I visited the 'My Cancer' blog on NPR again today. Breifly, it's a blog that was started by Leroy Sievers, a NPR correspondent, when he found out that he had cancer. Colorectal, I believe. The cancer metastasized and Leroy fought it day-to-day, blogging his valiant attempts. He passed away in August. It was odd, because I actually stopped reading the blog for a while when I was out of the country and I remember re-visiting the blog to find only a two sentence entry from Leroy that day. An unspoken air of endgame hung thick as I read his brief entry that day.
I stopped visiting the blog after his death thinking that the blog would be archived and nothing else would be added to it. To my surprise, Leroy's wife has continued to keep up the blog, now documenting her struggles with trying to move on after the death of her husband. It is crushingly heartbreaking to watch one human try to comprehend what to do now that their partner of many years is no longer around. She talks about going through her husband's medical supplies, about the bedpans, the medicines, the other supplies that inevitably make their way into one's house and one takes care of a loved one in the final days of their life.
Transferrance is a bitch. I forsee the brief respites that I will get to have while my dad sleeps, when I will sip on a hot cup of tea or coffee, surrounding by iv drips, other medical supplies, plates with half eaten foodstuffs because he's losing his apetite. Five, ten minutes before he wakes up, in pain, maybe short of breath, I don't know. I've seen enough heart failure patients professionally to know how this endgame is played. No queening of pawns or sudden checks, just the inexorable march of a disease process against a wounded king. These days are ahead; I have the days now to prepare for them.
Saturday, September 27, 2008
Thursday, September 25, 2008
The King
They called him "The King", a patient so notoriously known to the medical service that residents bragged about the number of times they had admitted him over a one year period. For his part, he was remarkably polite, and with a fantastically amicable personality: "I assume you gonna stick my veins", he asked me matter-of-factly when I met him in the Emergency Department, turning his neck to one side. Like most sickle cell disease patients, the King had, though his many hospitalizations for pain crises, been effectively turned into a human pin cushion. His veins had become sclerosed from multiple cannulations by cold, sharp needles. They now protrouded from under his dark skin, tortuous and rubbery to the touch from the fibrosis that occurs when veins heal themselves after the iv catheters are removed.
I asked him about his sickle cell pain and about his recent heroin relapse. "I ran out of pain meds, so I used". Lucifer himself couldn't have come up with a more nefarious confluence; take a population that is already economically disenfranchised (namely inner city baltimore) and add to it a high prevalance of a disease (sickle cell) that requires large amounts of narcotics and you've got yourself a perfect storm of sorts. A lot of sicklers don't have the necessary resources (insurance, transportation to/from clinic, money for co-pays) for close follow-up of their sickle cell disease, and with a substance far more effective than any legal narcotic available just outside their doors, the desire to put up with ten, twelve hour waits in the ED only to be seen by a 25 year old intern from Kentucky who doesn't know the first thing about the sickle cell pain or heroin and then wait for hours while being transferred to a floor before getting pain relief is understandably low.
I attempted to cannulate his external jugular vein on his neck. Once, twice, but with no success. The veins were so rubbery that it was hard to even pierce their outer walls. He was remarkably patient with my bumbling attempts to acheive accesss. "Try the one in the back", he suggested, sugesting that I try one of the branches of the EJ, one that perhaps wouldn't be so sclerosed. The third try was the charm, as we achieved a good flash and I threaded the catheter in, my back pulsing with pain from bending forward in the same position for over an hour . Earlier, while attempting to hide my incompetence in gaining access, I engaged the King in conversation: "Do you work?"
"No"
"Is it because of the sickle pain?"
"Yeah"
"What would you do if you could?"
"I've always wanted to work with animals. Maybe in a vet office"
His neighbor, another sickler I admitted earlier that day, chimes in:
"Eh, doc, how much you make, man?"
I chuckle: "How much you think?"
"Eh, I bet you make 40, 50 thou"
I was impressed with his accurate assessment of resident salaries.
"I like to draw, too", The King continued. I had heard about this. In the resident work room hung beautiful pictures of wildlife and other scenery. I always assumed that this was the work of a multi-talented resident or one of the other staff but in fact, they were the King's work; he often sublimated his sickle pain into these drawings. This night, before I subjected him to my poking around his neck, he had been working on a picture of a large cat, a puma or panther or some sort. It looked like something out of a zoology text.
