She loves me, then she loves me not…

36 minutes and 40something seconds for the 8km time trial tonight. I have to admit though that I was coasting over the last kilometer or two. I felt a tad sluggish. Like there wasn’t enough gas in the tank to do what I normally like to do. My usual approach is to go really hard the last two or three kilometers. At that point we’re coming down the other side of a pretty steep hill. Foley’s Hill street, Bernard road, then Williams road. I push progressively harder to the finish. Tonight though I felt the sting in my legs. From about the 6.5km mark I kept imagining myself sprawled out on the grass, exhausted after the run. Thinking how nice that was gona be.

Screenshot_2015-08-12-23-42-49-1 Image obtained from http://caitchock.com/blog/

As much as I tried to get this image out of my head and concentrate on finishing strong I just couldn’t. When we turned off Seventeenth onto Harold avenue I saw the small group of people gathered just outside the Italian Club where Charlo running club does their runs from and I couldn’t have felt more relieved. I did collapse onto the grass in an exhausted heap once I was done. I lay there on my back for a little bit. 36 minutes isn’t too bad for now, especially given the lazy last couple of weeks I’ve had. It is really difficult (I’m finding) to keep pushing oneself when there isn’t a big race coming up. A Two Oceans Ultra or some other big deal of a race.

Motivation is a cruel teasing mistress. When she feels like it she showers me with love, and I feel like the king of the world. I run hard, I do my work outs,I get up early to put in my quotas before work etc… But when she is in one of her moods she is cold. She doesn’t leave me outright, but stands at a distance just out of my reach. Starving me of that love so I can’t do what I feel I have to do…

It is much the same with reading. Reading internal medicine that is.

Malignant hypertension: exudates, and retinal haemorrhages on ophthalmoscopy. When was the last time I did ophthalmoscopy when examining a hypertensive patient? Gotta make more of a habit of that. Fibrinoid necrosis and deposits. The red blood cells are damaged when they pass through these… and, and, and. Microangiopathic haemolytic anaemia. I read up on that earlier in the afternoon ’cause we have a patient in the ICU right now who we strongly suspect has malignant hypertension. Tolosa-Hunt syndrome, cavernous sinus thrombosis, and rheumatic heart disease (and of course if you read that you gotta look up infective endocarditis right? ๐Ÿ˜) That’s what my ‘reading list’ has looked like lately. Based on patients that have passed through the critical care unit. I have swapped my medical physiology textbook for my medscape app. And I have read up on these conditions. To remind myself of the finer details (the last time I heard/read about cavernous sinus thrombosis I was in my 5th year at medical school!) It must be said though, that I read on the odd occasion when I was motivated. It is really difficult to sit and study when there isn’t some exam coming up.

I have a special admiration for the specialists I work under.Despite having worked so hard to get to where they are, to best help our patients they still read. An hour or two everyday, or at least every other day. To keep up to date with the latest findings (medical research is a never ending, ever progressing animal) and to remind themselves of the forgettable bits. I want to be like them.

At the moment though I find myself mostly waiting, lustfully waiting for Lady Motivation. She sidles up to me every now and then, and when she does. In those seemingly rare instances when she does I am able to do the things I want to do…

Maybe she'll call...?

Maybe she’ll call…?

Image obtained from http://vecto.rs/design/vector-of-a-cartoon-man-waiting-for-a-phone-call-coloring-page-outline-by-ron-leishman-22705

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If you drive out of Port Elizabeth in a northerly direction along Uitenhage road, after about 10 minutes you will arrive at an intersection where a right turn into Spondo street will take you to my place of work, Dora Nginza hospital in the township of Zwide in Ibhayi. At about 5.30am on last Sunday morning I was going along said road. I drove past Zwide however, continuing further away from PE. Past Kwamagxaki and Kwadesi, two townships that are served by my hospital. Motherwell township where a lot of our patients come from, is further eastward, away from the route I drove on this day…

