Montezuma's Revenge

Day 6

So I had chills on my 5th night and woke up feeling horrible ...weak...aches but I brushed it off to an unusually cold night and maybe some dehydration. 

Me and the girls headed out to clinic , hopeful that our three sickest patients made the night .

However , we all had reservations regarding our chef lady with gi bleed.

Needless to say I headed straight to her bed....and I saw a body covered by a blanket. 

...my heart sank

How naive was I to think my one day of interventions would save this medically complex and ill lady. I found out that despite having the blood , our iv access didn't work so by 6am , she had no blood and she passed . Our attending reassured us that we did our best and frankly they thought she'd have passed on her last admission for chf. 

May God rest her soul.

Our 30 yo metastatic ovarian ca lady felt a little better after our tap and started to eat some. However she has been anuric, without stool/flatus and remains sig. Anemic .....so we theorized she may have a bowel obstruction related to her huge solid mass cancer . Our attending said there's not a whole lot to do..she's not a surgical candidate ..that we can offer hospice at the clinic or home.... I will say that her pain was better controlled ....

So back to me...abdominal cramps and epigastric burning with aches throughout clinic. I took the free uganda govt rapid malaria test...negative . The techs ran my smear to be sure ..negative . So not feeling much better ...I walked the 30 minute walk home. I grabbed some carbonated drinks and buns as I'd been losing my appetite . Then it started . Politely..I was ...losing bicarbonate and intestinal epithelium via my gi tract . I crumpled over in abdominal cramps.... So..I probably have .... Diagnosis is what? 

http://en.wikipedia.org/wiki/Traveler's_diarrhea

So after some cipro and sleep... 24 hours after onset..feeling slightly better .

Needless to say...my mum was in a state of fright but I shall call her when its a reasonable stateside time :) 

That's all for today .

The day we ran the clinic

So I think it's important to appreciate who's on my trip and our situation. 

Dr Jan is at home recovering from a fracture or rather a compression fracture and trochanter injury.

So basically Joy Hospice is being run by the clinical officers an nurses. Clinical officers are sort of like pa/midlevels in the u.s. this is usually not a problem at a level two health center buuuuuut here's our census :

40s yo guy with recently dx aids , with night sweats and poor po despite being on art and broad spectrum abx.

80s yo lady with severe asthma on 30 mg of prednisone , oral salmuterol , and nebs spaced anywhere from q 11 to q4. This morning she was newly hypoxia to high 80s, auto peeping and tachypneic to 30s.

80s yo lady with ccf ( congestive cardiac failure ), kaposis sarcoma ( non HIV), hx of pud. P/w weakness and fatigue . She was found to have a high of 6.6 yesterday with black stool but doing okay. We had started a ppi and hoped for the best today. However, she was looking shocks with cool extremities , white conjunctiva and looking horrible. Our c.o. Told us her o2 sats were 60s before we rushed in to assess her. In short , her poor perfusion gave a poor pulse of read but my main concern was a gi bleed as she had inc stools overnight that were loose and black with left sided abdominal pain. 

30 yo f with metastatic ovarian cancer with malignant ascites and multiple implant sites in adores was referred to us by the bigger hospital " for morphine " and evaluation with very little explanation of her disease. 

50 yo f with metastic breast cancer who ran out of her pain meds and was constipated along with Complaints of leg parasthesias .

Solo that's our ward. Day 3 on the job and we were left to run this ward and make decisions. Let me first say that I am working with two amazing residents, almost attendings ash and court who basically helped me run this semi adult icu service from a small clinic in Mbale , uganda . We rounded , did our own vitals , made plans then met dr jan at home for lunch and to discuss cases. Dr jan basically agreed with our management which follows:

1.Gentleman with aids , I was concerned for a tb coinfection thought he had no cough. However he had no sputum so we couldn't do an afb and ironically to run the free gene test at the  regional hospital we'd need sputum . The other differential would be an IRIS type reaction .

2. Lady with asthma . We basically made her q3 nebs , adjusted her steroids to adult dose and give iv aminophylline with great improvement . Hypoxia had resolved by end of day. 

3. 80 yo lady with ccf/ pud hx. On my way to dr jan...I smell and saw the malena personally. After going back and forth wi the staff because her hgb was 6.6 (from 9s one month prior)apparently the hospital will usually send blood only if <5 . We basically got blood sent , obtained an iv , started 2 units prbc with lasix between and prayed for the best . ; TLDR: I managed a gi bleed in outpatient clinic. 

