I'm Sorry

*A fair warning, a rather long entry but a very personal one.

Three months in as an attending and one phrase I've found myself uttering at least once a week, "I'm sorry."

 It seems like every week I review charts and come up with the conclusion that someone is very sick.

Now in today's hospitalist life, the acuity is higher and this is hardly something unexpected.
What I mean to say/feel is later confirmed when I go to the bedside.
We have a person , a patient whose quality of life is impaired by some condition or group of conditions. There is a reasonable expectation that they won't recover and their quality of life won't improve or was poor prior to entering our hospital.

Now the colder, unseen aspect of our job as doctors is realizing that someone needs "palliative"  "goals of care" "hospice" "the talk" .
There almost a mental checklist that occurs before we step in the room for AM rounds.
Extensive end-stage comorbid conditions,  age, functional status, frequent re-admissions, complex recent admissions and we paint a picture which more oft than not is supplemented at the bedside.

Now, I hope the readers don't view this objective/cold decision making on an extreme, some kind of allusion to "death panels", etc. This happens outside the room. What happens, is the human element.

Good Morning I'm Dr. Abdullah, you can call me Robert/Dr. Robert if that's easier to pronounce / remember.
How are you?
I'd like to summarize your hospital course (if I'm taking over service), please correct me.
-or- I've reviewed your chart and I'd like to summarize what I've read.
Usually, I'm fairly spot on (which is a testament to EMR and good colleagues).
And the conversation usually leads to some variety of the following question "so where do we go from here, how am I (or my loved one doing)?

At this point (in this particular entry) I have already realized they are not doing well.
I tell them that I'm concerned about a,b,c.
I don't see a,b,c changing.
Then I ask them to paint me a picture on a good day, a day before hospitalizations, before being  confined to a bed.
Then we together contrast those things , the here and now and the best they've ever been.

At this point most patients and families can appreciate what I'm establishing.
The conversation may not conclude there.
I may request we allow time for interventions to work/not work.
I may ask them to discuss things together.

When I return, we discuss quality/goals. Here's where my approach has drastically changed.
Here's where my blog entry takes a very different turn.

I wasn't born a doctor and I don't envision myself as particularly gifted/talented in one fashion but I did experience something that changed who I am and how I care for others.

I was however born a grandson, the eldest in fact on my mom's side.

My maternal grandfather Tulsie Sookdeo passed away at Hospice on June 5, 2015.
He had concluded a struggle with pulmonary fibrosis.
I miss him so much and I realize that more and more each day.

He was diagnosed the latter part of 2014. When I was told by my mother, I attacked it like I attacked any diagnosis, any condition. I read anything I could get my hands on. I reviewed the literature, I talked with attendings I trusted. I reviewed the proposed medications his doctors were considering. I called his pulmonologist. I set with my fiancee, a fellow doctor (who was already an attending) and I reviewed his CT Scans.

Then it hit me. This is is not good. I know pulmonary fibrosis, this has a poor prognosis. There is not cure. This is not good, oh crap what am I going to tell my mom.
I asked his pulmonologist and he gave me a standard response of "let's see how he does with medication" but I knew the data.  I knew that meds won't change mortality, they may help with some numbers, some morbidity but there is no cure.
My grandfather wasn't a candidate for a new lung.
Then things started to progress quickly, he was wearing oxygen and titrating it up.
He has sig. hypoxia with standing.
Towards the summer, he wasn't improving.
His multiple outpatient courses of antibiotics, his cardiac cath, his visits all pointed to worsening disease.
My mom called me and told me to call my grandfather and for lack of a better work reprimand him and have him go to the hospital. His oxygen was dipping to 70s with standing.
Within days of being admitted he was in ICU.
My fiancee and I saw him in the ICU.
I swung back and forth between being a grandson, hearing my grandfather's stories and him telling me how so and so "are idiots"
and then telling him that he has terminal disease.
I was alone at his bedside and I told my grandfather that he wasn't going to get better.
That was one of the hardest things I've ever done. I even talked with him about code status and goals, ultimately leaving prior to him accepting hospice care.