"I prefer Dilaudid with a basal rate of 2", he continued. He was so familiar with the treatment of his disease that he practically managed himself. He told me when to go up on his fluids, when to change his pain meds. Pain management is often the hardest part of managing sickle cell but with the King, you simply asked him. "Tomorrow, let's go down to 1.5, doc", he told me the next day. I nodded, smiled, asked him about his breakfast, and then moved on to the next patient.
This was his life. Over the last year, he had spent more time in the hospital than out of it. His life consisted of episodes of pain control in the hospital followed by going back out to the street, staying on pain meds for a while, lapsing into a pain crisis and ending up back in the hospital. His toxicology had been negative for a few visits, so I was optimistic about his ability to stay away from heroin, but I didn't dare entertain images of the King beating this sickle cell thing, settling into a quiet neighborhood and start working at a vet's office in suburban Baltimore.
Two weeks after I discharged him, I was on my way up to the office when I saw him sporting his signature EJ IV line, walking in the lobby towards the smoking area. No doubt another intern had inserted that line last night. Another young doctor was now running around this campus thinking about how if he could just get this new patient's pain under control, he just might beat this sickle cell thing and not have to be hospitalized ever again. Three weeks ago, that young doctor was me, now it was somebody else's turn.
I asked him about his sickle cell pain and about his recent heroin relapse. "I ran out of pain meds, so I used". Lucifer himself couldn't have come up with a more nefarious confluence; take a population that is already economically disenfranchised (namely inner city baltimore) and add to it a high prevalance of a disease (sickle cell) that requires large amounts of narcotics and you've got yourself a perfect storm of sorts. A lot of sicklers don't have the necessary resources (insurance, transportation to/from clinic, money for co-pays) for close follow-up of their sickle cell disease, and with a substance far more effective than any legal narcotic available just outside their doors, the desire to put up with ten, twelve hour waits in the ED only to be seen by a 25 year old intern from Kentucky who doesn't know the first thing about the sickle cell pain or heroin and then wait for hours while being transferred to a floor before getting pain relief is understandably low.
I attempted to cannulate his external jugular vein on his neck. Once, twice, but with no success. The veins were so rubbery that it was hard to even pierce their outer walls. He was remarkably patient with my bumbling attempts to acheive accesss. "Try the one in the back", he suggested, sugesting that I try one of the branches of the EJ, one that perhaps wouldn't be so sclerosed. The third try was the charm, as we achieved a good flash and I threaded the catheter in, my back pulsing with pain from bending forward in the same position for over an hour . Earlier, while attempting to hide my incompetence in gaining access, I engaged the King in conversation: "Do you work?"
"No"
"Is it because of the sickle pain?"
"Yeah"
"What would you do if you could?"
"I've always wanted to work with animals. Maybe in a vet office"
His neighbor, another sickler I admitted earlier that day, chimes in:
"Eh, doc, how much you make, man?"
I chuckle: "How much you think?"
"Eh, I bet you make 40, 50 thou"
I was impressed with his accurate assessment of resident salaries.
"I like to draw, too", The King continued. I had heard about this. In the resident work room hung beautiful pictures of wildlife and other scenery. I always assumed that this was the work of a multi-talented resident or one of the other staff but in fact, they were the King's work; he often sublimated his sickle pain into these drawings. This night, before I subjected him to my poking around his neck, he had been working on a picture of a large cat, a puma or panther or some sort. It looked like something out of a zoology text.
"I prefer Dilaudid with a basal rate of 2", he continued. He was so familiar with the treatment of his disease that he practically managed himself. He told me when to go up on his fluids, when to change his pain meds. Pain management is often the hardest part of managing sickle cell but with the King, you simply asked him. "Tomorrow, let's go down to 1.5, doc", he told me the next day. I nodded, smiled, asked him about his breakfast, and then moved on to the next patient.
This was his life. Over the last year, he had spent more time in the hospital than out of it. His life consisted of episodes of pain control in the hospital followed by going back out to the street, staying on pain meds for a while, lapsing into a pain crisis and ending up back in the hospital. His toxicology had been negative for a few visits, so I was optimistic about his ability to stay away from heroin, but I didn't dare entertain images of the King beating this sickle cell thing, settling into a quiet neighborhood and start working at a vet's office in suburban Baltimore.