4. 30 yo female wi met ovarian can Er. Basically I had to discuss her whole case with her . I had to explain how bad her cancer was and that she would die from it. I explained her ascites would keep coming  back  with this cancer . I explained that we should focus on treating her pain and letting her be as functional as possible . We even assessed her home situation which we realized she lives with her husband who works most days and can't tend to her ..as a terminally ill patient . So after discussing the case with dr jan   , she told me to tap the ascites if I felt like it . No , this isn't stony brook. I don't have a sonosite, I don't even have a paracentesis or thoracentesis kit. In short dr jan told me to sort of make an iv / tubing / bucket work for me . So with the help of Ashley , sweating my --- off I attempted to canulate her abdomen with an 18 gauge needle. Then I would hook it up to an iv set and basically reverse a traditional iv drip to drain this to gravity. Long story short, after much anxiety and a bent catheter on the first try I was able to drain 2 liters of straw colored ascites to the relief of the patient . Sadly   , after get distended and Tympanic abdomen went down, we were able to see the large left sided abdominal mass ....the source of her terminal illness. Sad. 

Fun fact   , oral  morphine is provided free by the govt for palliative care. It comes in three concentrations that are color coded/dyed. 

Green (5mg/ml)  Red (50mg/ml) Blue (100mg/ml)

All in all , one of the most memorable days of my life.

Day 4 - Meeting Dr Jan

So today was the first day of our rotation. We set out to find Joy Hospice and our attending , Dr Jan.
http://www.mbalehospice.org.uk/
Read through the website, it's pretty amazing stuff.
So of course we got lost en route. We tried to cut through the regional hospital as opposed to turning right at the little clock / turnaround .

* will include day 4/5 stuff *

Joy Hospice is a special kind of place . It's a mixture of a mini hospital with ten "ward beds " and outpatient clinic . The kinds of patients I've seen in clinic this far :

Ward

Infant with diarrhea illness treated with ORS and zinc 

Older lady with spondylosis and uncontrolled htn 

Young gentleman with wasting / fatigue found to have AIDS, cd4 count in 100s. He's been having some hypotension . He's also complaining of nausea and weakness  . My theory was that he could have an element of adrenal insufficiency but without a Chemistry / cosyntropin/ cortisol level, it's hard to prove . My c.o. Was amenable to trying steroids though :) labs cost money to patients in clinic   . HIV testing is free when available but we have to pick the best test for the money so this far he's only had a cd4 count .

2 different ladies wi asthma exacerbations. One lady came in with hypoxia and severe distress , was given steroids and only two salmuterol treatments which ....blows my mind. Needless to say I requested at least q4 treatments , with Ashley and Courtney in agreement .

Outpatient 

Young girl with fever / abdominal pain = typhoid and uti ( cipro for both)

Older gentleman with tendon pain and early satiety = hpylori positive / pud and partially torn tendon ( a good find on me and Ashley's behalf with a bunched up tendon and obvious deformities when patient lay prone comparing the two tendons 

Young girl with follow up , she had previously presented with significant weight loss / night sweats / nocturnal fevers  / anorexia and had been treated several times for "malaria " without improvement . The person at joy hospice took a thorough history and realized there was a sister with newly dx tb and patients afb came back +++ = newly dx tb. On follow up , two weeks into treatment she looked happy and alert . She thanked the clinical officer for saving her life :) 

So that was clinic so far . I feel very fortunate to be helping and learning . People are referred to joy hospice in times of desperation when other doctors can't help them.  I feel very fortunate to help in my little way and learn from the Ugandan people and our fellow healthcare workers.

I will blog about our clinic staff and dr jan later, since there is so much to share. 

Uganda Trip!

Days 1-3

Day 1
Left Lake Grove at noon. We quickly found out our driver was a conspiracy theorists . His theories included jet fuel as a coverup to distribute an agent orange kind of agent to the atmosphere , that politicians are trying to revert us to feudalism with a ruling class and peasant class ,etc. Good Times.

Flying
Flying and traveling was ...lengthy
Brussels was 6-7 hours / layover then "chilled on runway for an hour " / Brussels --> Rwanda  7hours / layover ( people get off , bug sprays gets sprayed , potties get used approx 1h) then land in Entebbe around 10ish. We stayed at Entebbe Backpackers (http://www.entebbebackpackers.com/) which was a nice little place . Cheap / mosquito nets/ your own shower

We slept over from midnight to 530a then started our journey once again, to our final destination of Mbale , Uganda . We drove in a van half-awake / jet lagged until about noon. Stopped in Jinja (popular tourist stop , site of rafting ) for breakfast @ http://www.enjoyflavours.com/  . Here I learned some rules for traveling abroad from Ashley :

Rules for traveling abroad
1. Eat what the locals eat , which is usually veggie unless you're in a touristy area . Street meats are usually out all day and likely to give you the diarrhea ,etc.
2. Don't order ice , usually . Unless you know the water us treated / filtered (that makes the ice ) .
3. The children will call you Mzungu (http://en.wikipedia.org/wiki/Mzungu) which means white person / with the undertone of meaning someone with wealth / foreigner .
...more to come ...