Things were stable-ish.

And then my life collided with itself.
On one hand I was days away from graduating a dual-residency , the culmination of 12 years of schooling/training (undergraduate, medical and residency) and enjoy a very selfish type of experience.
I had been following closely with multiple phone calls and Grandpa was not improving.
I got several calls from my sister and cousin and I was torn.
I didn't know what the right thing to do was.
Could I finish my work obligations and come to Florida as soon as I could or was there an imminent event.
I was very close to making the wrong decision.
I had been a doctor for four years, making myself available, coming in for others, sacrificing time for my job and I was torn.
I didn't know what to do.
Then I made a decision that answered the question "If I don't go, would I regret it?"
I made work arrangements and was on a plane within hours and at my grandfather's bedside shortly.
I walked so fast into hospice, most of my family didn't recognize me and my dad didn't even recognize I was there.

Then I cried and couldn't stop.
I had to leave the room, I didn't want my grandfather to see me like that.
The next days would be trying for my family as we saw the last bits of his personality fade.
His dyspnea, anxiety progressed and we escalated his morphine and ativan.
I stayed up all night with him at the bedside, with my sister the night prior to his passing.
I went to sleep for a few hours prior to Friday prayers when I got the call that my grandfather has passed, just minutes after the chaplain came to give a prayer.

My Grandfather Tulsie was one of the hardest working, intelligent, funny men I know.
His spirituality transcended any particular religious tradition.
I am the grandson, the doctor I am today because of him.
His last gift, a gift that I'd gladly given back [ to have him back] , to me was empathy.

Going back to my original entry.
I empathize with families.
I have told them that I understand.
I know what it's like to have to talk about comfort, quality of life, terminal illness.
I know how hard it is to want so so bad to believe in a miracle a chance of recover despite all your other intuition.
I understand the burden of wanting to bring someone home in their last days/weeks.
I tell them I'm "taking my doctor hat off" and I'm talking to you as someone who's been there.
I have teared up more than once talking to families like this, it makes me remember my grandfather and feel helpless that I couldn't cure him, fix him but it also lets me share some of their burden.
I tell families that I am here for them. They can call me. I will make sure their loved one is comfortable.
I tell them I don't underestimate their spiritual care, I will call a chaplain for them.
While I haven't been offered yet, I would pray with my families, regardless of their religion.
I hope to provide comfort , dignity in someone's last days.
I hope I am empathetic.

(Empathy is defined as the feeling that you understand and share another person's experiences and emotions : the ability to share someone else's feelings ) 

I hope that the comfort I provide for my patients is deserving of what you taught me Grandpa.
I wish I could tell you this in person. Your legacy lives on in my heart and every emotion I share with families.
I love you Grandpa.

For you (from a patient),

I beg of my readers (whoever is out there)
 Family first. The rest of your life will go on, the job will go on. Don't live with regrets.
 Cherish your health, if you are walking, talking, eating, drinking, you are already better off than    many people.
 Wealth is in the people you impact , not the things you possess (be it money, knowledge, material things). 

The Human Experience

Lighting your arse on fire seems like a poorly thought out idea. 

Now if I add an element of etoh, the biological imperative need to procreate (in cruder terms , get laid )  being 

in a foreign country for a guise of anonymity, well that makes for some fun.

So while my crew enjoyed dinner, drinks and a majestic night sky overlooking the Nile, we also enjoyed the antics       O

Of some inebriated mzungas. 

Initially , their first contest of machismo was to try and consume a bottle of beer while a fire made its way up a 

sheet of toilet paper and towards their "rear passage." The goal would be to consume the beer prior to a fire 

Causing mucosal injury of the, of the rectum. 

My colleagues recommended that we keep quiet about our medical...training . 

Which left me to ponder how I would treat a rectal burn in this camp around the Nile.

I imagine I could order someone to generously apply neosporin (from my first aid kit) to his rectum and call for an ambulance? 

Such are the thoughts of an older, hopefully wiser me ( your blog author) 

Having said that, I decided to grab my ipad and author this entry , only to witness ...something remarkable .

