Interesting Cases

On call today (Tuesday)...overall it's been quite a hectic day which has brought in a slew of fascinating array of medical diseases gone unchecked...

Interesting Case #1: (actually a case from yesterday, but who's counting?) 27 year-old man with HIV+ with a CD4 count of 0 (the CD4 count is a measure of how advanced the HIV is...in general, a CD4 count of less than 200 is when you start seeing a lot of infections...a CD4 count of zero...well, that's the lowest you can go) comes in with a rash over his face and trunk. It's a painless rash of small white, raised spots a few mm in diameter, some of which have central umbilication. Grossly, it seemed to resemble something called "molluscum contagiosum", a benign condition for which there is not really any treatment, but doesn't really cause any harm. However, our attending Dr. Gluckman brought up the fact that it's possible it COULD be a rare manifestation of cryptococcal infection--a yeast which can cause a disastrous brain infection which can be fatal. We did a scraping of the lesion, did a gram strain, and looked under the microsope in our own little ghetto-style lab on the ward. Guess what? Teeming with cryptococcal organisms! While it feels pretty cool to make a suprise diagnosis like this, the thrill of discovery was unfortunately offset by the fact that the dude declined to have a spinal tap performed (to exclude cryptococcal meningitis), which would be a crucial step in his further management, and bolted from the hospital as soon as possible. I just hope he has the sense at least to take his fluconazole...

Interesting case #2: 53 year old man who comes in with profuse nose bleeding since 2 in the morning. Has been healthy his whole life and had an HIV test 1 year ago which was negative. His blood count was significant for a white blood cell count of 229,000....which is about 50 times higher than what is normal! Sadly, this gentleman has leukemia (more specifically, he has chronic myelogenous leukemia) and will be starting chemotherapy shortly.

Interesting case #3 actually comes from our own Penn medicine posse! One of the medical students in our group came down last weekend with fever, diffuse weakness, and lymph node swelling in her upper thigh. A couple of days later she developed a single small red rash with an overlying eschar (area of black skin necrosis). The diagnosis? An interesting bug called "Rickettsia africae", which is transmitted by a tick bite. Kind of like the Lyme Disease of Africa, I suppose. Fortunately, it is very easily treated with a short course of the oral antibiotic doxycycline... Get well soon!!!

Only 2 more hours of call left...then we are heading home for what is certain to be a scrumptious bry (the word for barbecue here in Botswana).

The Tuli Block

The Tuli Block

What a phenomenal weekend! On Friday afternoon we departed for the Tuli Block (the section of land in far-eastern Botswana which is located between Zimbabwe and South Africa) in the Land Rover of our friend Jeremy (a subset of folks rented an airplane in order to get there faster…on the way back they had to make an emergency landing somewhere in South Africa and as of yet had not returned to Gabs…but that’s another story…)

We arrived late at night, driving across bumpy dirt roads to our tent campsite which was being watched over by a troop of noisy baboons. A herd of impala ran across the front of our vehicle in the middle of the night. Truly amazing. We went on a total of three game drives over the weekend and saw an even more amazing collection of wildlife than the weekend before: elephant, giraffe, impala, kudu, hyenas, eland, wildebeest, guinea fowl, ostrich, zebra, monkeys.

Perhaps even more striking than the wildlife for me, however, was the amazing scenery. It reminded me very much of the Zion & Bryce Canyon National Parks back in the United States: lots of reddish rock outcroppings with magnificent formations, along with a sense of desolation and spirituality about the place. I guess my blog readers will just have to wait for photos in order for me to describe Tuli with any justice.

We made it back to Gabs just before nightfall and I thoroughly enjoyed my shower & evening meal. Tomorrow it’s back to work for Week #4. We have a few more additions to our merry University of Penn band: my friend Helen Azzam (another 3rd year Internal Medicine resident, like myself), Nabila (a Neurology resident), Allison (an Emergency Room resident), and Dr. Dick Root (a Professor Emeritus who had founded Penn’s Department of Infectious Diseases way back when) & his wife. This is apparently the most Penn people who have ever been in Gaborone at the same time

Cannula Master

Had a somewhat frustrating day at work today: much of the day was spent attempting to obtain iv access in our patients! In the U.S., we're used to the nurses putting in iv's into patients. However, here at PMH that duty falls squarely on the shoulders of the physicians.