Two weeks after I discharged him, I was on my way up to the office when I saw him sporting his signature EJ IV line, walking in the lobby towards the smoking area. No doubt another intern had inserted that line last night. Another young doctor was now running around this campus thinking about how if he could just get this new patient's pain under control, he just might beat this sickle cell thing and not have to be hospitalized ever again. Three weeks ago, that young doctor was me, now it was somebody else's turn.
Sunday, June 15, 2008
Fred
He was about ten or eleven, with a stocky build and puffy cheeks that made him look uncannily like a young Biggie Smalls. Of course the build and the cheeks were newly acquired; like most of the other kids in Kempala, he was on the border of being malnourished before his kidney disease relapsed. Now, the fluid building up in the interstices of his tissues gave him the deceptive appearance of being plump. During morning rounds, he sat under the bed, determined not to let me disturb his morning meal of bananas with a side of bananas. A small red transistor radio next to him noisily blared soccer match highlights in Lugandan. Both him and the flies that were enjoying his breakfast with him seemed content to slowly ruminate on the piping hot matoke, mashed non-sweet bananas, while the commentator wailed on about a recently scored goal. The room itself held about fifteen kids, each separated from the next by his or her parents' bedding supplies, which were spread inbetween the beds. Outside a quilt of orange, purple and yellow covered the grass on the hill; morning was laundry time, and the moms were out hand washing their previous days' clothes.
He did not like me pushing around on his fluid filled belly, but grudgingly agreed after a winnie the pooh sticker. His look was arresting; I did not think kids at his age had learned, or rather, had the life experience to discover, the facial expression for apathetic resignment. The flies too seemed to be cognizant of this; they flocked to his matoke meal in droves, arrogantly convinced that he would not spend any energies in keeping them off his meal.
"He has recurrent, resistant nephrotic syndrome".
"So, can we try immunosuppressants"
A chuckle that had by now, two weeks into the rotation, become irritatingly familiar, followed.
"Doctor, you forget that this Africa. This family cannot afford cyclophosphamide. We will give them a prescription, of course"
It was one in the afternoon and Fred was squatting next to the wall, outside the kidney unit, hanging out in the shade with several of his fellow puffy friends. They warily check me out as I approach. I ask him how he is and if he would like another sticker, in English. I get a weak smirk back. Fred was never one for flippancy, especially when talking with foreigners. I liked this about him; he had a "So what if you are foreign, I'm not impressed" air about him that I found amusing.
I was late for a lecture across the sprawling campus. The lecture was in the pediatrics department and I was still stuck in casualty. I passed laboratory specimen collection table and a familiar body habitus lying atop one of the tables caught my eye. It was him, but he was unconscious. His mom was next to him, muttering continously in Lugandan. I piece together that he had been feeling worse since yesterday and spiked a fever this morning. The attending on service agrees with the plan to start antibiotics, and with it being Friday, I leave the ward feeling pretty confident. I had found Fred by luck, in the nick of time, and antibiotics and fluids are fast entering his system to help his fight off his infections as I walked back to the guest house to pack for a fun weekend of sight seeing.
Fred died that weekend. While I was lounging on the banks of the Nile, Fred's body, weak with a lack of calories and anti-bodies that he had lost because of protein loss in his urine, gave up.
When I returned Monday morning, his bed was simply empty. No chart, and none of the nurses knew where he was. The flies that had gotten fat off Fred's meals were still buzzing around the empty plate lying under his bed.
He did not like me pushing around on his fluid filled belly, but grudgingly agreed after a winnie the pooh sticker. His look was arresting; I did not think kids at his age had learned, or rather, had the life experience to discover, the facial expression for apathetic resignment. The flies too seemed to be cognizant of this; they flocked to his matoke meal in droves, arrogantly convinced that he would not spend any energies in keeping them off his meal.
"He has recurrent, resistant nephrotic syndrome".
"So, can we try immunosuppressants"
A chuckle that had by now, two weeks into the rotation, become irritatingly familiar, followed.
