Why Botswana?

Why not?

No, seriously. My friend John Pederson asked this question on my blog last week, and before I leave I might as well explain to my plethora of blog readers why I will find myself in Botswana, Africa in less than a week. My residency program (the Penn Internal Medicine Program) has a long-running affiliation with one of the larger public hospitals (it has over 550 beds) in Gaborone, Botswana called Princess Marina Hospital. As such, it is relatively easy to set up an "away elective" where we serve as residents in this hospital. It's also quite affordable compared other potential foreign electives, as the Penn program will pay for my airplane ticket (which is about $1700!) as well as my lodging in a communal flat not far from the hospital. I'll be spending 5 weeks working at PMH in Gaborone, followed by a week of vacation in Cape Town, South Africa. Hopefully I'll be able to get some traveling in on weekends, too--one of my goals is definitely to see some elephants. Throughout the 6 weeks I'll be accompanied by my resident friends Kara & Jon; plus we're going to overlap with a few other residents (Sameer, Matt, Helen, and George) so fortunately I'll have some good company.

Why did Penn choose Botswana? I'm not sure of the history. However, I think the fact that it's considered a very stable political situation helped. Also, while Botswana has one of the highest rates of HIV infection in the world (I am told that about 40% of the population is HIV+, and about 85% of the inpatients at the hospital I'm working at), it is also one of the few African countries which can afford anti-HIV medications AND has a sensible plan for halting its progression. A really good HIV in Botswana web site can be found here.

I'm told that I should have Internet access, but that it's not that fastest ever. I've also heard that I'm going to be crazy busy while working, so we'll have to see how often I'm able to make it my blog. However, it certainly sounds like a very blog-worthy place, so I'm going to do my best to keep things updated.

Stupid Toy Tricks

Okay, so I'll admit that yesterday's blog entry left something to be desired. But that's only because the "Display Image" function on blogger.com was transiently on the fritz and I so wanted to share with you all the veritable treasure trove of stupid items I found last night while web-surfing on stupid.com.

The gold-prize winner has got to be the "Ear Wax Candy", as pictured above, a gelatinous candy substance packed into a plastic ear to simulate, yep, you guess it, real human ear wax. Cerumen as we doctors might say.

Honorable mentions have certainly got to go to the "Crazy Cat Lady" action figure as well as "Nihilist Chewing Gum" (motto: "we don't believe in flavor.")

It is my hope that my life will continue to provide me with such meaningful and substantive blog-worthy topics with which to write about in the future.

In other news: I took my first dose of Lariam yesterday. Lariam (mefloquine is the generic name) is one of the anti-malaria medications you can take for prophylaxis which I am indeed doing prior to my Botswana adventure. It allegedly can cause nightmares or vivid dreams as one of its side effects but I slept like a rock last night...

To DC & Back...

Had a great time this weekend visiting first with my friend Iqbal and his family and then later with my sister Cathy, her husband Tim, and All-Star nephew Henry O'Malley. As you can tell by the expression on little Henry's face in the photo on the left, he still spends a substantial amount of his time voicing his discontent, to the delight of Cathy & Tim.

However, every once in awhile, a smile will creep across his face...causing all of us to momentarily forget his temporary lapses into fussiness! Here's a cute one on the right of Henry while being held by Claire...

In other Hellman news, scroll down this website to read Susie Hellman's bio from the Sarasota Opera's web page (Susie is performing for 3 months with them in the opera "La Boheme").

Penn Sweatshirt

My new Penn sweatshirt rocks the hizzouse. A birthday present from my wife last December, it has over the past several weeks developed into my default item of clothing to wear, in large part due to its tremendous versatility. Observe how the sweatshirt can be worn to give two dramatically different "looks":

What's cooler than being cool?

Trivia Question of the Day: According to the song "Hey Yeah!" by Outkast, what is cooler than being cool? Click here for the answer.

New season of Beauty and the Geek starts tonight. I watched a little bit of it...is this the stupidest television show of all time, or what? Maybe I'd consider watching if they had the mack-daddy himself, Chuck Munyon, put in a cameo appearance or something.

Not much else to report on today. I will end with some photos hot off the presses of my nephew Henry, who I am planning to visit this weekend...