We finally arrived at our new home around  noon  on Sunday , Palm Sunday .  Since we travelled so early , we got to appreciate Ugandans dressed in their Sunday best carrying palms as they made their way to church. ( kinda looked like below ( from google images ))

Casa del Turista
http://www.tripadvisor.co.uk/Hotel_Review-g668276-d4367873-Reviews-Casa_Del_Turista-Mbale_Eastern_Region.html#

We were greeted by the owner and wonderful host at casa , Baker . Casa is  nice little dorm kinda of setup. Our rooms have beds/nets/ standing showers/ western toilets . We can actually see mount Elgon from the rooftop at casa. Baker is a wonderful host and helped us build a dinner menu and let us know about all the outreach casa takes part in from supporting two high schools to recycling straws to make purses which can be resold.  

You should specialize.

It's been 2.5 years since I've written a blog post!

In that time period, I've completed half of my  internal medicine and pediatrics residency.

I've met a wonderful young lady, who I've been with for almost 19 months.

I've been stuck in a blizzard and 30 inches of snow.

I've had my tire slashed by some disgruntled employee at my apartment complex.

I've gotten a bike, which I'm slowly breaking in. I need to ride more.

But the reason I'm writing this.
After two years I've made a decision on what I want to do with my life.

I started off Congenital Cardio (after spending a month in Orlando @ Arnold Palmer), then considered Nephrology strongly. My goal was to do boards in Adult Nephro and see both kids/adults.  Now, finally, I'll do my alma mater proud and go into primary care.

Med School Alma Mater

Despite the warnings of :

1. You should specialize
2. You'll never make enough money.
3. Primary care is underpaid, under-appreciated.

I've come to realize something.

According to Webster:  Primary means
a : of first rank, importance, or value : principal primary
 purpose>

b : basic, fundamental primary
 need>
They are potentially the most important doctor you see.
Having done ICU, Cardiac Units, 1 month in ER, I've learned just how important a good primary care doctor is.
They can be your cardiologist, nephrologist, endocrinologist, pulmonologist, gastroenterologist, psychiatrist. 
They can be your nutritionist, your advocate, your ally, your friend. 

I've had the pleasure of working with some amazing attendings in my continuity clinic , both in pediatrics and medicine. I've also worked with private attendings as well.  It's enjoyable to see the same patients, to help fix their diseases. I enjoy my conversations with my patients. I enjoy seeing them lose weight and get their diabetes under control. I enjoy seeing them overcome diseases and diagnoses and prognoses. I am humbled every day in clinic. I am challenged.  

The good internist/primary care doc is a Renaissance Man/Woman. They will know enough about every organ system to start a good workup and often complete and treat those diseases. I can schedule a colonoscopy, follow up the results and keep surveillance on my patients. I can titrate their statins to optimize their LDL goals. 

The most important thing about this realization is that I can see myself doing this for many years. In 20, 30 , 40 years, experience will only add to me knowledge and skill as a generalist. 

Perhaps, my mind will change in the next two years, though unlikely. 

Catching Up

So , I haven't blogged in.. a long time. Apparently, since August when I discussed the Mosque Debate that was going on at the time in New York.

I'll go ahead and summarize what's been happening in my life, of course with as many pictures as possible and extra length for things that take up extra brain space for me.

Infectious Disease (September)
Originally I was attempting to get an away rotation/elective in Infectious Diseases in New York but vaccines, yes vaccines got in the way. That's right, Jenny McCarthy was right, vaccines not only cause Autism but ruin lives in general. NO, that's totally wrong. Jenny McCarthy has her attention misplaced much to the detriment of Autistic and Unimmunized children in America, I'll expand on that later..

Back to my vaccines. I never got chicken pox as a child. Blame my nurse mother or my introverted, outcasted schoolage version of Robert, Robert -2.0.


