The race is not always to the swift…

“Ag man look at this, it’s disgusting! How’s a person supposed to read this?” Andries said, pointing to a note someone had made on the patient’s ICU chart, “And you guys are always giving me a hard time about my handwriting!” “No Andries,” I replied “When you’ve made notes we have to pass the file around in order to get some sort of a consensus on what it is you wrote.” “Nonsense man, when did this happen??” He asked looking shocked. “Every single time you make notes for a patient” I said, and at this point I could no longer keep a straight face and I may have broken into a giggle. “Ag piss off man!” He said when he realized I was having him on.

Andries is quite a character, somewhat of a legend actually in PE circles. When he was with in ICU with us I found working with this guy like trying to run alongside a fast moving train. He seems to have an endless supply of energy, doing everything at a 110%. If one didn’t know him one might describe him as brash. “Listen here, I don’t care I’m a surgeon I just want to cut!” He once said when I asked him about a patient’s electrolytes. That is obviously not the case, he does care very much about his patients. I used to hear stories about this guy before I came to Livingstone hospital. During my community service year at Dora hospital an intern once told me a story about how once when he was on call in surgical admissions he telephoned Andries for some advice. “Where are your seniors?” Andries asked. The two registrars both happened to be in theatre, operating. “Agg no man!!” Andries replied, uttering a few choice expletives. He proceeded to go to the hospital and on a day when he was not on call and should have been at home, he saw every single patient in surgical admissions with the intern and wrote out a plan for them, much to the junior doctor’s surprise and relief!

Then there’s Jonathan or Jon as we know him. Originally from Kwazulu Natal, schooled in Cape Town and now here in Port Elizabeth for the last 4 years or so, he is the archetypical coastal boy I suppose. His main interest like me, is internal medicine. He is quite literally one of the most intelligent people I have ever met. Insight, and lateral thinking are what come to mind when I try to describe him. He says things on the ward round that give the impression that he is thinking further than what has been presented about the patient. All of this is tempered by the fact that when dealing with Jon one on one I have found that it is always good to have one’s guard up, if only ever so slightly. This is because there is always a small possibility that Jon might be taking the piss.

He once walked into the doctor’s tea room and told Sashelin that there were three patients on their way down to ICU right at that moment, two of them medical and one surgical. They had been discussed telephonically earlier and needed to be admitted. Sashelin is another one of the doctors in ICU, he was on call that day. Jon delivered this message in the afternoon, just as the rest of us were getting ready to call it a day, leaving Sash on his own for the night call. Three ICU admissions all one right after the other is quite a bit of work for one doctor to have to get through on their own. One generally hopes to have that many over the whole night maybe, along with having to look after all the other patients already there.

“What the…?! Tell me a bit more about the cases?” Sash said, a little bit worried. Grinning Jon said “Had you a little worried there eh!”

Also, Jon has two accents: most of the time he sounds like himself, the coastal laid-back ZA boy, but every now and then when he is excited or wants to emphasize something he breaks out into what he thinks is a black African accent. Asides from being incredibly inappropriate it is a little funny at times, in doses. He’s a good guy though, we get along. In between work we’ve had a few good convo’s about the meaning and purpose of life, rugby and other such deep topics.

Sashelin is another character all together. Everything about this guy just screams linear and organized. Including the way he presents patients on the ward round and his approach to answering questions from consultants. He is also a budding surgeon. When he and Andries aren’t arguing about some or other surgical topic they can be found giggling (yes giggling) about something that is only clear to the two of them. Their respective personalities offset each other. Andries will typically storm into a room and exclaim “I just saw this patient,” and he’ll scrunch up his face “Absolute chaos, complete disaster!” While Sash is more calculating.

As one would expect from a perfectionist Sach thinks that anything that any other doctor does is below par. “They did what?…Slacking!” He’ll say while shaking his head disapprovingly. “You’re a slacker!” He’ll say to Andries, “Ja, jou bastard!” Andries will return.

I have mentioned before that I find it hard to (that is to say I don’t) write when I’m not inspired. This translates to not wanting to write when I’m unhappy. So I am much more likely to share the good bits about my Eastern Cape experience than I am to divulge on the times that are not so good.