We have two patients with cryptococcal meningitis and as a result they are gorked out for much of the day. Both of them managed to tear out their iv's overnight as a result of the nurses unadvisedly taking them off their restraints. It took about 45 minutes, but I just barely got a 22-gauge iv into this dude's foot this afternoon...let's hope it lasts until the morning! In general, I'm getting a little tired of performing these menial tasks--like putting in iv's, serving as the transport for bringing patients to X-Ray, doing all the EKG's myself, etc. Initially the novelty was kind of neat, but at this point I'd much rather learn new skills or learn more about the fascinating disease states that are surrounding me at all times.

This weekend: another safari trip, this time to Tuli, which is in the far east part of the country. We're going to stay in some high-end tents (not quite camping but not quite a hotel room either, it sounds like), take a bunch of game drives, and (once again) try not to get eaten by lions.

Cannula Master

Had a somewhat frustrating day at work today: much of the day was spent attempting to obtain iv access in our patients! In the U.S., we're used to the nurses putting in iv's into patients. However, here at PMH that duty falls squarely on the shoulders of the physicians.

We have two patients with cryptococcal meningitis and as a result they are gorked out for much of the day. Both of them managed to tear out their iv's overnight as a result of the nurses unadvisedly taking them off their restraints. I just barely got a 22-gauge iv into this dude's foot this afternoon...

This weekend: another safari trip, this time to Tuli, which is in the far east part of the country!

The Magnitude of the Problem

The problem of HIV in subsaharan Africa is mind-boggling. I am starting to realize it now.

As an example: I was all excited on Monday when we diagnosed this guy with malaria. 29 year-old Botswana resident, had traveled to Namibia about 3 weeks ago, presented with fevers and chills, low platelets. We got a blood test called a malaria smear (basically you just smear blood on a slide, look at it under the microscope, and look to see if there are any malaria organisms living in the blood) which came out positive. I was ecstatic! A potentially lethal disease which we know how to treat, completely reversible. Before the malaria test came back, an HIV test had also been sent in the ER.

Mere moments before discharging him, the HIV test came back positive.

It's not the worst news in the world. We can still help him with the malaria, and now that Botswana has a comprehensive HIV treatment program, there are medications available (free for all citizens...one way in which this African nation is more advanced than the good ol' US of A!). But it's sad.

In the past two days we've also found +HIV tests on patients who presented with complaints as diverse as right leg cellulitis and subarachnoid hemorrhage--which are likely completely unrelated to the HIV status. It's gotten to the point where if somebody comes in with a broken pinkie--I'm coming to expect that the HIV test will come back positive...

Kalahari!

Well, I survived my weekend camping in the Kalahari...and I didn't even have to perform any lion-wrestling!

We left as a large caravan of 3 macho 4x4's, including Jason's kick-ass Land Rover. It was 17 people in all (2 of which were less camping-inclined than the rest of us and opted to stay at the nearby lodge). It was a 4-hour drive to the Khutse Game Preserve, smack dab in the middle of the Kalahari Desert. We then proceeded to snake through the meandering paths of the Kalahari looking for game. It's actually quite a draining experience: you are sitting on the top of a Land Rover going 40 kilometers an hour over a bumpy, punishing terrain, all the while with a scorching sun and blinking the dirt out of your eyes. We did a pretty good job on the animal sightings, though--the highlight of which was a veritable shitload of giraffes. There were about a dozen of them milling around at our campsite, which was conviently located near the main waterhole. During the course of the weekend we also saw several hemsbok, springbok, kudu (all varieties of antelope), ostrich, jackals, and a variety of interesting birds. We camped out beneath one of the most amazing starry skies I've ever witnessed and had a fabulous meal over the campfire.

Another lesson I learned this weekend: ostriches are stupid. During one of our game drives we encountered a group of 3 adult ostriches and 6 baby ostriches. They took off down the road (they are pretty fast, too--even the kids!) and we followed at a distance. You could tell the ostriches were distressed, but it took the adults about 10 minutes of sprinting down the dirt road that perhaps they should try getting OFF the road to avoid being chased by our Land Rover. And it took the poor babies about 25 minutes of us chasing them before they managed to get off the trail...

Still having problem with the photos...but I'll try and put them up eventually!!!

Pie City

Another way in which medicine is practiced very differently in Botswana versus the United States is the approach to lunch time.