Therefore I had to get a varicella titer. Turns out my titer was 0. Zero. Nil. No more anti-varicella antibodies in me. So I needed a booster, which I got a bit too late. It'd take weeks to months to change my titers and I gave up. Plus I found out my insurance wouldn't cover labs, later I found out said insurance wouldn't cover me, being 25 and somehow stuck in a noncoverage gap.

Oh Frustration.

Immune status, FAIL.

So instead of spending time in my favorite city, I teamed up with our ID Doc @ my home hospital. This was fun because I was able to function at several levels. Initially I backed up the intern on ID and we split patients. Then our intern switched to another doc and I became a sort of resident intern working with a visiting student. The ID team is like the super internal medicine team. We're consulted when the main teams , be it ortho, surgery, internal med can't figure out what drug to use or what's causing the fever, etc. Ask a couple questions, draw on some people's legs. ( I love outlining cellulitis legs because you get to draw on people) , and then round with the attending in the afternoon or night.

I had lots of fun on ID. I liked thinking at a different level and doing a careful review of the patient as a whole to try and pinpoint the reason why we were consulted. At one point , I considered this as a career option, but not so much anymore.

Pediatric Cardiology (October- 4 weeks and December (@ home) - 2 weeks)

This rotation probably was the hardest I will work all of 4th year. This was my favoritest rotation.

First, I started off kinda rough. I didn't really have a schedule to begin with, so I kinda floated around for the first week. At first, it seemed intimidating being the only student in a congenital heart clinic. My attendings were as follows (all Peds cardio):

Maternal/Fetal Echo Mainly
Electrophysiology/Syncope/Chest Pain
Interventional
Echos/ Regular
Peds Cardiac Intensivists


Second, I'm used to guessing my way to an answer or making assumptions and whittling my way to an answer and my attending wasn't having any of that. So I realized I'd have to quickly learn my way around murmurs, a good physical exam, EKGs, etc. And I did. By week 3, I could skim an EKG, diagnose a murmur and even guess a diagnosis, work up chest pain/syncope and counsel like nobody's business.

The attendings eventually were won over by me. I find that if I prepare with reading and come in with a smile, I can win most anyone ever. I loved my peds cardio patients loads. A sampling of the things I saw:

Kabuki Syndrome: In essence it's a congenital condition that can involve cardiac conditions, hearing defects, mental retardation, growth retardation, etc. The syndrome is named as the children take on the appearance of a "kabuki" doll. My little guy was super cool, playful (interestingly, 50% are described as unusually playful). We played with toys as the cardiologist counseled the parents.


HLHS: B-T (Or Sano) , Norwood, Atrial Septostomy followed by Glenn followed by Fontan. This is one of the more amazing patients to follow on peds cardio. The Hypoplastic left heart kids and friends (friends being the various kids who have shunts for reasons like atresias, etc) In short, with the use of gortex, some fancy stitching , connect the aorta to the right/single ventricle. You shunt blood into the pulmonary arteries , patch it here and there as the kiddo grows, hopefully you outpace the inevitable cirrhosis.




The Tet Kids. Patch this, band that, call it a day and wait it out. I do have a story that warms my heart a wee bit. Please indulge me. So I was working with the E-P doc and NP doing stress tests. A cute little blonde teenage girl with ToF comes in for a stress test to determine the nature of her dyspnea and sats. So there goes the stress test, it finishes and the girl sits down.

A few minutes in , she starts crying. We ask her what happened? She says " I want to go to college." We realize that for whatever reason, she thought she was going to get bad news, that she wouldn't live to college years.

The EP Doc in a very classic Dr. N way (Dr. N has these phrases he uses to relate to adolescents and he uses them consistently and somewhat awkwardly) goes, well the only thing that'd keep you from college would be your SATs and grades...

Then he follows up with his old adage. As far as your heart goes, it's fine.. but I can't say a boy won't break it.....

Syncope/ Chest Pain

So I know what you're thinking. First, what does Gatorade have to do with Syncope. Second, what kind of innuendo is gatorade aiming for here. Young female athlete perspiring selectively in her "thorax" area.

Vasovagal syncope, the body's inability to restore homestasis in the setting of orthostatic changes and stress. (At least that's my definition) For my teenagers, basically your tank ain't full and your pumper aint pumping appropriately so your brain says woah and your body says get low.. and ya faint or feel faint rather. So to fix this, you keep your tank full with some gatorade, before , during and after sports and in hot weather , even without sports. With further dysfunction such as the autonomic dysfunction of Pott's syndrome, you might throw in some mineralocorticoids such as Florinef (fludricortisone) and vasoconstrictors to clamp the vessels a little.