I have been going through somewhat of a lull at work. I spent about four months working in ICU full time, and the last two months in the renal unit, while still doing my calls in the ICU. It has been quite an experience. My brain is constantly racing, or flailing I should say. Much more appropriate.

Too. Much. Information... Image obtained online from rainnamail. files.wordpress.com

Too. Much. Information… Image obtained online from rainnamail. files.wordpress.com

It is quite something to be in a ward round or sit in in a discussion where after every few beats I’m thinking “Wait, what was that? Wow is that what we think it is, ok… but what does that actually mean, and how on earth did we get to a point where we’re considering a diagnosis of..? Man I’ve gotta read that up (picture scrunched up face emoji). So as I mentioned before I made lists, of topics. EVERY. DAY. It was crazy. I tried to keep that up. The list is as long as my arm right now (and I have long arms!) I can’t honestly quite say how far I am with that…

It’s one thing to look up something but quite another to know it. I very much doubt that I’m the first medic to wish that I could read something once and know it (If only!) You have to see a case, discuss it, go read up about it, see that same case again then see another similar case again later, be reminded of what you read, have the discipline to go back and read it again. This may be over a period of a couple of weeks, months, maybe even years and then, only then can it maybe be said that you know a few things about said condition, maybe… And even then there’s knowing something and there’s knowing it, with all the nuances that it can’t go without. I say it’s advanced HIV and the response is “Stage it, three or four? then I know exactly what we’re talking about…” I say it’s nephrotic syndrome. “No, it’s renal dysfunction with nephrotic range proteinuria, not quite the same thing…”

'Don't over-think it' just doesn't apply here... Image from clipartof.com

‘Don’t over-think it’ just doesn’t apply here… Image from clipartof.com

Herein lies my little conundrum. I have been comparing myself and my level of knowledge (or lack thereof) with the guys that I’ve mentioned above and others like them. We’re all roughly about the same age but they all have at least a couple of years on me in the profession. Sash and Andries have both recently written and passed their surgical intermediate exams and are well on their way to becoming surgeons. Jon has worked in the renal unit where I am currently and in ICU previously and he has just started a masters research degree in anticipation for starting as a registrar some time soon. I finished my year of community service just a few months ago. The difference in experience, and my lack of it, goes a long way towards explaining my sense of inadequacy.

“The first 2 months you’ll feel like you have no idea what is happening, then the next two months you’ll think you know what’s happening but the truth is you’ll have no idea what you’re doing and the next two months you’ll carry on, you’ll feel much more comfortable and you will know exactly what it is that you don’t know…” This was my buddy Gareth breaking down the phases one goes through when starting in a new place of work. “It’ll take you like three days to get into it…” one of the consultants said before I started. “You’ll be fine in about three months…” another doctor had assured me. I had admitted to feeling a little nervous before starting in ICU. Take all of those estimates, average them out and add in the ‘slow learner’ factor and the fact that my learning curve in ICU was truncated after four months and you might get an idea of my slight sense of disorientation and not-knowing. “You don’t have to know everything bru, you just need to have an approach.” Jon said once…

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I read somewhere that to live a creative life we must lose our fear of being wrong. In the art form that is medicine however we prefer to be as exact as possible. Given what is at stake most medics would prefer to get as little wrong as possible. This comes with time. With time there is more learning. With time there is experience. I can say with absolute certainty that I am a better doctor today than I was about six months ago when I first arrived at Livingstone hospital but even so I am far, very far from the finished product. The further one goes in the profession the less we can be forgiven for not knowing. The buck stops at the specialist really. Ideally once they have spoken there should no longer be any need for continued discussion about the diagnosis right? Yes, and no. The time factor still plays a role I think: The difference in experience and exposure between the specialist physician who qualified a short while ago one who qualified a few years ago (and continued to learn-it must be added) means that there really will always be some room for a question or two.