I know these places by little more than their names and I have a vague notion of their geography around Dora hospital. When a patient has just arrived at the hospital they get their file at the clerk’s window. It comes with a fresh set of stickers with their personal information: name, date of birth, street address, telephone number, and lastly at the bottom of the sticker in bold capital letters the name of their township. That is where I know these names from. New Brighton is another one, closer to Port Elizabeth along that same Uitenhage road. I get my car washed in New Brighton every now and then… Approximately 80% of South Africans can only access public health care. That is to say the majority of South Africans cannot afford private health care. They have no choice but to go to a place like Baragwanath hospital in Soweto, Johannesburg (where I did my internship) or Dora Nginza hospital where I am currently almost at the end of my community service year. I vaguely remember being taught in family medicine back at medical school, that it is best if a medical doctor lives in the community that they serve. In South Africa bring a medical doctor means that one is relatively well off and most doctors, even those who come from townships do not reside in them. If one works in a peripheral public hospital most of the patients one sees come from the townships. We could get into a heavy analysis of the unfortunate lasting legacy of apartheid, the current gap between rich and poor, or the average South African’s struggle to access good health care but that is not what I want to do here (as juicy as that would be!). I was driving along Uitenhage road at that ungodly hour to get to my latest road race. And going along I got to thinking about these things, hence my musings. The absolute truth is I consider myself somewhat unqualified to comment on this subject in this forum. Asides from knowing that South Africa’s current problems are real and pointing them out, going any further than that at my amateurish level of knowledge of history and politics might not do justice to the real situation, the real problems, of the real people…

At a certain point along Uitenhage road there are no street lights. At that time of the morning this is a problem, especially when one doesn’t really know where one is going. So yes I got a little lost, just past the little town of Uitenhage, about 40 minutes away from PE, trying to find my way to Rosedale township, where we were running from. I got there, after only having to ask for directions once. Yes I had a GPS but you see Rosedale ‘Stadium’ isn’t actually on the system! I realised why when I eventually arrived there. It is really more of a sports complex-come-recreation center with a couple of soccer fields that double up as a cricket field, and a tennis court or two.

image Rosedale ‘Stadium’ image Woke-up-way-too-early/pre-race face

Not a lot of runners showed up, at just over one hundred it was a smaller crowd than I am used to seeing. The usual PE running crowd being quite conservative (another socio-political discussion we could get into but won’t) were not up for getting out to ‘rural’ Rosedale for a race. There were a few familiar faces though. Allister was there. I have mentioned him before, he runs for Charlo running club. He is at most races in the PE area. We exchanged a few friendly words. I knew a few other people, including funnily enough a couple of guys I had met on that disaster of a run the previous week, and also Bennie, who I haven’t seen for a while. He is super fit, forever alternating between mountain biking and running during the week.

I had a good hit out, 2hours 42mins over 30km is as good as I could have asked for, especially considering how I fared just one week previously over the same distance. The course had it’s fair share of hills again, but race-mode being what it is I was in an aggressive frame of mind, while at the same time trying to keep myself as relaxed as possible. I raced out at the beginning, my first few kilometres were at sub-5 minute pace but I didn’t feel strained. I finished the first 10km in approximately 48 minutes, faster than I would have wanted but I felt good. Got past 20km at 1 hour 48 minutes, 25km at 2 hours 11 minutes. The last 4 or 5km were quite hilly to end off. I put my head down and worked. I couldn’t resist the urge to beat myself on the chest once I crossed the finish line, even though my legs were feeling decidedly wobbly.

image We ran through the streets of Rosedale township. image We ran through Rosedale, and also past Uitenhage onto the road back towards PE. This photo and the one above it was taken on my drive back to Port Elizabeth. I showered and dressed.

There wasn’t as much as a hot dog stand in sight on the grounds around the Start/Finish area which I thought was pretty poor. After some chit chat with a couple of runners I drove off, stopped at a petrol station for a pie and a drink and then got onto the road back towards PE. Just before getting to PE I peeled off left onto Spondo street to Dora Nginza hospital. On weekends if none of the three doctors that work in my ward is on call then one of us has to go in. Inpatients have to be seen at least once on the Saturday or Sunday. This weekend happened to be my turn. I walked into the ward just after 11am.