Apparently one of these ..young people decided to strip nekkid and scale the roof of this bar . 

Classic. 

Now , perhaps I'm a bit hypocritical in my assessment of these young people. Having rafted the Nile, surely they 

are entitled to antics. I've had my share of brilliant ideas and trying to .. attract the attention of ladies...back in the

 day ;) 

Naw, who am I kidding, this makes for great observational humor. 

Having scaled mountains, treated patients in desperate situations and seen truly amazing individuals in Uganda, 

I'm using my free pass to critique and creatively write. :) 

Due to my sketchy wifi , I'm drafting this entry while reading a book on my kindle..and of course mzunga watching .

Now , I truly admire a good narrative writer. The kind of writer who uses his words to paint a picture, to elicit 

emotions in his reader, to transport us to the setting. Some authors come to mind, Sandeep Jauhar , Atul 

Gawande , David Sedaris and most recently : Ishmael Beah , author of A Long Way Gone : Memoirs of a Boy 

Soldier.  This is such a captivating read, just read it, worth it.

Props to Traci Downs for the recommendation .

I hope my readers can laugh with me, try to share in my experience as well. 

Oh and now the reappearance of "that girl."

You know the one, that can't quite dance but finds herself repeatedly standing on the bench awkwardly swaying 

to garner the attention of...some phallic driven male . 

Dare I say , her efforts won't be in vain . 

The doctor in me says exercise some protection .

The Darwinian in me says, wrap that .... Up.  ;) 

Then of course , immediately behind me, the philosophers and political scientists . 

I'm only hearing a few words here and there mostly consisting of:

Americans 

Imperialism 

Africa 

Etc. 

Now someone got their hands on a unicycle. 

Wowsers. 

Now things have quieted down a bit.

There's still one guy whoring for attention on the unicycle. 

A larger group has gathered to play circle of death 

http://www.thecollegesurvivalhandbook.com/2010/09/how-to-play-kings-cup-circle-of-death.html

At 1130, it looks like things have largely cooled down . 

The only other character to arrive on scene was a shy asian gentleman . He is of average height, glasses , button up and long cargos with above the ankle socks in very conventional sneakers. He appears to be in deep conversation with another ... Um... Nerd. Both fortunately and unfortunately , he is unlikely to be involved in .. Sexual impropriety this evening . 

Good night. 

- Rob

Healthcare in Uganda

Today, our team set out to visit the regional hospital. 

Now , you have to appreciate how Uganda's health care system is set up. Ideally, there is a tiered approach with health care centers. The smallest centers would be closest to the village but have the narrowest spectrum of clinical services. As you move up to regional hospitals, they offer more services but are further away from rural patients. For example, if a health center 2 ( which joy hospice technically falls under) needs to refer a gi bleeder , they would move up the system and refer to somewhere like regional hospital, for a scope .

There's a good article explaining this for another town:

http://www.theguardian.com/katine/2009/apr/01/uganda-healthcare-system-explained

The highest referral would be to Kampala for the national hospital. 

The sort of kink in this system is that while the regional hospital certainly has more staff and government support , it doesn't mean the care is necessarily better or focused. This is not to slight them,  but it's a matter of staffing/ patient volume/ acuity and resources.  This speaks to Dr Jan's patient centered care and a great staff at Joy Hospice. The fact that I may be able to manage chf in a ten bed unit at hospice better than a district hospital ...is crazy. It's also humbling and sad. 

So we all headed to the regional hospital ,after procuring permission from the hospital director , to shadow / observe the pediatric units. The permission was vital, as we found out that some visiting person had been arrested for taking pictures / touring with consent/permission .

The pediatric units at regional include a general unit, an HDU (high dependence unit ) and a ward split by age groups . 

We showed up a few minutes before 8am to catch ward rounds. Now, factor in the Uganda / Africa time factor and we finally saw some house officers by 9am. In the meanwhile I'm going to switch to stream of conscience mode ( as I couldn't take pictures ) so ill try to paint on with my words / awkward writing.