Back in the 'States, I do usually manage to grab lunch..."never miss a meal" is a motto I had learned from one of my favorite residents very early on...however, often times the meal is rushed and I find myself gulping down graham crackers and cranberry juice stored in the "Nutrition Room" for my afternoon meal, which is highly unsatisfactory. In contrast, it is expected that all the doctors leave from 1pm-2pm in order to enjoy a nice, leisurely lunch. As the hospital cafeteria at Princess Marina Hospital is currently under constrution, we instead walk the 15 minutes or so to the downtown mall area to eat. My favorite place thus far is "Pie City", which serves these awesome little pastries stuffed with various meats or veggies; the Seswaa Pie (beef) and Chili Russian (spicy sausage) varieties are quite popular. Perhaps most exciting, however, is the price: 3.50 pula (which translates into about 60cents).

Today being Friday we had "Grand Rounds", which I attended for the first time. The topic: an update on the state of Botswana's medical school program, which is still in the very early stages. Although the Botswana health care system is considered one of the better programs in Africa, only about 10% of doctors in Botswana are Botswana citizens. In order to change this, they are trying to encourage more and more university students to study medicine. The main problem with this is they do not as of yet have a true medical school. They have the students do their pre-clinical work here in Botswana, then get shipped off to medical schools in South Africa and Australia with whom they have formal agreements in place. Ideally they would like for this to change: to have a teaching hospital here in Botswana where students could train. One scenario has Princess Marina Hospital being converted to such an institution; another scenario calls for the building of an entirely new medical center. Another issue which has gotten a lot of attention is the inability of Botswana to retain their newly-trained medical graduates--it seems as if the best & brightest of the housestaff trained here are lured away to Europe or the U.S. because there aren't enough financial or professional incentives to keep them in their native Botswana.

Hearing this discussion about building an entire medical education from scratch made me realize how lucky we have it in the 'States. Although we certainly have our own problems with regards to medical malpractice, piles of paperwork, etc etc--at least as doctors we have the opportunity to make a decent living within our country.

That's it for now. This weekend: camping in the Kalahari! I'll try not to get into any arguments with any lions while I'm there...

Dumela rra

Dumela rra!

This the standard Setswana greeting--Dumela mma when addressing a female--which I'm getting a lot of practice using. The Batswana are a very polite people (except when you forget to say "Dumela rra") . Thus far my basic Setswana consists of the following:

Dumela mma/rra: Hello, ma'am/sir
Gosiame: Goodbye
Kealeboga: Thank you
Tswee: please
Ke nna Dr. Nate tswa Penn: My name is Dr. Nate, from Penn.
Howzit?: slang for "How are you?"
Re tang!: I'm well.
ngaka: doctor
breathe!: Hema!
ee: yes
nnyaa: no

Fairly primitive, I know. One of the amusing things which occurs on rounds each morning is that for many of the patients we have the nurses (referred to as "sisters") translate for us. Occasionally you will ask them to translate something simple, such as, "Does it hurt when you breathe in?", and they will proceed to embark upon a 10-minute Setswana conversation about god-knows-what.

Interesting case today of a young man who presented with the "worst headache of his life" and a spinal tap showing multiple red blood cells. In medical speak, this translates into having a very high suspicion for having a subarachnoid hemorrhage. Well, we finally got a head CT to clinch the diagnosis, and sure enough he has a bleed. Now what? In the U.S. of A., he'd certainly be followed by the neurosurgery service and perhaps undergo a clipping (surgical) or coiling (endovascular) procedure. There is apparently one neurosurgeon in all of Botswana who resides in Francistown, but rumor has it that he has not performed a surgery in several years, which to me sounds pretty suspicious. I guess in the morning we'll look into transferring him directly to South Africa where they are better equipped to deal with these issues...

Botswana's Neighbors

Another interesting aspect of working in the public Botswana health system: who patients from neighboring countries are dealt with. We had the Zimbabwean Express while on call last night; 3 of the 11 patients admitted to our service were from Zimbabwe and thus are not covered by the state. As a result, we are even more severely limited as to what we can and cannot do. We can order labs, X-Rays, and so on, but the patient must pay for these out-of-pocket (which is understandably impossible for many of them). A guy came in last night: 34 year-old male complaining of weakness and tremors; he was febrile and very wasted. Our differential diagnosis at this point includes HIV, tuberculosis, or malignancy--and unfortunately I don't think we're going to be able to provide him with the care he needs regardless of the diagnosis--they won't be for his ARV's (anti-retrovirals) or ATT (anti-tuberculous therapy)...