No one wants to be at work on the weekend if you’re not on call (hec even if you are on call! ๐Ÿ˜“) so if one looks through a patient’s file and check for the doctor’s notes from the weekend ward round it is very likely that you would find a very hasty: Patient has no new complaints. On examination: Appears relatively well, Vitals (scribble blood pressure and pulse here). Assessment: Stable. Plan: Continue management. Seriously! ๐Ÿ˜Œ I struggle with this, and as much as I too walk in thinking to “Lets get this over with quick so I can go home” I confess, I am incapable of any sort of efficiency. Left to my own devices I almost always do things the long way. So, as lame as my legs were feeling I saw every patient, checked blood results, and made notes that were far too thorough for a Sunday afternoon. Xolani, one of the other medical officers that works with me, during the week on seeing my notes chirped “You went a bit overboard there chap, eh?” 30 patients, and I left the ward about 4 hours after I had arrived. I will say though that the upside to that sort of a ‘work day’ is that one walks away with no lingering worries about something that may have been missed, and because of that I’ll happily be the last guy to leave the ward on most days.

That was Sunday. The week seems to have flown by. I was on call on Thursday and the other days have consisted of 5am wake-ups to study before work, a short hill sprints session on Tuesday, a 8km time trial at Charlo running club on Wednesday, a hard 20km run Friday evening and trying to squeeze in as much studying otherwise and in between everything else. There is one week to go before the Two Oceans Ultramarathon in Cape Town. There, now I’ve said it! It seems to take away from the surreal quality of this significant running event. There is also the very real possibility of my giving the FCP part 1 exams a real crack in the not too distant future. “If I feel ready…” as I’ve been saying for what feels like the longest time. This would be the first concrete step towards becoming a specialist in internal medicine. I first thought about it in late 2013 during the last few months of my internship. I was tired and drained, on autopilot dragging my feet through orthopaedics, one of my last couple of rotations. I need a goal, I thought… And here we are about one year and a half later. Studying on and off in between life, love, running and everything else has been as difficult as most other doctors told me it would be but also easier than I expected. Motivation being what it is… The sheer volume of everything that has to be grasped though is such that even when one has done a lot of work one always feels like a lot more could have been done. I ask myself (more often than I care to admit) How are you left with so much still to cover when you’ve spent so much time at it…? The scary part is that once this is done, if it goes well it’ll just mean more studying. The specialist physician who runs my ward has been a medical doctor for over 20 years, and he still reads every night. Such discipline. Imagine knowing all that stuff. I wanna be like him when I grow up! ๐Ÿ™„

A good day at the office

Aside

Write when inspired?

 

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Yesterday was a long day ๐Ÿ˜ The kind of day that I normally wouldn’t write about, but precisely because it had been that type of day, I found myself sitting on my bed bored, uninspired and writing. I really shouldn’t have been (writing, that is) but there you go.ย I think that the main reason I was so bummed was that I didn’t study yesterday. I didn’t put in the usual 2-3 hours. There was no valid excuse, not really. What I did do with the time wasn’t nearly as good, or as rewarding.

 

The day had started out well. Alarm clock 5.30am; snooze; out of bed at 5.45am; bathroom (the regularity of my bodily functions is starting to scare me, I’m only 31, why is everything becoming so predictable aaargh! ๐Ÿ˜“…) 5.55am (at least ten minutes later than initially planned) push-ups: sets of 32, no… 35 (this was decided halfway through the first set ๐Ÿ˜) done with that by about 6.15am; weights: 10km dumbells aren’t much but when you get to about 28 of a set 35 reps there is some pain in the places where you want some gains. Done with all of that by about 6.50am. Kitchen, fix fruit and cereal quick, fix some lunch for work, quick. Shower, then seated at my desk/dining table at 7.15am, quick breakfast. 7.30am Housekeeper arrives, “Aren’t you late for work?” she asks, “Only by a little bit,” I say while chucking the bowl and spoon into the sink. I’m outta there within the next 5mins.