-begin-

So we take our usual back path / dirt road with signs that warn about a fee for public trash and/or urination. People are cooking on the side streets. We pass a sign for public restrooms .  Every once in a while, we pass a stray dog, usually sleeping in the sun which is starting to warm up. As we reach the regional hospital, we can see the bodaboda drivers arriving with patients/ employees and waiting for people leaving . 

The hospital itself consists of many wings / buildings. There are names like ENT/orthopedic wing, Masaba wing, casualty wing. The wings are connected , more or less, by a walkway . The walkways are constructed of pipe, aluminum siding and some wood. There is a series of drains running parallel to the  walkways. There's occasionally some fencing, presumably to keep chickens/ dogs away from patients?  The buildings themselves are okay. Quite a few of the have at least one broken window. 

Now what about the patients and their families? They are scattered throughout the hospital walkways. In the morning, many of them are preparing / eating breakfast. People have bins of boiled eggs. Some have porridge.  Their linens/clothes is laid out on the sun covered grass for drying . Lines start to build as a queue forms. Mothers hold their children close to them. The hungry or irritable child is quickly placated with an exposed breast. Now, being my third week in Uganda , this doesn't startle me quite as much. At one point, Ashley told me she happened to walk past me while I was interviewing a patient and this lady who had lifted up her shirt for the exam stayed uncovered for the duration of the interview. She didn't seemed bothered In the slightest , with "everything all hanging out." 

So anyway, breast is best and be it far from me to suggest any sort of breast feeding impeding behavior. Not like in the us where you see this :

Yeah , that doesn't exist here. 

So as we wait for house officers , several hilarious things happen.  The first, a chicken kind of strolls into the waiting area for pediatrics and clucks  around for a bit then disappears. Now something about random chicken appearances and chickens general behavior is very amusing to me . The second thing that happens involves a ginormous moth creature . Apparently, unbeknownst to me, a large (maybe 2/3 the size of my hand) moth had attached itself to my black backpack, camouflaging itself . Dr downs drew attention to this ... By standing up and pointing and saying "WHAT IS THAT?!" While my first inclination would be to say my backpack ( a slightly sarcastic reply), I lowered my gaze and saw this moth thing whose size may rival some small birds.  I walked over to the fence with my backpack and dislodged this behemoth. It landed on the ground and fluttered a bit with its wing things. At this point I left to sit back down. Our friend Eric continued to watch the bug who started to fly off. Simultaneously a surveilling bird spotted the insect and swooped down to eat it. After one failed attempt, he caught his prey and ... Finished him. It was national geographic worthy. Eric was astounded , as were. 

As an aside , we also had a janitor incident. So while waiting for the house officers, a gentleman was cleaning the floors. He pragmatically cleaned each segmented. Having spotted us, he politely motioned for us to reposition to the other side while he mopped which we obliged. During this time, some moms(and their respective kiddos) started to line up. However, their passage into the ward would violate / trespass the newly wiped floors mr. Janitor would not tolerate such a thing. He went as far as to physically scoot a bench and block off the corridor , right in front of this lady. It was hilarious, if only you could hear Ashley tell the story.

Shortly after this Darwinian drama, we met the house officers who'd be rounding . 

We split into two groups , one would go to general ward and the other to the HDU (sort of a picu).

HDU was intense, depressing, humbling all at the same time.

Our first patient was a newborn with resp distress. Imagine a small child who frankly is ashen in color , slightly cyanosis and limp. What appeared to be an NG tube in his left nare was actually his oxygen support. I asked our house officer about this and he explained that they've managed to an oxygen concentrator to an empty dextrose container via iv tubing. Coming off this dextrose container is feeding tubes arranged almost like an octopus. Each of these tubes can be used for different patients. Since they lack nasal canula, they simply place the Ng tubes into the nare. There's no pulse ox, I looked . The only sign that this child was doing any different was that his breast feeding had apparently picked up. :( 

Several other patients were in the HDU. Mostly resp distress of unclear etiology. Later , I'd find out they can't do blood cultures at certain times . After abx, they don't ever do cultures . 