"Doctor, you forget that this Africa. This family cannot afford cyclophosphamide. We will give them a prescription, of course"
It was one in the afternoon and Fred was squatting next to the wall, outside the kidney unit, hanging out in the shade with several of his fellow puffy friends. They warily check me out as I approach. I ask him how he is and if he would like another sticker, in English. I get a weak smirk back. Fred was never one for flippancy, especially when talking with foreigners. I liked this about him; he had a "So what if you are foreign, I'm not impressed" air about him that I found amusing.
I was late for a lecture across the sprawling campus. The lecture was in the pediatrics department and I was still stuck in casualty. I passed laboratory specimen collection table and a familiar body habitus lying atop one of the tables caught my eye. It was him, but he was unconscious. His mom was next to him, muttering continously in Lugandan. I piece together that he had been feeling worse since yesterday and spiked a fever this morning. The attending on service agrees with the plan to start antibiotics, and with it being Friday, I leave the ward feeling pretty confident. I had found Fred by luck, in the nick of time, and antibiotics and fluids are fast entering his system to help his fight off his infections as I walked back to the guest house to pack for a fun weekend of sight seeing.
Fred died that weekend. While I was lounging on the banks of the Nile, Fred's body, weak with a lack of calories and anti-bodies that he had lost because of protein loss in his urine, gave up.
When I returned Monday morning, his bed was simply empty. No chart, and none of the nurses knew where he was. The flies that had gotten fat off Fred's meals were still buzzing around the empty plate lying under his bed.
Tuesday, March 25, 2008
Jamaica, Part I
I landed in Montego Bay, walked outside and basked in the glorious, cloud-free sunshine. It was around noon and the area in front of the terminal was teeming with cab drivers yelling out destinations in patois (or, patwah) - the Jamaican version of english consisting of shortened words and continuous run-on sentences all spoken in a slurred fashion. It did not sound even remotely like English, especially when spoken fast. I met the pastor, who was to take me and my attending doc to the church clinic where we were going to work for the next four days. The clinic was in the mountainous region of Jamaica in between Montego Bay and Kingston.
While waiting for my attending's flight to land, the pastor and I spoke about Jamaica and religion (he was a devout evangelist protestant with a lisp, a head of mossy hair, a protuberant belly and a cane). Apparently, Jamaica has the most number of religious institutions per square mile of any country. He continued speaking of discipline, sins and redemption and I listened half-attentively as we sat on plastic chairs at a table still covered with empty Red Stripe beer bottles, with hungry, possibly tipsy flies circling above them. As the afternoon wore on, the heat only intensified the aromas of fruit, spiced meat and beer that hung thick over the canopy outside the airport.
With several hours to kill, we decided to grab lunch (chineese, of all cuisines). He continued speaking to me about his twelve years in Jamaica and how he had once been a lost teenager in Missouri, a casualty of teenage foolishness, and about how he had found God in a revival ceremony once summer night, and was now in Jamaica trying to save more lost souls. He was going deaf in one ear, and perhaps partly as a mechanism to ensure that he didn't overcompensate by speaking too loudly, he spoke in soft tones, ending his sentences in trailing "sh" sounds that added to the comprehension difficulties.
After my attending arrived, we set off to the car. The driver, Killa' (apparently, everybody in Jamaica has nicknames, and Killa' got his nickname for his soccer skills) was a tall, lanky appearing guy with a neatly trimmed mustache and a seemingly endless supply of patience. He negotiated his way out of the Mo' Bay traffic, deftly weaving in between cars and pedestrians as we sped past the resorts, the golf courses and the air conditioned buses that were taking American tourists to their all-inclusive vacations. The facade is paper thin; within minutes, the road turned to unleveled asphalt, the views from the car window turned from flowing golf greens to clusters of tin-roofed shacks with clotheslines strung haphazardly across houses, covered with brightly colored shirts and pants waving to me, welcoming me into the Jamaica proper.
