Flags

Hometown main street.

You're welcome

Weekend overnights at the county hospital ER can be a parade of drunken brutality -- accidents, assaults, all-around bad judgment and poor life choices. These are the patients whose stories so often begin "I was just minding my own business...." They're generally soused to the gills. We spend hours stabilizing their fractures, scanning their head bleeds, sewing up their lacerations, and in return we get cussed out, vomited upon, spat at, and even assaulted. All part of the job, although sometimes it gets a little stale.

And then, usually once a night, there will be the patient who has equally bad injuries but who was, in fact, just caught in the crossfire -- a sober citizen who was assaulted out of the blue, or who had the unfortunate but non-alcohol-related auto accident. These are the patients who, as we're sending them home with a cast or admitting them to the Orthopedics service at 4:00 in the morning, will say "thank you." And that usually makes all the rest of it worth it.

Golden spire

The human condition

Halloween aftermath

When you're in San Francisco for Halloween it can be hard to know who's in costume and who's just in their regular clothes. And the leftovers on the train today were fascinating: bits of fluff and sparkle and hairpieces littering the platforms; a dazed and very authentic looking US soldier; the guy who got on the train carrying his enormous curly wig and sporting a big, fresh black eye (the real thing). As late as this evening (the day after) there were still plenty of people out in full costume and makeup.

Photos from Ghana

Spent quite a bit of time on the beach.



The lovely coast.



Our accommodations near Busua.



Helping out with a procedure in the Mampong District Hospital.



Suspicious finding on an X-ray.



Helping out with training.



This boy had been hit by a car and needed a leg splint.



Working with the plaster of Paris.



Another satisfied customer!



The countryside near Mampong.



The balcony of the Doctors Transit Bungalow.



Sunset from the balcony.

Evening in Accra

All alone in Accra tonight, having left the gang behind in Mampong. The highlight of the flight from from the north was seeing Lake Bosumtwi -- a water-filled meteorite impact crater -- from the air.

Made it to the happening Osu district without much hassle and took myself out for what turned out to be kind of a nostalgic dinner. Needing to spend the last of my cedis before I fly out, I picked an expensive Chinese restaurant that came recommended where I had a delicious fish dish (the fish all along the coast in Ghana has been first-rate). Dining alone, I found myself reading over the meal in a Chinese restaurant full of Africans; weirdly reminiscent of many of my meals during my time in East Africa. And the waiter even brought a candle to the table for reading light!

Afterwards wandered around for a while, taking in the frenetic sights and sounds (and music) of Saturday night in a big West African city. But an early morning to catch my flight looms over me, so it'll be back to the hotel soon.

The Doctors Transit Bungalow

The electricity bill on the dining room table reveals that the physicians' residence officially goes by the delightful name of the Doctors Transit Bungalow. I'm spending one last morning on the second-floor balcony here, which has become one of my favorite spots anywhere. Following a downpour earlier this morning, there's mist lying low over the green hills, with solitary trees sticking up above the canopy and bright flowers everywhere. And, as always, there's a rich variety of birdsong on the breeze.

Yesterday morning I took a long walk out into the countryside (where I noted the formidable local insects -- do not mess with the ants and bees here...) and then back through the adjacent village. In the afternoon we made an expedition to the clinic in the nearby town of Kofiase. This is one of the feeder clinics for the district hospital here in Mampong. Although resources may seem limited at the hospital, the clinic in Kofiase really has to make do with the bare minimum: no doctors, half-stocked shelves in the dispensary, no running water. The delivery room in the maternity ward left us all a little thoughtful: a bit of a grim prospect to be there as either a patient or a provider.

Last night we headed out to one of the two restaurants in Mampong, the Farmer's Cave. Far out of town on rutted roads, it's the Ghanaian equivalent of a midwestern supper club. We stuffed ourselves on jollof rice, goat meat, chicken, and yams while watching distant lightning on the horizon.

Sadly, I need to leave Mampong this morning. I'm off to Kumasi, capital of the Ashanti district, where I'll catch a flight to Accra; then tomorrow I leave for home. However, I've already been talking with the program coordinator here about the possibility of coming back for a rotation when I'm further along in my residency and get some elective time. Until then, I'll content myself with fond memories of the balcony of the Doctors Transit Bungalow.

Training day

Yesterday I helped out with the Basic Life Support training here at the hospital. It went well and turned out to be a lot of fun. The program had brought a set of adult and peds training mannikins and there was a good crowd in attendance. Everyone was very involved. When we were teaching the Heimlich maneuver, the enthusiastic nurse I was working with practically left bruises on me. Very curious to see whether the next patient to arrest in Casualty will get CPR.

Ghana

Writing this sitting on the balcony of the doctor's house on the grounds of the Mampong District Hospital. We just had a refreshing mid-afternoon rain, and now I'm looking out across the dripping trees and listening to all sorts of birdcalls.

Last week was spent at a series of lovely beach resorts along the coast. Beautiful beaches, almost no one around, and surprisingly fantastic food. And nothing beats falling asleep to the sound of surf.