One kid that stuck out was a young girl with resp distress and significant syndromic features. He had displaced / dysplastic ears , jaw changes . Apparently she was admitted for this and a cardio eval. When I inquired as to whether she had a murmur, the house officer said not one that was mentioned. As such, I asked to listen and appreciated a loud 4-6/6 systolic murmur . Given the kids liver and resp symptoms , I figured it was probably a vsd.... But nothing to do...

We then visited the general ward, not too much to say there . Our last stop at regional was to the general ward which was short lived given how busy it was . The interns/house officers were stretched and had little time to devote to visitors , which we could appreciate given the acuity and numbers.  

So, prior to concluding our visit at regional , I had stepped out of the wards for air and to purchase a water. En route , I happened upon a crowd staring at a lady in a ditch who appeared to be in distress. I weighed my options at this point : keep walking orrrr...remember that you're a doctor ..so I stopped. I inquired as to the situation and found out this poor soul had just lost her husband. In the midst of this she was alternating between hysterics and near syncope. At one point she passed out. I tried to get a gentleman who was standing by to help me to lift her to safety, to no avail. As such, I resolved to get my bottle of water out and instruct the ladies closest to her to give her the water to drink and splash her face. I was concerned shed eventually have a heat stroke in the sun. At that point, she looked a little more alert and I rejoined the gang. 

-never a dull moment-

So then we stopped by Joy Hospice for a bit, to help out a little. I decided to finish up inpatient rounds as the clinic officers got busy with outpatients. The most interesting patient I saw was a 16 yo girl newly diagnosed with HIV. Based on her parents premature death , it was assumed to be vertical transmission ( from mom to child). However, in true art of medicine / old school for , I retook bits of the history and realized she had prior partners of unclear hiv status and inconsistent barrier protection so this very well could be acquired from such. So, I proceeded to explain hiv as a virus and how this virus attacks the cells of the immune system over time . When this overwhelms the cells , you can get symptoms like other illnesses,fevers, weird rashes, loss of appetite . I explained that we have to treat these infections and then begin attacking the virus with meds. Once the virus goes down and the immune cells return, she should feel better. The last thing I mentioned to this poor girl was making she informs these men about her status when she can safely do so. 

This was one of the sadder cases I've dealt with. I had to counsel her via translator and reassure her that we value her confidentiality and want her to get better and strive to do that. 

One of my concerns was this diffuse skin rash all over her body.  My first thought was to r/o syphilis . Rpr nonreactive, thank goodness. 

And so ends the day. There's a sharp contrast between a very unique care at joy hospice and the over stretched / taxed regional hospital. 

All I can say is that I was humbled and grateful for what we have at home, be it flawed and imperfect.

Fridays in Uganda

ASo Friday was a mental health day so to speak.

Every once in a while, Dr.Downs advocates for us to take a mental break from the intensity / the culture / the emotional aspect of being in Uganda.

We all set out to do different things.

The girls (ash, court, traci) went to Mt. Elgon for some swimming and eats.

http://www.tripadvisor.com/Hotel_Review-g668276-d667363-Reviews-Mount_Elgon_Hotel-Mbale_Eastern_Region.html

I decided to visit IU for Friday Prayer. Being my last Friday in Mbale and last Friday in Uganda, I wanted to have a spiritual kind of goodbye/closure. I've had the pleasure of meeting many Godly people: the Zaales , Tess/Tabbe , our Casa hosts . They don't all share the same religion per se but these people have a relentless spirit despite obstacles  coupled with warm hearts , welcoming natures and humility that puts me to shame .  

When I first signed up to go to Africa , I figured it'd be a once in a lifetime thing. Now , court and ash being smarter than I said I would change that sentiment , having travelled to Africa thrice. I have to agree, I've grown as a doctor, a human being in these three weeks . I can't imagine not traveling more in the future. 

