv tubing. It's gravity and the most benign thing likely to happen to you during your ED stay. Besides, if you're conscious enough to tell me, you may not even need it).

It's a two-way street, though. I mean, I'll let you know when I get the labs back-- every time you ask me is time I can't use to do something about those results, if need be. (Trust me, your ED doc would love to discharge you-- really, no matter how cute you think you are, we'd rather you be home. But constantly checking to see if you can go home will in no way change the order of things we have to do in a shift such that you'll go home before I get that child over there breathing again. Just try to understand that, and I'll try to understand when you don't. One of the things ED providers always fantasize about is going to each of their patients' places of work (ok, big assumption there) and following them around asking questions implying they don't know how to do their jobs. :) One of my favorite responses that I think every time but have rarely said is to ask the insistent/entitled patient to get a note signed by all the other patients that they should be seen first, and I'd be happy to do so... Goes over better in my head than in real life.

Anyway, got called over to the hospital on a “day-off” by one of the Pas to help with a patient. So, I should never really get called to the hospital, and so when the call came I threw on some clothes (was about to take a shower) my flip flops and grabbed my stethoscope. I saw her, in the VIP room up on the floor, and made a few recommendations. Turns out, though, that she is a former head of the interim government of Liberia and close personal friend of Ellen Sirleaf. And it turns out the President wanted to visit that afternoon. So, t-shirt, flip-flops, jeans, bed-head and all, I met a woman whose historical significance (as the first elected female head of an African nation) is certainly in the same range as President Obama's. Yeah, I made a winning impression, I'm sure. ;)

Not uplifting?!?!? / Fauna of JFK

So, thanks for the emails and the comments on the blog and the general well-wishes. I also want to thank my Jacobi friends (ok, mostly Chertoff...) for all the pictures from Graduation. Wish I could've been there. I'll miss my Jacobi buds.

And, thanks to Schultz for the pictures from the Kenyon 10 year reunion! So good to see you guys-- sorry I couldn't make it!

It has been commented that the postings have been “depressing.” While likely true, this is mostly my fault. You'll notice pictures are primarily of things and situations and cases. I think this is partly because I'm taking, and therefore not in, most of the pictures. And, probably also because I don't imagine people who aren't here are going to be interested in random pictures of people. And maybe it's because my personality is such that I focus on situations and goals and “the work” and less on “the relationships.” That probably is true of me, but I also hope some of it is because the good stuff I like to live while I'm there having it, and the pictures of it sort of fall by the wayside. I'd like to think that's true, anyway.

So, this is a wholly positive posting to counter the "not uplifting" naysayers...

The kid in the bed smiling was hit by a car, a pretty common reason kids come in. While I was examining his leg, he actually sat up in the cot, grabbed my elbow and bit me. I looked at him, attached as he was to my arm, and said “Really? You're biting me now? I can't believe you're biting me.” He laid back down. But now we're friends, because pictures don't lie.

He also introduced me to a phrase I've been hearing a lot with these kids. Introducing the concept of pre-examination analgesia/sedation, I often draw up a bunch of meds in front of them. To a toddler, they all scream out “White Man, don't juke me!” I have learned this means not only “trick” or “get the better of” but also very specifically “Don't stick me with that needle,” it's most common usage. I enjoy that this verb has evolved to serve so specific a purpose. I'm reminded of the verb enratonar, which Chris Stoltz from high school and I found in one of the Marlows' old Spanish dictionaries. It is a verb (regular conjugation) meaning “to become sick (vomit) from eating too many rats.” I'm pleased not only to imagine that this was a common enough occurrence to warrant an entire dedicated verb, but also to think that there existed such a thing as eating an appropriate number of rats...

Speaking of which, the two mice in my room (I've named them “Lassa” and “Hanta” for reasons close to my heart-- don't worry, hemorrhagic fever is mostly a late rainy season phenomenon. Mostly...) recently finished off the rest of my trail mix (thanks, Dorrit II). They are pretty acrobatic in that they enter the room by climbing down the window-side of the 7 foot dark red curtains that hang over and next to my bed. I would hear this progressive scratching on them at night and used to wonder, but then I hit the noise with a flip-flop and one of them, Hanta I believe, fell from the other side. So now it's kind of reassuring to know they're there.

And while on the topic of interesting fauna, the biggest example of the common Hobo or Aggressive House Spider I have ever seen, Nemesis, is no more. He's documented here, living in the supply closet designated for HEARTT equipment.

The other day I was looking for c-collars because the President of the country was going on a trip and one of the admins thought it'd be a good idea for us to lend them some (I'm not kidding), and Nemesis jumped out of a box of cardiac monitor adhesive leads (We have no cardiac monitors). And maybe I screamed like a little girl. Look, I'm wearing my Keanes, which offer no protection, ok? So one of the patients on the trauma side of the ER came over and killed Nemesis for me, as I cowered in a corner. Not really cowered-- I was trying and failing to squash him with an old Harriet Lane handbook. Still, this surgical patient thought I looked like I needed saving. Score one for manliness, USA.

Oh, and the reason I'm giving a talk about rabies to the medical students is because this little beast was in the common lounge in the medical dorms the other night when I'm trying to post to this blog. It's not enough to hope there's power and signal and time, now I have to hope there are no bats.

Ok, soldiering on...