Heading north to the hospital involved a fairly typical 12-hour trek involving multiple taxis, long-distance buses, roads in various states of repair, and that workhorse of intercity travel around the world, the mini-bus (called a "tro-tro" here). Had an interesting changeover in Kumasi, Ghana's second city, where we waited after dark in a what was basically a smoky, excavated pit for a tro-tro that turned out not to be coming. But the daylight segments on the roads were very scenic -- lush greenery and all sorts of interesting roadside activity.

Mampong is a town of about 20,000 with a district hospital. I've been hanging out in Casualty (basically the emergency room) and following along on rounds. Have already seen some interesting cases, including a relatively rare tropical worm infection.

Today was market day. On the way back to the hospital we passed what was obviously a recent and serious two-car collision and hustled back to Casualty, figuring that the victims had probably been taken there and to see if we could help. As we pulled up we saw two men wheeling a person-sized metal cart from the mortuary to the hospital, and inside we found one of the patients dead in the room used for resuscitations. Another patient from the accident was also being treated and was fine, and a third person had already been seen and released. We tried to figure out what had happened to the dead man, but realized that it would have been unlikely that we could have done anything for him, given the limited resources available.

Tomorrow is a big training day and I've offered to help out; we'll see if my vacation-dulled mind can recall any emergency medicine.

Back to Africa

12 years ago I started out for an adventure in Africa. That trip changed my life and set me on the path I've been following ever since. In just a few hours I leave for Africa again....

Smoke and a roar

I've been sleeping during the day, working night shifts, and this afternoon I was awakened by loud jet airplane noises. It took me a moment to realize that it's Fleet Week, and the Blue Angels were practicing. We live pretty far up the hill where the hospital sits, so those F-18s were flying just a few hundred feet above our apartment, rattling it pretty good. Ordinarily I'm into loud fast things, but I realized with a sinking feeling that they're going to be flying every afternoon -- on the days I need to be sleeping! Basically, I'm gonna have jet flighters waking me up at my equivalent of 3 am for the next several days. "Smoke and a roar," according to the Chronicle. Even more sleep deprivation than usual, according to me.

Back on the road

Off to Ghana next week to visit Dr. N, and since I'm now on nights I was actually able to stop by a travel store during business hours for some odds and ends. It was a bit of an upscale place. The woman working there asked where I was going, and when I told her she looked up and said "that's great! Mostly people say Florida. I didn't think people did adventure travel anymore." I think it made her morning -- and I hope she gets a vacation and a chance to travel soon herself.

Neurological exam

We see large numbers of intoxicated people in the emergency room who come in after unknown events. The problem is, most of them are just drunk or high, but some of them have had injuries including head trauma. So we need to watch them and see if they sober up or if they have other problems that we need to take care of.

The other night a young lady came in, apparently drunk, and spent a few hours face-down on a gurney. As she started to clear and move around, it was time for a repeat neurological exam. I looked down the hall, and saw that she had put on her 4-inch stilettos and was starting to walk around. I figured that anyone who can walk around in those shoes must be neurologically intact, and started printing out her discharge papers.

Unstormy weather

Today I was going back through some older posts, looking for something that might be expanded into a larger piece. (Any suggestions?) I'd forgotten that I used to have a category called Weather Geek. Gotta say that moving from the extremes of Iowa weather to the Bay Area's temperate climes has kind of eliminated that category for me. Time was when I would blog about tornadoes (even live-blogged a couple), ice storms, heat waves, blizzards. I think the most I've managed from the Bay Area was a short post about rain. Not even a torrential, car-floating downpour; just noting that it was raining, as opposed to not.

Washing up

This recent exchange with a houseguest is what passes for normal in our little apartment full of residents:

Houseguest [noticing something in a plastic basin]: "What's that?"
Me: "It's a bloody shoe that I'm soaking in hydrogen peroxide."
HG: "Is it your blood?"
Me: "Is it better if it is, or better if it isn't?"

Entertainment news

A while back NBC shot a pilot in San Francisco for a new medical thriller called Trauma. Many of the folks who work in the hospital here, including some of my co-residents, were extras. We didn't know if anybody made it into the final cut, but the intent young physician on the right in this promo pic is one of ours!

Rapid cycler

Working the night shift can be difficult, but it's even harder to cycle between days and nights. In the past 10 days I've worked swing, day, night, day, night, with no more than two of the same in a row. I've got today off, then I'm back to days tomorrow. Truly disorienting.

Harmonic convergence

This evening all three of us residents who live in the apartment were briefly home and awake at the same time. I think that's the first time it's happened in about a month.

Pet peeve

Waking up at 4 am to catch the bus to work and realizing that I don't have any clean scrubs....

Invisible Immigrants

Hmm, seem to be reading the Times a lot lately. Was struck by this article, by its poignant subject, its proximity to where I'm living, and the fact that these issues are ones that we deal with daily in the emergency department.

Remembering the floods

I was touched to see this article in the Times. Our little crew moved away from Eastern Iowa just as the floods hit, and it was a very emotional experience.