Introduction to Botswana

So I'm done with the MICU and have started my 2 weeks of blissful "elective time". What's in store for the next few weeks? Well, as much as I'd like to sit on my ass and finish off my kick-ass video game "Star Wars: Knights of the Old Republic", I have quite a lot to accomplish in the next two weeks. The checklist:

#1: Write & submit a grant to the Fondation Recherche Medicale, a French scientific organization which gives out scientific grants--which I certainly will need if I don't want to find myself panhandling the Paris subway system next year. This will be the third grant that I've written on the same general topic (cystic diseases of the kidney) so hopefully I'll be able to do a lot of liberal cutting & pasting, however there's a kicker: the grant has to be written in French! Fortunately I have a good translator around the house (my wife) who has a vested interest in me not panhandling next year, so hopefully this can be accomplished in a timely fashion.

#2: Apply for a French visa. More bureaucracy, my favorite.

#3: Organize HUP BOWL III. More on this later. A bone-crunching, testosterone-laden annual contest of tackle football amongst the Penn Medicine housestaff which has become something of a tradition.

#4: Physically & mentally prepare myself for traveling to Botswana. I leave on Monday, Feb. 6th. So far my preparation has largely consisted of the following: I have plane tickets, and I bought the "Lonely Planet" book on Southern Africa yesterday. Beyond that I'm pretty much lost. However, I learned yesterday that somebody from Botswana is described as "Motswana" (DON'T use the term "Botswanese" or "Botswanan" or you will appear a ignorant fool) whereas a group of people from Botswana is called "Batswana". Good trivia material. Incidentally, I will be living in the capital of Gaborone, which is the largest city of Botswana with a population of approximately 186,000.

#5: general life organizational stuff (e.g., doing laundry, paying bills, shaving my ugly-ass beard) which has kind of slipped through the cracks while in the MICU...

Morbid Statistics

Okay so I'm cleaning out my backpack, into which I typically stuff all my patient-related papers and organizational sheets before I go home each day. I have a month's worth of MICU-related crap to sift through. As part of my personal organizational tactic, for each patient I take a regular sheet of 8.5 x 11" paper and fold it in half. In going through these cards, I note that over the past four week period my service has admitted a total of 26 patients over 9 full calls--an average of nearly 3 per call (which is actually a little higher than the other services I'm pretty sure--we had the bad luck this month).

Of the 26 patients, 8 died in the MICU. There were still 5 left in the MICU when I went off-service, so this number may be higher. The breakdown of deaths is illuminating:

pancreatic cancer (3)
lymphoma/leukemia (2)
hemorrhagic stroke (1)
delerium tremens (severe alcohol withdrawal) with a stroke (1)
pulmonary embolism (blood clot in the lungs), I think with sepsis to boot (1)

The moral of the story is that cancer is bad. Of the 18 patients I admitted who are still alive, only two of them had a diagnosis of cancer.

Here's the breakdown of the (tenative) survivors:

cancer (2)
asthma (2)
diabetic ketoacidosis (2)
liver failure (2)
diaphragmatic paralysis (1)
paroxysmal nocturnal hemoglobinuria (1)
altered mental status (1)
status epilepticus (1)
congestive heart failure (1)
sepsis (1)
tracheobronchitis (1)
alcohol-related metabolic abnormalities (1)
cystic fibrosis (1)
obstructive sleep apnea (1)

In completely unrelated news, please tell me that this website is a joke...

Holy Shit Sports Update

Holy shit! (which, incidentally, is one of my wife's favorite Americanisms she has picked up recently...)

Did you see that Kobe Bryant poured in 81 friggin' points against the hapless Toronto Raptors last night? This is the 2nd-most points in NBA history behind Wilt Chamberlain's historic 100-point night (a record many insist will never be broken given the way in which the current NBA game is played). As much as I dislike Kobe (always have...even before all the rapist accusations leaked out), I've got to admit that the man is a scoring machine.

In other sports news, it looks like the Pittsburgh Steelers will be facing the Seattle Seahawks in Super Bowl XL. Aside from the weird fact that this year's Super Bowl is named after a T-shirt size, it seems like a good match-up. The Steelers have a good squad of guys with a vet who clearly deserves to win the Super Bowl before he retires (Bettis), and the Seahawks deserve to win one by virtue of the fact that they've never done so before.