And lastly, a review on Marfan's. Many of us have read up on the Marfanoid appearance. The pectus chest, the long limbs, the lens dislocation, the MVP, the joint laxity, hyperextension, scoliosis, elastic vessel changes.


So we saw a young man who looks Marfenoid but the genetic tests were all negative but we were keeping an eye on him for his aortic root dilatation.

Cool kid, basically got to d/c his beta blocker and say: Sports, have it chap!



























And lastly, lastly. Autism and Vaccines

I could rant about this for hours and hours. But here's my line. Vaccines do not cause autism. There is the possibility that they might trigger an underlying disorder but that's like blaming someone who steps on a remote mine for the explosion, sure they set it off, but they didn't put it there.

I read a really great book about the whole "link" and the publicity and Jenny McCarthy's campaign.

Take home message: We will see a resurgence of diseases such as Measles, Mumps, Rubella, Rotavirus, Influenza, etc.


Sure, there have been circumstances where Rotavirus vaccines had been pulled off the market for an increased rate of intussusception and then there's the Guillain-Barré syndrome warnings.

From the CDC:

What happened in 1976 with GBS and the swine flu vaccine?

Scientists first reported a suspected link between GBS and vaccinations in 1976, during a national campaign to vaccinate people against a swine flu virus. The investigation found that vaccine recipients had a higher risk for GBS than those who were not vaccinated (about 1 additional case occurred per 100,000 people vaccinated). Given this association, and the fact that the swine flu disease was limited, the vaccination program was stopped.
Since then, numerous studies have been done to evaluate if other flu vaccines were associated with GBS. In most studies, no association was found, but two studies suggested that approximately 1 additional person out of 1 million vaccinated people may be at risk for GBS associated with the seasonal influenza vaccine.

Well that's that. You've been updated. To follow: Med-Peds, the journey... where I talk about Med-Peds and the interview trail and why I chose this path for residency.

Finding a Place to Pray, The Mosque Debate

Summer of 2008, "The Last Summer of Medical School"

I did what I always did when I have a few days off and want to go have fun somewhere, I go to my second home, New York. While I can't call myself a tried and true New Yorker, I'd say being born in Brooklyn and living there for 5 years allows me some claim. I've probably visited there most every year after.

So I spent a week there between my first and second years of medical school. I did the things that touristy people do, I went to the museums, ate the gyros, etc , etc. Then comes Friday. You see while I'm certainly not the most committed Muslim, praying 5 times a day, etc. but I will always make a sincere attempt to make it to Friday (congregational/Jummah) prayers. If I'm not in Georgia, I usually google the nearest location and head that way around 100/130p. I was in the Financial District, having spent the morning at South Street Seaport at a Whaling Museum and Restaurant with Andrew and Helen. The nearest location was off Warren Street , a few blocks away from where the World Trade Center was.

Now, I've got a horrible sense of direction but I found the Masjid (place of prayer) readily enough. You see, the main "masjid" was the basement of a store that extended out into the street and across the street. There was two services, so one I saw one service come to completion. Men in their business attire, colors as varied as the rainbows, catching a service in the middle of their work day. As they filed out, a new group replaced them, joined by me. I attended, enjoyed a relatively short sermon and went about my day, just like the rest the attendees.

And therein lies the beauty of New York. It's a place where you can grab breakfast at the Dunkin Donuts run by an Indian Family, grab a gyro from the Arab vendor, eat dinner in Little Italy and go get some sketch electronics in Little China. I've been to a college Model UN conference hosted at the Marriot on 6th Avenue. I've debated with an Ethiopian Guy on the loving nature of Christ in New York City. I've walked through Central Park after a day at the museums. I've been to Columbus circle to go hear some Jazz with my cousin and aunt. New York is the greatest city I've ever been to. It's dynamic, it's accommodating, it's always moving, always awake.

Given that, I've felt ambiguous about this Cultural Center being proposed to be built near Ground Zero. In one sense, it's inflammatory in the sense that there is a strong emotional component to how we feel about 9-11 and the victims and their families. So the suggestion is that they move the Mosque to somewhere more P.C., less inflammatory, safer.

But that's not the New York I know. It's a place where things do stand in contrast to one another and things work because people are smart. They would want a place where their fellow citizens could pray and Interfaith Dialogues could take place. If Muslims like myself have failed in distancing themselves from the attacks of 9-11, it's not because we haven't spoken out against it or distanced ourselves. It's because we don't do a good enough job in taking part in the community we exist in, as Americans.

-Robert Karim Abdullah