The pastor had other business to take care of in the car before reaching the church, so we switched vehicles to a giant '80s style minibus (which apparently had just had it's engine rebuilt). Cars, like most other goods, continue to be taxed heavily in Jamaica, the pastor told me, and he had to rely on second hand vehicles for transport. I met the drivers, Beckman (apparently named after a English soccer star, which made me wonder if perhaps he meant Beckham, but I didn't ask any further questions on the matter) and Steve (one of the few guys on the island without a nickname, it seemed). We continue driving inland, past the new cricket stadium and soon, we were in mountainous terrain, the van faithfully chugging along at a blazing 45 km per hour. The vegetation was dense beyond belief, thick green vines wrapping around crowded trees, shrubs and grasses. Through the small openings in the thick vegetations, one could see farther into the forest; red stone hills rose at incredibly sharp angles, the angles of their valleys blunted by the forest below.
Amongst all this unperturbed wildlife, faint traces of human life showed; a canopy here, a thatched roof showing there. This was the cockpit country, home to a very reclusive group of Jamaica peoples who notoriously known for raiding British plantations back in the day of colonialism and for coining the phrase "Me no sen, you no com". They preferred their isolation, and the forest itself seemed to have embraced them with its sinous vines and thick grasses, shielding them from the prying eyes of passers-by tourists.
We continued on past some of the smaller mountain towns: Albert Town, Wait-A-Bit, Clarke's Town. We drove past the sugar cane fields as the fires were being set in order to convert the dried sugar cane cellulose into charred remains; this will serve as fertilizer for the next year's crop. The men working on the fields were silhoutted in black against the conflagration behind them, making for a visually assaulting scene. As we approached the end of our trip, we decided to stop for some grub. At a roadside stand, Beckman and Steve hungrily tore into their jerk pork while I nibbled on a piece of hard-dough bread, sympathetically given to me by the shop vendor as he did not have any other vegetarian options to offer. The night had turned cool, and I was enjoying the unpolluted view of the stars offered by the Jamaican sky, one replete with multitudes of shimmers stars in hues of blue, red and gray.
Steve returned to the van only to start exclaiming loudly in patois. I had no idea what the matter was, but within seconds, Beckman too was gesticulating wildly, spewing heaps of English sounding syllables with no seeming beginning or end. He opened the hood of the van and started looking around. Now, it became clear that the van was not starting and these guys had no idea why. As if sensing automotive distress by telepathy, four other guys appear out of the nearby shrubbery, each speaking rapidly in patois. One of the them pulls out a cell phone and uses the backlight to try to see deep into the recesses of the engine. He points to a wire and then yanks it out, then motioning Steve to try starting the car again. No good.
As the evening wore on, guys passing by on the road would stop and come by to see what was going on. One guy tried to jump start the van with his battery by removing his battery then connecting his battery to the van's battery not by jumper cables but with two metal spanners. By the time an hour had past, Beckman had resorted to punching the starter motor with his hand. We even pushed the van back a few feet, up a hill and then back down the hill, but to no avail.
Suddenly, without notice, Killa' shows up, now in a different car and with his wife and kids in the back seat. I was starting to get the feeling that I was in a Carribean version of a S.E. Hinton novel. One of the guys in fact did bear a striking resemblance to my internal image of Sodapop. A few more attempts at starting the van and the guys decide that the situation is hopeless. More to the point, the store owner, who had been quietly putting up our nincompoopery all night was getting testy. Also, several of the guys working on the van were getting pretty intoxicated and had became belligerent, and were starting to yell at Steve for his lack of skill in starting a car while it was being pushed down a hill. Beckman for his part looked like he had just swallowed a sack of lemons; he was panting and complaining of pain in his stomach (only later did I find out that Jamaicans, including portly Beckman, often called their chest their stomach).
So, we decide to abandon the van at the roadside and pile into Killa's car, finally reaching the church around midnight.
All this, and clinic work hadn't even started yet.
While waiting for my attending's flight to land, the pastor and I spoke about Jamaica and religion (he was a devout evangelist protestant with a lisp, a head of mossy hair, a protuberant belly and a cane). Apparently, Jamaica has the most number of religious institutions per square mile of any country. He continued speaking of discipline, sins and redemption and I listened half-attentively as we sat on plastic chairs at a table still covered with empty Red Stripe beer bottles, with hungry, possibly tipsy flies circling above them. As the afternoon wore on, the heat only intensified the aromas of fruit, spiced meat and beer that hung thick over the canopy outside the airport.
