Monday, March 31, 2014

allocation of resources & teaching

it's been a few days' hiatus from the blog, however i assure you much has transpired despite the availability of the world wide web! for ease of reading (and writing), i'll tell you about a few days at a time here and in my next post.

last thursday was our first taste of rain and cool weather. this made navigating the outdoor wards a bit tricker, although a whole lot less sweaty for all parties involved. (hooray!) prior to catching up with the registrars for rounds, we accompanied dr. draper to the radiology department to make a case for a patient having a CT chest. 

visiting the radiology department
it was a pretty straight-forward request, really. 60-something year-old gentleman, long-term smoker, recurrent right-sided pleural effusion requiring chest tube drainage with suspicious-looking CXR. six weeks prior, when a CT chest had been requested, radiology had denied the request stating that because cytology had been sent from the pleural fluid sample, the results would need to come back prior to obtaining the CT chest. [at edendale, if you want an imaging study, you must fill out a "request form" for the radiologist and plead your case. the radiologist has the final say in who gets imaged. tests are not guaranteed to be done.] after six long weeks, the cytology came back: negative. nobody really believed it; certainly his story, imaging, and clinical signs were still quite suspicious. cytology is notoriously low yield anyways, and it was a head-scratching decision to have waited for its results until the CT was obtained. 

armed with this information, we followed dr. draper into the head of radiology's office. he pleaded his case on behalf of the patient. "his diagnosis has already been delayed six weeks," draper reasoned. the radiologist faltered: "can't you send off some kind of tumor markers or something?" the discussion continued; after almost begging hand-and-knee, the radiologist relented and gave the patient a CT chest spot THREE weeks in the future.
although we occasionally have our issues getting imaging done at columbia, this was certainly shocking. a timely article in the health section of this week's mail & guardian (south african newspaper) addresses the frustration of regular south africans who need outpatient imaging tests, and unless they have oodles of cash lying around, have to wait two months to obtain them (and still pay a fee!). i'm still learning about the south african healthcare system, but it seems to be similar to many others throughout the world where there's a huge chasm between public and private; those that don't and do have money.

the interminable wait for imaging
afterwards, we headed out to the con wards (outdoor wards i previously described) for rounds.

the walkway to the outdoor wards
i've really enjoyed rounding with dr. draper. he has a strong clinical sense and excellent bedside manner; he looks at patients as a whole and then focuses on specific points of their care to teach the team. interacting with the staff throughout the open wards, you get a sense that he holds respect from them as well. he speaks a bit of zulu and is religious about organizing the paper charts (carries a small stapler and portable hole-punch with him!). he is an excellent role model for the registrars here and undoubtedly has a strong impact on the tone of care on the wards.

a medical ward: windows open, breezes crossing through, nurses hard at work
the variety of diagnoses i'm exposed to on a daily basis is staggering. i find myself often asking, with eyes wide, "does that present that way? how often do you see that? wow, i had no idea..." i feel very lucky to have this opportunity; even if i never see these diseases or presentations going forward in my career in the US, the experience of growing my clinical experience and ability to think "outside-the-box" of typical cases is invaluable.

 oxygen at a patient's bedside. open wards don't lend well themselves to wall oxygen points.
an aside: for those asking about whether or not marybeth's black cloud stowed away on the plane to africa... i think she might have left it at milstein. (can anyone confirm or deny?) i can proudly say that we haven't had any patient care disasters occur that are exceedingly different from the usual here. so... WHATEVER YOU ARE PRAYING, KEEP PRAYING. :)


after the rain and cool temperatures of thursday, we woke up to absolutely gorgeous skies on our drive to work friday morning. although i am not a morning person (not even a little bit), it's been a lovely experience driving to work at sunrise. on the left side of the road. with cows and pedestrians and things. but seriously!

clouds, mountains, and cars coming up at you on the wrong side!
on friday, we had prepared teaching for the department's current hoard of clinical medical students! our topic was ECG reading, one specifically requested by the group. MB had rustled up an old powerpoint, and we put some cases together to make things more applicable to the patient population. after morning report (which on this particular day was a very positively-toned M&M conference), we swiped a projector, computer, and screen. MB manned the powerpoint, and i took the whiteboard to jot salient points as we went along. our conclusions? medical students everywhere are the same: totally smart, hilarious, and easily overwhelmed. (plus, who doesn't love the shouts of 'atrial fibrillation!' and 'V TACH!' in a south african accent?) we resolved to meet again next friday for CXR reading.

after teaching, we gathered with the residents for what they call "tea", but was really indian-themed catered lunch in the morning report room (dominican friday, columbia?). this was one of the best opportunities we've had so far to just kick back and chat with the registrars and interns about life in general. we chatted about the differences in our medical education systems, then transitioned to where we should go on safari. and oh, that roti. mmmmm.

roti friday!
we had a low-key afternoon of helping out with technological things (helping to set up video-conferencing... not sure how we got picked for this task, but it worked out on the end!) before we packed ourselves into our little left-sided toyota corolla and headed for the dolphin coast. could really get used to this mini-vacation-every-weekend-thing.

until next time,

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