District 9

I've been cycling between day and night shifts, which leaves some odd chunks of time off in the middle of the day. So a few days ago, unable to decide whether I should be sleeping in the middle of the afternoon, I went to see District 9. Then on my very next shift, a young man came in having his first psychotic episode. The subject of his psychosis? Among other things, he believed that he was trapped in -- District 9! By the end of my shift, I was beginning to suspect that I was, too.

Bitten

Yesterday we had a great teaching conference: how to protect yourself when attacked by the out-of-control/psychotic patient. For example, what is the correct reaction when a patient bites you and won't let go? Or when you are grabbed by the hair? (My answer to that one: "I'd just walk away.") There's a reason many ED docs don't wear their stethoscopes hanging around their necks....

Transitions

Very interesting article in the Times today: Doctors in Cuba Start Over in the U.S.

One thing that struck me was the way certain aspects of American medical training are addressed in this article. By coincidence, earlier today I was talking with another resident about how almost every article we see in the general press about medical training tends to use the same formulas and cliches.

"...most hospitals seek young doctors who can work long hours for little pay. A 40-year-old doctor is often deemed too old to be accepted in a residency program." Oddly refreshing -- and, in some ways, more accurate -- to see the issues examined from a different angle.

Contempt for the newbies

Reading this article, I was reminded of an impression that I've been developing as I spend year after year in medical training. Health care places enormous value on an individual's cumulative experience, and appropriately so. However, I often see that value expressed as disdain, even outright contempt, for inexperienced individuals -- i.e., people who are simply in an earlier stage of their training. I can't even count the number of times I've seen a student, intern, or junior member of a team publicly excoriated, not for incompetence, not for doing anything wrong, but simply for their lack of experience.

Case in point: a while back I was a few days into a new rotation, trying to operate in a system I'd never worked in before. I was trying to get a patient's visit wrapped up expeditiously, and made a mistake filling out a new lab form. A senior nurse walked up to me in the hall with the form, and in front of waiting patients flicked my nametag and half-shouted "you don't know anything!" in my face.

Now, I don't think that this person was actually questioning my clinical judgement or my ability to make reasonable choices about appropriate lab tests. We're all trying to do our best for our patients. And frankly, health care is very, very hard, and we all feel insecure about our own abilities from time to time (daily, even). But I'm frequently shocked by how often this comes out as what seems like little more than hazing of the junior personnel, simply because they're junior. I guess this is much on my mind these days because with every year's turnover I become more responsible for teaching -- and modeling behavior for -- junior members of the team.

Of course, I've been lucky -- the worse things that have happened to me during my training so far have been trivial compared to things that are routinely inflicted on trainees other places. But still, I'd like to think that there's value in consciously striving not to perpetuate these behaviors.

Spider bite

It's quite common for people to come to the Emergency Department reporting a spider bite, but most of the time it turns out that they weren't actually bitten by one of our eight-legged friends. (This phenomenon is very interesting to me, and I have a theory about it that I should share in a future post.)

However, tonight our team in the ED had a rare moment of being able to sit down together for a few minutes, and as the newly-minted big bad R2 it was my duty to use the time well to do some teaching for the intern and medical student. So we talked about black widows and brown recluses and the diagnosis and treatment of actual spider bites. And the weird part wasn't the medical information (although some of it is kind of weird), but that I was sitting there, knowing a little bit about the subject and able to share it. Maybe these long hours in the hospital are driving something through my thick, sleep-deprived skull after all.

$64 word

My iPhone spell checker knows "opisthotonos." I'm impressed.

Getting out early

Today I had a 12-hour shift that ended after... 12 hours! To a resident, this feels like getting the day off.

Phrase of the workday

"Aerosolized vomitus."

That is all.

Diapers

I'm on Pediatrics this month, seeing a full range of kids from the very sick to the not really sick at all. Lots of diapers, and I've managed not to get peed on. Yet.

Fly fishing

The other day I bought some new underwear. It looked like my current favorite model in the packaging, and I was glad to be extending my laundry cycle. (Unlike a 90s-style politician, I will not be revealing what type of undies I wear -- although rest assured that they are both sporty and sexy).

Imagine my surprise, then, when I got home and discovered that they have no flies! I checked the packaging, and not a word about this design update anywhere. What the hell? Is this the new thing? Have I drifted so hopelessly behind the tide of fashion during medical training that I don't even understand underwear anymore? I don't want to get too hung up on this, but when you work a resident's hours convenience is very important.

Mass casualty incident

Long time, no post. A week of vacation followed my last post, and now I've started R2 year -- the second year of residency.

I worked an overnight shift last night on the Pediatrics team. When I arrived in the Emergency Department things were pretty chaotic; there had been what we call a mass casualty incident: two light rail trains had collided. As you can imagine the department was pretty backed up, but fortunately no one who presented to our hospital was too badly hurt. One of the trains involved was headed to a Chinese-American neighborhood, so when I got there the halls were full of elderly Chinese people in cervical collars.