With several hours to kill, we decided to grab lunch (chineese, of all cuisines). He continued speaking to me about his twelve years in Jamaica and how he had once been a lost teenager in Missouri, a casualty of teenage foolishness, and about how he had found God in a revival ceremony once summer night, and was now in Jamaica trying to save more lost souls. He was going deaf in one ear, and perhaps partly as a mechanism to ensure that he didn't overcompensate by speaking too loudly, he spoke in soft tones, ending his sentences in trailing "sh" sounds that added to the comprehension difficulties.
After my attending arrived, we set off to the car. The driver, Killa' (apparently, everybody in Jamaica has nicknames, and Killa' got his nickname for his soccer skills) was a tall, lanky appearing guy with a neatly trimmed mustache and a seemingly endless supply of patience. He negotiated his way out of the Mo' Bay traffic, deftly weaving in between cars and pedestrians as we sped past the resorts, the golf courses and the air conditioned buses that were taking American tourists to their all-inclusive vacations. The facade is paper thin; within minutes, the road turned to unleveled asphalt, the views from the car window turned from flowing golf greens to clusters of tin-roofed shacks with clotheslines strung haphazardly across houses, covered with brightly colored shirts and pants waving to me, welcoming me into the Jamaica proper.
The pastor had other business to take care of in the car before reaching the church, so we switched vehicles to a giant '80s style minibus (which apparently had just had it's engine rebuilt). Cars, like most other goods, continue to be taxed heavily in Jamaica, the pastor told me, and he had to rely on second hand vehicles for transport. I met the drivers, Beckman (apparently named after a English soccer star, which made me wonder if perhaps he meant Beckham, but I didn't ask any further questions on the matter) and Steve (one of the few guys on the island without a nickname, it seemed). We continue driving inland, past the new cricket stadium and soon, we were in mountainous terrain, the van faithfully chugging along at a blazing 45 km per hour. The vegetation was dense beyond belief, thick green vines wrapping around crowded trees, shrubs and grasses. Through the small openings in the thick vegetations, one could see farther into the forest; red stone hills rose at incredibly sharp angles, the angles of their valleys blunted by the forest below.
Amongst all this unperturbed wildlife, faint traces of human life showed; a canopy here, a thatched roof showing there. This was the cockpit country, home to a very reclusive group of Jamaica peoples who notoriously known for raiding British plantations back in the day of colonialism and for coining the phrase "Me no sen, you no com". They preferred their isolation, and the forest itself seemed to have embraced them with its sinous vines and thick grasses, shielding them from the prying eyes of passers-by tourists.
We continued on past some of the smaller mountain towns: Albert Town, Wait-A-Bit, Clarke's Town. We drove past the sugar cane fields as the fires were being set in order to convert the dried sugar cane cellulose into charred remains; this will serve as fertilizer for the next year's crop. The men working on the fields were silhoutted in black against the conflagration behind them, making for a visually assaulting scene. As we approached the end of our trip, we decided to stop for some grub. At a roadside stand, Beckman and Steve hungrily tore into their jerk pork while I nibbled on a piece of hard-dough bread, sympathetically given to me by the shop vendor as he did not have any other vegetarian options to offer. The night had turned cool, and I was enjoying the unpolluted view of the stars offered by the Jamaican sky, one replete with multitudes of shimmers stars in hues of blue, red and gray.
Steve returned to the van only to start exclaiming loudly in patois. I had no idea what the matter was, but within seconds, Beckman too was gesticulating wildly, spewing heaps of English sounding syllables with no seeming beginning or end. He opened the hood of the van and started looking around. Now, it became clear that the van was not starting and these guys had no idea why. As if sensing automotive distress by telepathy, four other guys appear out of the nearby shrubbery, each speaking rapidly in patois. One of the them pulls out a cell phone and uses the backlight to try to see deep into the recesses of the engine. He points to a wire and then yanks it out, then motioning Steve to try starting the car again. No good.
As the evening wore on, guys passing by on the road would stop and come by to see what was going on. One guy tried to jump start the van with his battery by removing his battery then connecting his battery to the van's battery not by jumper cables but with two metal spanners. By the time an hour had past, Beckman had resorted to punching the starter motor with his hand. We even pushed the van back a few feet, up a hill and then back down the hill, but to no avail.