I began my morning learning (from ash) how to wash my mud covered pants by hand. Let me show you my system ;) 

Three buckets: rinse / wash / dirt removal in bucket 1       Soap water wash in bucket 2 (the water container ) and end with soap rinse in bucket 3 

Muddy

Rinse the mud, scrub it off

For the tough stains 

Soap 

Suds cycle 

1.5 hours later , clean. 

Then I headed to Jummah (Friday Communal) Prayers . I wasn't quite sure when it started so I  headed to IU around noon via boda . Now, i rarely an early to prayers and today i was about 30 minutes early but it was nice to sit and reflect . I heard the call to prayer and watch the 100s of attendees start to pile in for the sermon. Today's sermon was on cheating. As in most religious traditions, cheating is frowned upon. Integrity is oft valued and usually viewed in parallel to piety.   Now the interesting thing is that this sermon is garnered towards the students of IU. As such, there's a very tangible concept/lesson to be taught . As they were approaching their final exams, the imam(priest) was reminding them of this important trait, of integrity and not cheating even when you are faced with difficult exams/ tests . 

The rest of the day was fairly unremarkable . I did some laundry and we were invited to dinner, by our casa hosts and now friends. 

One thing that I hope has become apparent, is that we were treated as friends / family of our many Ugandan hosts from the Zaales to our friends at Casa.  It's with a heavy heart that I enjoyed a meal with our friends Saleh and Baker and hope to hold true to their request for me to return in the future.

Uganda, you haven't seen the last of Scribe for Life. 

To Zion

First, I want myloyal readers to get in the same vibe as I am as I write this blog.

Listen to this song: 

Delerium - Terra Firme 

http://youtu.be/LKUxE8UE7S0

-or-

Deadmau5 - Sofi Needs a Ladder 

http://youtu.be/gDndZn0YPdI

Welcome to my mind palace ;) 

Our destination today was to a rural clinic , in the mountains. 

Some background : http://ugandambale.help-international.org/blog/zion-medical-community-clinic

Interestingly , the co-directors for Help International in Uganda were actually staying in our same hotel/hostel. 

So getting to clinic turns out to be quite a journey . In short, our driver could get us only so far into town and we'd have to walk/hike the rest of the way.  So let's do this in pictures :

Car getting stuck, we get out to drop the weight.

Do not pass go. The car cannot go any further uphill.

So we begin .

Our goal is somewhere on that hill to the right .

After climbing uphill for a bit , burning some serious calories, some friendly neighbors told us we were going the wrong direction . We were actually going uphill as well. As such. We should go back downhill to the main path. Downhill = using trees / grass to grasp onto and rocks to anchor your feet so you don't slip. 

Here's Courtney getting help from the locals.

We make it up to clinic after about 1.5 hours of hiking. 

Now, you have to consider this in perspective . This clinic services a rural, mountain community. They don't have power or running water. The chlorinated water treatment areas may be empty. This clinic does antenatal, postnatal , pediatric and adult care. It is set up in stations so there is a triage area, counseling area, treatment area , dispensing area and lastly follow up/counseling area. 

We are greeted by people who work at Zion and the local pastor/church members. This takes place in ..what's best described as a roomy treehouse 

Up the steep stairs 

We are warmly greeted and welcomed as guests and people whose help is appreciated. The community members were so grateful for our help . They also voiced their concerns with their community. Things like needing transportation for sick patients from off the mountain to the main hospital, teacher salaries, medications ( as they keep running out) and housing for staff who can't get off the mountain on certain days. 

Here's a stretcher in my examination room . 

A guide to treatment.

The view from my window 

I saw a couple of pediatric patients : new diagnosis of malaria ( splenomegaly , pallor, jaundice , fevers ) , pneumonia , viral uri , blepharitis , contact dermatitis. 

Now to head back , down the mountain.

Uh oh, gloomy skies. Don't want to be going downhill ...in rain... On a mountain 

Downpour 

Ashley in a geico poncho, though she looks like she's in a kimono 

Pig.

Moo moo 

And the clogs came off .

My boots

Our collective feet/footwear 

The car ! Finally !

Dinner @ endiro , our new hipster locale.

Sketch path to endiro.

Food selfies!

Ashley got waffles !