VICTORY in the MICU

I have seized victory in the MICU! Never before shall I return to the morbid halls of Founders 9. Never again shall I find myself sono-siting somebody's right internal jugular vein in the middle of the night! Gone are the days of debating the virtues of synchronous intermittent mandatory ventilation versus continuous positive airway pressure ventilation!

The last night was a doozy. There was somebody with a fairly massive GI bleed that involved calling in attendings from both the Gastroenterology & Interventional Radiology services in the middle of the night, but fortunately (knock on wood) I think they were able to work their magic and get a hold on the blood loss.

Seriously, though; although I have certainly complained a lot about the ridiculously intense nature of the MICU, in retrospect I have to admit that it was overall a good experience, and a much more rewarding one than when I had done the rotation as a 2nd year. A lot of the difference I think was myself being more confident concerning procedures and ventilator management; in addition, it was a lot of fun working with my intern Ali and watching him develop into a powerful MICU force to be reckoned with. I'm leaving the oncoming resident taking over for me with an intern who is now "signed off" (in order to do a procedure independently, you need to be supervised a certain number of times by a senior resident, at which point you are said to be "signed off") on central lines, arterial lines, and lumbar punctures, and needs only one more paracentesis to boot.

The content of my blog will understandably be shifting...as a result of my ability to experience life outside of the MICU! I have two weeks of elective in order to get my life organized, and then it's off to Botswana...

Last Call!

For alcohol!

Just kidding, of course. Last call in the MICU for yours truly. The "Last Call! For Alcohol!" is of course a tribute to George Thorogood & the Destroyer's memorable song "One Bourbon, One Scotch, One Beer", a song which also contains the pithy lyrics: "you know when your mouth's a-getting dry.... you're plenty high."

Crazy Saturday night so far with an unusually high number of admits (in keeping with my "black cloud" this month.) Six admits in total, a veritable smorgasbord of human disease: we've got a GI bleeder, a community-acquired pneumonia with increased oxygen requirements, a guy with esophageal cancer and bowel obstruction, a diabetic who stopped taking her insulin, a woman with a history of a bilateral lung transplant with difficulty breathing and a CNS lymphoma with sepsis. The worrisome thing is that it's not even midnight...

Health Insurance Companies Suck

The barriers created by health insurance companies that stand in the way of patients getting quality medical care is completely out of hand.

The common strategy taken by the health insurance industry is to automatically deny expensive treatments that are prescribed by the physician. It is often possible to get these treatments, but it requires the physician to navigate a ridiculous maze of paperwork and bureaucracy in order to get that treatment approved. The companies figure (and rightfully so) that not all physicians are going to have the time and energy to do the appropriate paperwork, so not everybody who needs the therapy will end up getting it. Not surprisingly, this helps save the insurance company money.

I'm ranting because I spent a significant amount of time trying to frantically arrange lovenox (an expensive but necessary injectable medication used as an anticoagulant) for a patient who needed to leave today. In the end, it could not be arranged, in large part because the health insurance company which requires physician approval of the lovenox is closed for business beginning on Friday at 4:30pm for the entire weekend. This patient now faces the choice of remaining in the hospital for an unnecessary three more nights getting lovenox as an in-patient versus going home on sub-optimal therapy. He chose to go home, despite my recommendations not to. All in all, extremely frustrating.

Came home & watched a movie on pay-per-view with my wife which I highly recommend: The Island, a sci-fi thriller starring Ewan McGregor (one of my favorite current actors) and Scarlett Johansson, who I'll admit is pretty easy on the eyes.

Tomorrow: Last Call in the MICU!!!

This is SPINAL TAP

Hey, hey, hey it's Wed night in the MICU...my penultimate call! My very last one shall be on Saturday night and after that I have 2 weeks of elective, during which time I plan to get my affairs in order before going to BOTSWANA (more on that later in a future blog entry).