Suddenly, without notice, Killa' shows up, now in a different car and with his wife and kids in the back seat. I was starting to get the feeling that I was in a Carribean version of a S.E. Hinton novel. One of the guys in fact did bear a striking resemblance to my internal image of Sodapop. A few more attempts at starting the van and the guys decide that the situation is hopeless. More to the point, the store owner, who had been quietly putting up our nincompoopery all night was getting testy. Also, several of the guys working on the van were getting pretty intoxicated and had became belligerent, and were starting to yell at Steve for his lack of skill in starting a car while it was being pushed down a hill. Beckman for his part looked like he had just swallowed a sack of lemons; he was panting and complaining of pain in his stomach (only later did I find out that Jamaicans, including portly Beckman, often called their chest their stomach).
So, we decide to abandon the van at the roadside and pile into Killa's car, finally reaching the church around midnight.
All this, and clinic work hadn't even started yet.
Saturday, February 16, 2008
So, I'm going to Uganda
The stroke service has to undoubtedly be the most depressing and uplifting service at the same time. The old to older patients with devastating MCA strokes just kept on coming. One after another. So much so that the patients starting running together. The talk to the family became upsettingly repetitive: "He's suffered a big stroke", "he may not get a lot of his function back", "he arrived too late for us to give tPA", etc.
The blast of winter weather outside did not help matters. Throw into this somber situation, a good number of patients who seem to be stroking out for no good reason. What did these people do to anger their brain? 20, 30 and 40 year olds showing up in the ER without the ability to speak, numbness...it just didn't add up. There was dicussion of the usual rare conditions that can cause strokes in young folk, but I still refuse to believe that 3 people admitted at the same time all suffered from moya moya, a rare condition typically only found in japaneese kids.
The moya moya discussion was pretty funny, though:
Attending: "So, what's moya moya?"
Student: "Isn't that a kind of fish?"
Attending: "No, that's mahi mahi"
After two more weeks of Neurology, I am going to be in Bowling Green for 4 weeks, doing a homecare rotation. As part of that rotation, I also get to spend a week in Jamaica, doing international work. Afterwards, it's off to Uganda for a month for a peds/adult rotation. All around, it will be fun to try to graduate without having contracted malaria.
Oliver Sacks, the famed doctor/writer, wrote a book called "The man who mistook his wife for a hat". It's called prosopagnosia, one in a number of "agnosias", where a patient does not recognize something, whether it is a loved one's face or an entire side of the his body or even the fact that anything was wrong with him or herself. I saw the first patient with neglect this week, and it was striking. He simply refused to acknowledge the right side of his body. You move to his right and all of a sudden, he would not respond to you, would not even look at you. I wonder what his visual field looks like; it wonder if it is somewhat analagous to watching tv with half the screen blacked out.
The entire stroke team, all 12 of us, crowded around the patient, along with his family, and watched him fail auditory and visual tests. He couldn't speak, his arms limp, his face without any expression.
I watched this documentary once where a pride of lions surrounded a hurt female and simply stood there, their manes hung low, watching the female lick her wounds, knowing that there was nothing they could do.
Friday, January 4, 2008
So, it has been a year...
So, a year has gone by since my last entry, and save the multitude of calls and shelf exams and such, nothing too exciting has happened. Interview season has now come and is on its way out. Mostly, the hospitals all blur into one; some combination of nurses, beds, sick people and a tour guide talking about the upcoming renovation. It was remarkable same, regardless of which part of the country I was in. Hopkins was by far the most impressive, with a staggering number of residents and fellows all roaming around a gargantuan hospital with hallways all named after former chiefs of medicine. So, directions were often given as such: Go down Nelson, turn into Halstadt, etc...
As far as interesting cases goes, there were certainly two that stand out. First was a middle aged man with rheumatoid arthritis who developed fulminant sepsis / septic arthritides (that's right, polyarticular septic joints) and an abdomen full of abscess all due to immunosuppressive therapy with immunomodulators. The second interesting case was a gentleman who arrived in the ED with very labile blood pressures and a remote history of heart disease. He developed respiratory failure with subsequent failure to wean and was finally diagnosed with FSGS with concommitant HCV infection. Those two cases pretty much take the cake as far as zebras go.
I'm still waiting on my first pheo...It's bound to show up one of these days.
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