Another interesting case: 25 year old man with known hemophilia B, which is pretty rare. Most patients with hemophilia (like the famous Romanov family in tsarist Russia) had hemophilia A, which is a deficiency in coagulation factor 8. He has hemophilia A, which is due to a deficiency in coagulation factor 9. First patient I've ever seen with this particular disorder. In any case, he has the rather unfortunate luck of having BOTH hemophilia B as well as a seizure disorder...which means that when he has a tonic-clonic seizure on the bus like what happened yesterday, he has trauma to his joints that results in massive bleeding into his joints. His right shoulder had barely no range of motion when he arrived and he was in a considerable amount of mine. The treatment for hemophilia B? Simple: just give them concentrated factor 9 (what their blood is lacking) to stop the bleeding. Unfortunately, our pharmacy had run out, and we had to wait until morning in order to get some (we did give him some fresh frozen plasma, which has a small amount of factor 9 in it, to get him through the night, and fortunately this morning he looks pretty good).

Well, it's a hot n' humid day, and I'm going to jump in the pool while it's still nice out. On tap for this weekend (I hope, if everything can be arranged): a camping trip to the Kalahari, which is famous for its high lion population!!

Weekend in Gabs

We’re spending the weekend hanging close to Gabs (the popular, shortened name of Gaborone, the city in which I’m living and the capital of Botswana). One of the nice aspects of this rotation is that we get the weekends off (I know, I know—this is perhaps something normal people have come to expect…but as residents it is not always so common). The “weekends off” thing is a bit interesting from a patient care perspective. Technically, there is always a PMH (Princess Marina Hospital) resident present at the hospital who can take care of emergencies. However, that resident is responsible for seeing a ridiculous number of patients (apparently the patient load has exceeded 100 at times), and as a result a number of critical patient issues (e.g., iv’s that fall out over the weekend, a change in mental status) may go neglected. So I’m curious as to how many of patients will still be alive upon my arrival on Monday morning…

I am, however, certainly happy about the “weekends off” policy, as it should allow me to do some exploring around Africa. This weekend a few of us opted to stay closer to Gabs to get to know the area a little better and generally take some much-needed R&R. I began the day by sleeping in (my first decent night since I’ve been here…looks like my clock has finally reset!). Around noon, one of the medical students (Vanae) & I decided to be adventuresome and take a cab out to the village of Mochudi, which is about 35 km north of Gabs. We took a fabulous hike up into these cool rock formations—the only drawback was that when we got to our destination, a local museum, we found that it was closed on weekends. This slight disappointment was offset, however, by multiple monkey sightings. Who doesn’t like monkeys, right? Other activities for the weekend included watching a local soccer game as well as attending a Zambian art exhibit at the Botswana “Alliance Francaise” building (don’t ask).

Another Day At Work

Well, I can't exactly be considered a veteran of Botswana medicine, but I've now completed my first week (albeit incomplete) of inpatient medicine at Princess Marina Hospital!

Since I arrived here on Tuesday night, I can honestly say that I've been exhausted for just about every waking moment. One of my goals for this weekend (in addition to getting myself familiarized with the city of Gabarone) is to catch up on some zzz's and hopefully reset my sleep-wake cycle to something more reasonable that inexplicably waking up every night at 2 a.m. and staring aimlessly at the ceiling for several hours.

Recall my excitement at helping out with 5 procedures the day previously? 3 spinal taps, 1 thoracentesis, and 1 paracentesis? Well, a very frustrating aspect of Botswana medicine reared its ugly head today when we realized that the lab had completely LOST one of the spinal tap samples and the results of both the para and the thora weren't back despite having been sent to the lab greater than 24 hours earlier. Crazy. Why subjuct a patient to a painful and potentially dangerous procedure if you can't get the results? It made me want to go nuts, but having been previously warned about the pitfalls & frustrations of the health system here (which interestingly enough is considered one of the finest on the African continent) I told myself to remain calm and go with the flow. You have to really base a lot of your decision-making on the physical exam.