So far it's your average day in the MICU....baseline busy, but not completely insane (yet). One intubation. One groin line already placed; another neck line to be placed later this evening. My intern got signed off on LP's (which stands for "lumbar puncture", the same thing as a spinal tap)--there's a dude here with refractory cryptococcal meningitis, the treatment for which is serial LP's...he's received TEN spinal taps in the past ten days! We've got two new admissions thus far and a busy emergency room which is the source of potential business throughout the night...

That's it for now...let's cross our fingers for a humane night...

Flavor of the Week: Metastatic Pancreatic Cancer

I'm extremely reluctant to jinx our pleasant call by writing about it, but I don't have anything else to do, so here goes.

One admission thus far today...this makes now THREE patients over the past THREE days that have been admitted to our service with metastatic pancreatic cancer. Unfortunately, pancreatic cancer is one of those aggressive bullies of the oncologic community which once it starts metastasizing to your liver, lung, and other areas there's just not a heck of a lot that you can do about it. It's painful and my sympathy goes out to anybody with the misfortune to get this terrible disease. The plan for each of these three patients (which has been entirely appropriate, in my opinion) can be boiled down to one key intervention: a morphine drip.

I actually had the chance to catch the tail ends of both the Steelers-Colts games as well as the Panthers-Bears game. My picks (Colts, Bears) won neither. From this point on I will be rooting for the Steelers to win the Super Bowl--for sports in general, I tend to root for the teams containing a veteran who has yet to win a major championship before they retire. In this case it's Jerome "the Bus" Bettis, though I'm certain the Panthers, Broncos, and Seahawks all have vets worthy of a Super Bowl on them...

Cleaning House

As my alarm rang this morning at 5:15 am...I was decidedly *not* looking forward to going to work! Due to the insanely busy events of the previous call, I was facing the prospect of taking care of eight of the most critically ill patients in the entire hospital, all without the aid of my capable intern Ali (who had by all criteria earned a day off). How long would I be stuck in the hospital? 5pm? 7pm? 9pm? The chances of none of these eight patients crashing and burning during my time there was exceedingly low...

But the stars were aligned, and my list is looking far more manageable at the end of the day. One patient had died overnight--which for the most part was not a big surprise, as he had been coasting along with a blood pH just a shade over 7.15...not exactly compatible with life. Another guy who had been getting sicker and sicker--on top of his alcohol-ravaged heart disease, liver failure, and pulmonary infection we had just discovered a very large stroke covering a good chunk of the right side of his brain--his family decided that he'd had enough and asked us to stop with our resuscitative efforts, which of course we respected. Three other patients had actually improved over the course of the past 24 hours (it does happen sometimes!) were deemed well enough to move from the intensive care setting to more normal places in the hospital, and all of a sudden my list was down to THREE at the end of the day...

That sucked.

I won't talk much about my call last night...only to say that it's one of only two nights during my residency during which my body never entered my call room (that is to say, a got a sum total of ZERO hours of sleep over my 30 hour+ shift). The low point was when I thought my intern had accidentally cannulated somebody's carotid artery with a large multi-access central venous catheter, a scary large-bore catheter you put in sick people. The good news was that after calling a stat Vascular Surgery consult and reviewing the information we ultimately figured out that we were safely in the good ol' internal jugular vein as originally planned...

I'm going to sleep. It's time to take a break from all this suckitude...

The Hedonism of Days Off

Ah, the Hedonism of Days Off...after a horrifying week of MICU Madness, I certainly feeled that I have earned my 24 hours of freedom.

In my view, the MICU is so emotionally taxing that days off should be spent basking in the glory of mindless activities and frivolous comforts. Activities which might make your brain hurt, such as reading scientific papers, studying for the medical boards, or checking the labs of your patients hanging out in the MICU online are to be avoided.

To that end, today's Day Off activities were certainly a success! I slept in, spent the first 3 hours of my day laying the smack-down on the Sand People in my Star Wars video game, ate a heaping pile of French toast with my friend Ann-Marie (check out her new blog as she and her fiance embark upon a 5-month journey to India, China, & Southeast Asia), took a sweet nap, and just returned now from playing some basketball at the gym. I'm returning to a nice fire in the fireplace and perhaps a glass of wine with dinner...