 

At 8.05am I parked my car in the doctor’s parking lot at Dora Nginza hospital (actually on the grass next to the lot along with a bunch of other cars as there aren’t enough parking bays for everyone employed at this institution) At 8.10am I walked into the ward. Here we go: 30 patients between myself and another doctor. Our intern had been on call the previous night so she did not join us. I saw 17 patients throughout the day, in addition to three call backs. Call backs are patients that I had seen in admissions the previous Thursday when I was on call, discharged home and asked to come back for review of their condition or blood results or to discuss with the specialist physician who runs my ward.

 

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There are two patients in my ward who have multidrug resistant TB (MDR TB). Both are HIV positive, one also has end stage kidney disease, and the other has cryptococcal meningitis (CCM). Serious stuff. The lady with CCM is one week and a half into her course of treatment, and once she completes the two weeks of amphotericin B we will be able to transfer her to the local TB hospital, a much more appropriate place for someone with her condition. We won’t be able to transfer the other lady, she is very ill, cachexic, with decreased consciousness. Her prognosis is very poor, we’ve discussed it with her family. We’re keeping her comfortable, as pain free as possible. Blood tests every couple of days to review her kidneys and make sure her electrolytes stay in check.ย These two ladies are ‘isolated’ in the side ward. They are receiving the right treatment, a veritable cocktail of pills that would frighten even the bravest of souls. It’s just that they shouldn’t be here in a general medical ward.

 

Our other patients are more of the general medicine variety, I discharged five today. An old hypertensive diabetic lady who had suffered her second stroke. No sense in keeping her here, she needs to be at home with with her family. Regular follow up with physio- and occupational therapy. Another lady who had completed five days of intravenous antibiotics, now no longer dyspneic, not coughing, and overall looking much healthier. A clear sputum sample had excluded pulmonary TB. Off back home you go. The other three were the same simple sort of cases.

 

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Then there’s a 41year old with frightful blood pressure readings despite our escalation of her antihypertensives. She has been in the ward since last Thursday, and also has very bad kidneys. Possibly the cause of her refractory hypertension? Maybe. One could be the cause of the other in this case, and conversely. How does one have bad kidneys at age 41 anyway?! We’re doing a full work up on her, to exclude causes of secondary hypertension, hyperthyroidism for example or some sort of rheumatological abnormality. Once we have all the results together if we haven’t found an obvious answer we will discuss her with the renal unit at Livingstone hospital (LVH).

 

My last bit of work for the day was a lumbar puncture (LP) on an old lady. She is somewhat confused and none of her blood results or her initial lumbar puncture show a possible cause. It could just be good old dementia (pun intended ๐Ÿ˜› but she doesn’t quite fit the bill for that diagnosis) The consultant had me do a second LP (unusual as it’s quite an invasive procedure) to look for cytology in cerebrospinal fluid. “Cytology?!” I asked. “Malignancy maybe. What else could be causing the abnormal normal protein levels in the first sample?” He replied, almost shrugging.

 

Done with all of that (work and stuff) by about 3pm. Gotta get some studying in today, I thought as I walked to my car. To follow up with the good bit I did over the weekend. I had spent all Sunday morning and the early part of the afternoon at the books.ย I had to pop by the bank on the way home, then make a quick stop at a sports shop in town to fill in an entry form for the next road race, even as I felt the residual pain in my legs from last Saturday’s marathon. I then stopped at the Spar not far from where I stay, as I had finished the milk that morning. Meryl called. I probably shouldn’t chat to her the phone while I’m driving but hec she’s far away and I miss her. I got home much later than I would have liked and used that as an excuse not to study. Not good. Physicians don’t make themselves man! I mentally scolded myself. It didn’t work on that particular day. It’s ok I thought, it probably means that I’ll hit it extra hard the next day.

 

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So there I was yesterday evening feeling guilty, bored and unispired. So I thought I would write about it, and I did. I did not post it up yesterday though, as I have this idea that I should only really write when I am inspired? Yes and no. I have had a bit of a think about it. To only write when I’m inspired would be to only write the good stuff, the fun bits of my experience here in Port Elizabeth. This was an example of an average day. Average uninteresting day at work. ย Average day in terms of inspiration, or more appropriately the lack thereof. To study I suppose, and to write…

 

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