I also experienced a very interesting cultural phenomenon today: many Batswana share the belief that if a doctor performs a spinal tap on you, it can cause you to become an invalid or even kill you. Unfortunately, I found this out about 20 minutes after performing a spinal tap on a half-comatose patient and speaking with his distraught brother. (By the way, the spinal tap yielded critical information which led to the diagnosis of cryptococcal meningitis, which is potentially treatable with antifungal therapy and yep, you guessed it, repeat spinal taps).

Holy Shit! I'm in Africa!

Well, folks, I made it Botswana! There's so much to describe about the past few days that it obviously won't fit into this single entry. But I will try and give a basic flavor of the place and fill in the blanks later on.

I left early, early Monday morning from the City of Brotherly Love, flew to Atlanta and then to Johannesburg, South Africa on a hellish, 17-hour cruise across the Atlantic (stopping briefly at Sal Island for refueling), followed by a puddle-jumper to Gaborone, Botswana, where I'll be staying for the next 5 weeks.

There's a ton of other Penn people here, all of whom are living in the same apartment complex, in fact the most that have ever been here at one time. There are two attendings (Drs. Kessler & Gluckman), 2 I.D. fellows (Svenja & Rose), five residents (myself, Jon, Kara, Matt, & Sameer--though Matt & Sameer had their last day today), and six medical students from Penn.

Every morning we wake up and meet in front of the flats at about 7:10pm, then take a 20 minute walk or so down some dirt paths to the Princess Marina Hospital. We're in charge of two medical wards (one male and one female). Jon & I flipped a coin & I ended up on the male side. The MMW (male medical ward) is comprised of 5 cubicles of 10 beds apiece--each cubicle is essentially a big room that all the patients share.

When I arrived, we had been ''on call'' the night before and had inherited a list of 16 patients. To give you an idea of how common HIV is here, 13 of the 16 patients had known HIV infection. Probably about 40% I would say had tuberculosis. In the U.S. when somebody with pulmonary T.B. gets hospitalized, they get thrown in a special negative pressure isolation room and anybody entering the room must wear a mask to prevent transmission. Here in Botswana there are no special precautions whatsoever, and I guess I'll just have to cross my fingers and hope I don't infected (thus far of the 40 or so Penn residents who have rotated for 5-6 weeks on this service, fortunately none of them has ever had their PPD come back positive).

People are admitted for stuff that's both common in the U.S. (asthma, diabetes, stroke) and also uncommon in the U.S. (disseminated T.B., malaria, all sorts of weird infections & cancers you get from AIDS). In general there are lots of procedures to be done--today, for example, our team did a total of 3 spinal taps, 1 thoracentesis (removing fluid from the lung), and 1 paracentesis (removing fluid from the belly)!

I'll try and post more later including some pictures. Not sure what I'm doing this weekend (we were going to go on a safari, but being that it's been the rainy season I've been told it may not be the best weekend to do this) but if I'm hanging around Gabs I should be able to catch up on my blogging...

Sending my regards back across the Atlantic,

Nate.

Boy voyage

See you in Botswana!

Quizzo Results

Blogger.com has been acting weird lately and somehow managed to delete my recent Quizzo entry. I've reproduced it here:


In an epic Quizzo battle for the ages, the Myoclonic Jerks narrowly edged the Cool Chaussures by a score of 34-33 last night. The evenly-matched teams were tied after each of the initial 3 rounds and it wasn't until the 4th & final round that the Jerks eeked out a victory. Honorable mentions go to the Rectum Rouge & Rectum Bleu (don't ask) teams.

For those of you unable to make it or would like to try out your quizzo knowledge online...I have included questions from rounds 1, 2, and 4 (Round 3 was a picture round of famous paintings which would be too much of a pain in the ass to put online) below. A link to the answers can be found at the bottom of the page. Happy Quizzoing!

Round 1
1. Who was recently confirmed and sworn in as the 110th Supreme Court Justice of the United States?
2. What is the capital city of the Ukraine?
3. a) In which country was the first-ever World Cup of soccer held?b) The French team won the World Cup in 1998. How many games did the French team win during the 2002 World Cup?
4. In Greek mythology, who was the father of Hercules?
5. What instrument does Yo-Yo Ma play?
6. Napoleon’s final defeat is considered the Battle of Waterloo in 1812. In which present-day country is the battlefield found?
7. In Victor Hugo’s novel “Les Miserables”, for what crime is the main protagonist Jean Valjean initially imprisoned for 19 years?
8. In the National Basketball Association, who is the All-Time leader in 3-point field goals made?
9. In the board game RISK, how many territories are there on the continent of South America?
10. Who wrote both the novel and the screenplay for “The Godfather”?