It's almost enough to make me forget that I'm on call again tomorrow :)

Oh What A Night

Last night was a night to remember...I know I keep on saying things like, "Last call was one for the ages!"...but in all seriousness I will not be forgetting the events of last night's call any time in the near future...

The situation: A patient who has been gradually getting worse over the course of the past 2-3 days--we think she has some kind of infection, just haven't figured out what yet--decides to stop breathing at about 1 in the morning. The standard practice in such a situation is to perform endotracheal intubation: sticking a tube down somebody's trachea, then hooking that tube up to a ventilator in order to let the machine take over the process of breathing. The hope of course is that it's a temporary measure--once you figure out how to get the patient reliably ventilating on their own again, you eventually wean them off the ventilator.

In any case, we had problems ventilating her on the breathing machine from the get-go. Usually you would try and push breaths in at a volume of about 400 cc's (same thing as 400 milliliters) of air with each breath. However, her lungs were stiff as a board--we were only able to move about 100 c's of air in with each breath--which would be incompatible with life if allowed to go on indefinitely! Why were we having so much trouble ventilating? A frantic search was turning up few answers...the machine seemed to be hooked up correctly...we got a stat chest X-ray and it looked like the endotracheal tube was in the right place...there was no pneumothorax (a collapsed lung due to the inadvertant puncturing of the lining of the lung)...all the meanwhile, her blood pH was heading down to critically low levels. Normally the acid in your blood is kept in a very narrow range of 7.35-7.45. Her pH was down to 6.88 at one point, an indication that we were not ventilating her adequately...

Fortunately, an answer revealed itself...on physical exam she had an abdomen that was rock hard--you pressed down on her belly and instead of being nice and soft it was markedly distended and felt like a gigantic mushy mass was filling up the entire peritoneum. So much so, in fact, that the reason the lungs weren't allowed to expand was because they simply couldn't inflate past the pressure being exerted on themselves by whatever was going on in the abdomen. But what the hell was it? We rolled our handy-dandy portable ultrasound machine over to the bedside and took a glance...it was fluid! Just liters and liters of fluid which had leaked out from her blood vessels and eventually into the peritoneum.

Postulating that she had something called "intra-abdominal compartment syndrome"--basically, that the large amounts of fluid was creating such massive amounts of pressure, they were not allowing the lungs to expand--we performed an emergent paracentesis at her bedside. This consisted of me plunging a relatively small, 19-gauge needle into the fluid and draining out about 2 Liters of the straw-colored liquid into bottles. The response was dramatic! Her tidal volumes of only 100 cc's instantly started increasing...first to 150...then to 200...then 300...then up to a healthy 400 cc's! Before long she was adequately ventilating, and by the morning her pH was actually within the normal range. Whew!

Problem solved? Yes and no. If she had gone on for another 10-20 minutes, I believe she would have likely died. So we prevented her from dying that night. However there are still a whole host of other problems which still need to be addressed (such as why all that fluid was in her belly in the first place). The ICU is a very humbling place to be...

In addition to the above fireworks, my intern was The Man yesterday when it came to procedures. While it was I who had the glory of performing the emergent paracentesis, he came through in spades with two successful spinal taps, an expertly-placed central line, and a (non-emergent) paracentesis of his own. And on his birthday, no less!

Day off tomorrow...should be nice to decompress a little...

A word from our sponsor...

Well, I'm about to embark upon one of my epic 30-hour shifts...still at home munching on some cereal. My sole blogthought for the day: my favorite snack these days are the chips at Qdoba, a nearby fast-food Mexican joint. They're crispy, salty, and just plain tasty.

See you in 30...

A Week In the Life

The schedule in the MICU is a bear. My team consists of myself and my intern Ali, and we're on-call every third night--each call being scheduled as a thirty hour shift. Every third day either myself or Ali has the day off (so each one of us gets every sixth day off). As an example, the week for me has been the following:

Monday: "good day" (worked from 6:30am-5:30pm)
Tuesday: on call (came in at 7am, left the next day at 1:30pm)
Wednesday: post call (leave at 1:30pm)
Thursday: day off :)
Friday: on call (came in at 7am, left the next day at 1:30pm)
Saturday: post call (leave at 1:30pm)
Sunday (today): "good day" (worked from 6:30am-present--I am looking to get out of here early today, probably 4:30pm).