Round 2
11. The current Pope is Benedict XVI. From what country is he originally from?
12. In the original “Star Wars” movie, which character does Han Solo shoot and kill while at the cantina?
13. Who was the head of the German Luftwaffe (airforce) for the majority of World War II?
14. Who is slated to host the 78th Annual Academy Awards on March 5th?
15. What two countries share the “Tierra del Fuego”?
16. The Statue of Liberty was a gift from France to America in the 1880’s. Who was the engineer (not the sculptor) of the structure?
17. What is the capital of our great state of Pennsylvania?
18. Who won the first-ever Super Bowl, in 1967?
19. A woman named Cindy Sheehan has been in the news a lot lately. What is she famous for?
20. Nate Trivia: How did Nate lose his last pair of glasses?

Round 4:
21. In the movie “Fight Club” starring Brad Pitt & Edward Norton, what is the #1 (and also the #2) rule of Fight Club?
22. Between what two countries is the tiny country of Andorra located?
23. For what invention is Alfred Nobel, the rich chemist who endowed the Nobel Prizes, best known for?
24. What is the longest river in Asia?
25. Who was Robert Kennedy’s assassin in 1968?
26. In a similar vein, who shot & killed Marvin Gaye, Jr in 1984?
27. Who is the current president of Mexico?
28. Who was the husband of Mexican painter Frida Kahlo?
29. What was the first animated Disney movie, in 1938?
30. Who is the next-door neighbor of Homer Simpson?
Bonus: write down an expression, any expression, that Flanders might use in conversation.
2nd Bonus: what are the names of Flanders’ two sons?

Click on the link for the answers!

Who will take home the Brunelli Cup?

The entire season has been leading up to this glorious moment...

The fans are rabid with anticipation, the players in deep, intense meditation...

Yes, it is time for...

HUP Bowl III.

The HUP Bowl is an annual tradition which takes place each Super Bowl Sunday. It's a no-holds-barred, bone-crunching game of tackle (yes, tackle) football amongst the Hospital of University of Pennsylvania (HUP) Internal Medicine residents.

HUP Bowl I took place after a big snowfall, which helped cushion our falls. HUP Bowl II, due toa large thunderstorm the night before, was a gigantic mudfest, which helped prevent achieving any type of forward momentum. Today's weather looks pretty nice, so let's cross our fingers and hope that there are no career-ending injuries today...

The most valuable player of the HUP Bowl each year wins the coveted (and at this point, highly theoretical) Brunelli Cup, named after famed Nephrology fellow and ruffian Steve Brunelli. The winner of the Brunelli Cup for the past 2 years has been, fittingly, Steve Brunelli.

Kickoff begins at 2:05pm.

License to Grill

The vegetables are sizzlin' on the grill as we speak. Once the veggies are nice and charred it will be time for the chicken, of which I've bought sixteen full cutlets.

That's right, I'm declaring a jihad on fajitas and tonight they shall feel the force of my wrath.

Fajitas and Quizzo. Can you think of any better combination?

After tonight's action I will eventually post the Quizzo questions I came up with in case anybody wants to test their Quizzo worth online.

Hot Quizzo Action Fri Night!

Things have been kind of slow around Philadelphia, so I've taken up a new hobby: making balloon re-creations of famous artistic masterpieces!

Of course I jest.

In all seriousness, however, Claire & I are having a kick-ass party this Friday which will feature some homemade Quizzo questions by myself.

In the hypothetical situation that you plan on coming to our party Friday night and participating in Quizzo...you might way to look up the artist of the original painting ("American Gothic") parodied in today's blog photo in the off-chance that it's one of the questions. A purely hypothetical situation, of course.

Bonus Henry pics!!

More photos from our recent trip to check on the progress of our nephew Henry O.
Henry preparing to let loose a big belch in front of Mom.

Henry "working out" in his play gym. He's able to bench press a little more each day!

Somewhere beneath all those layers...there's a baby boy in there!