In general we're pushing the maximum of the work-hour rules (about 3 years ago the ACGME, which oversees all the different residency programs in the United States, decided to institute work-hour rules reform in response to a particular legal case involving a medical error made by a resident who had been working an absurdly long shift), which is defined as 80 hours a week or less and no shift longer than 30 hours. By the calculation above, looks like I'm at 82 hours a week and our call shifts are 30.5 hours, so by and large it looks like we're more or less in compliance.

Last Friday night on call was one of the worst...our team had three different deaths! Two were expected and one was not--a new admission with Alzheimer's disease who became severely septic, went into florid DIC (a form of craziness in the blood that affects the clotting factors), and spiraled out of control rapidly. There was also a cardiac arrest by one of our long-timers in the MICU (I think it was his fourth "code" during this hospitalization, an indication of his severely ischemic heart disease and reflecting his overall poor chances of making it out of the unit alive). He remarkably pulled through after about 12 shocks, multiple rounds of epinephrine, and is still with us this morning. Our team also achieved a moral victory when a young woman of 24 years of age with liver failure that had been with us for about 2 weeks and was at death's door remarkably obtained a liver transplant at the last possible minute...there are occasionally some good stories here!

I saw the movie "Fantastic Four" last night on pay-per-view...it was a lot better than I expected, even with the multiple deviations from the standard plotline. It did a good job of tackling the complicated family dynamics of the FF, and also I was also tickled to see Stan "The Man" Lee's cameo as famous Marvel mailman Willie Lumpkin.

Late Night

I know my blog has been dominated by MICU-related events, but when that's where I spend the vast majority of my time, I guess it makes sense. One of our Attendings, the great humanist Critical Care doctor John Hansen-Flaschen a.k.a. "The Flash", this morning likened our MICU rotation to being on a submarine...submerged for a long period of time under intense conditions with a group of people you get to know almost too well.

It's been an interesting call thus far. My intern Ali's first day in the MICU I'll have to characterize as a ringing success by any criteria. He's already faced a number of challenges today--having to present the largest service of any of the other interns (started the day with 5 patients), getting one new patient first thing in the morning, dealing with the Big Move the ICU underwent today, and having to put his first internal jugular central venous catheter ("central line") on an elderly patient who was flailing around in confusion during the procedure, which he carried out with resounding success! (I was actually quite proud of my contribution to the procedure: the idea to use some nursing tape to secure his head in an appropriate position so at least his neck was still while the rest of his body was writhing around).

Today's major issues: a chronic alcoholic going into delerium tremens (basically a bad form of alcohol withdrawal), a patient with severe congestive heart failure who may or may not be getting septic (still trying to get a handle on his fluid status), a man with pancreatic cancer coming in confused because his calcium level is through the roof (hopefully, something which can be easily corrected over the next few days), and a woman with a history of a bilateral lung transplant 10 years ago who's having trouble breathing because she's ever-so-slowly rejecting her lungs. There were two additional admissions slated to come to us from the Emergency Room, but they expired before they could even make it up...

At the moment I'm writing this it's 4:14am and I'm going to try and catch some precious zzz's for a short bit.

Fresh Meat

Tomorrow I get a new intern to play with!

Let's hope he can handle the pressure of the MICU...

I'm on call again tomorrow...I'm certain that it is going to be one disaster of a day, for a few reasons. First, it'll be the first day after a long holiday weekend, and sick people who have avoided going to see their doctors will be teetering on the brink of severe badness, necessitating at least a couple of admissions to the MICU. Second, I'll be dealing with my fresh new intern who will be predictably both shocked and appaled by the Apocalypse Now-esque aspects of the MICU. Finally, tomorrow is the historic occasion of the GRAND OPENING of the full 24-bed MICU. Previously we have been dealing only with a 12-bed MICU & and a 12-bed IMCU (and intermediate-level setting where the patients are only *potentially* sick as dogs). By doubling our MICU beds, we will be doubling the pain.

What shall make things bearable for me, though, is the light at the end of the tunnel: Claire is returning to the U.S. on Wednesday, and Thursday is my ever-so-precious DAY OFF!!!