This is acute kidney injury secondary to new onset sepsis. It will resolve with the systemic infection. A week or so of antibiotics. Me thinking last week while we were going around seeing the renal in-patients with the consultant. I smiled and claimed a personal victory (however small it may have been) when the consultant looked up from perusing through the file and voiced out loud almost exactly what I’d been thinking. There is something very satisfying about nailing a diagnosis. “The patient was on Tenofovir though,” (a nephrotoxic antiretroviral) I hadn’t picked that up. But the creatinine levels had been normal before the infection…

We each of us run our own race. Some will fly out of the blocks and we may not even see them along the route because they’re so far ahead. They may have been blessed by nature with the right combination of traits that make them really fast, or they may have had a look at a route map before setting off making them better prepared. Others may find the course a little more challenging, what with the hills and other obstacles (those that are part of the route and others that we make for ourselvesπŸ˜‹) Some of these strugglers will learn along the route, gaining momentum as they go, gathering pace. A marathon I have found-is all the more enjoyable once one ‘finds a rythm’ so to speak.

The tortoise wins this one we all know that, but what if these two characters were each running their own race? Image from quoteinvestigator.com

The tortoise wins this one we all know that, but what if these two characters were each running their own race? Image from quoteinvestigator.com

We each of us run our own race. At the road races I am one of that crowd that starts out fast. I lose pace the further I go, and I have to fight to finish with a nice time. In life however (at work-in medicine more specifically) I have found the converse to be true, a typically slow start with a slow but sure upward trajectory.

It is probably not entirely correct to liken running to a career as a medical doctor but hey each to their own-frame of reference. I love my job, and I love my running so here goes: It took me over four years of road running to figure out what I had to do to get my body to a level where I could do a sub-4 hour marathon and along with that a sub-5 hour 50km race. Once I had done that it changed the whole game for me, I broke 3hrs 40mins just the other day, but more on that later… I have come to understand that it is going to take me longer than four years to get to a point where it is being said that the buck stops by Pascal, he’s the go-to physician in these parts, no need for a second opinion.

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Take a wrong turn out here…

There’s that saying ‘a picture tells a thousand words‘. I’ve been known to use well over a thousand words at a time in describing the goings-on in my life since I arrived here in the Eastern Cape a year and a couple of months ago. I thought I’d switch it up a little, and let a few images tell this latest story.

After I wrote that exam at the end of June my girlfriend Meryl came down to Port Elizabeth for a little bit. Having her around, and being able to see her everyday was a welcome reprieve from having to think about medical physiology all the time…

Dinner at one of the very many nice restaurants in Summerstrand. Good view of the beach that evening...

Dinner at one of the very many nice restaurants in Summerstrand. Good view of the beach that evening…

A bench in a little clearing at the bottom of Fordyce road in Walmer is a good place to sit and look out over Settlers Park Nature Reserve which is in a deep valley in between Walmer and Port Elizabeth Central. It was a llittle chilly though, Meryl wouldn't get out of the car so I just took a couple of snaps.

A bench in a little clearing at the bottom of Fordyce road in Walmer is a good place to sit and look out over Settlers Park Nature Reserve which is in a deep valley in between Walmer and Port Elizabeth Central. It was a little chilly though, Meryl wouldn’t get out of the car so I just took a couple of snaps.

Will Shakespeare has a play, I have a theatre. The curtain is yours…‘ It being that time of year we drove out to Grahamstown for the first weekend of the Arts Festival.

We're always roadtripping off to somewhere...

We’re always roadtripping off to somewhere…

Meryl being silly (ie being Meryl :-P ) in front of this cool sculpture we came across in Grahamstown

Meryl being silly (ie being Meryl πŸ˜› ) in front of this cool sculpture we came across in Grahamstown

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I've mentioned the Jittery Citizens before I think. They are an improv comedy act that Meryl and I saw on our first date. So almost exactly 2 years later it was good to catch them at the National Arts Festival.

I’ve mentioned the Jittery Citizens before I think. They are an improv comedy act that Meryl and I saw on our first date. So almost exactly 2 years later it was good to catch them at the National Arts Festival.

The best piece of theatre we saw over that weekend was Body Language II: The Mating Game, a 50 minute solo high energy physical comedy in which Gaetan Schmid animatedly gave us his take on everything from the Big Bang Theory right through to the underlying evolutionary reasons for the roles of the sexes at a traditional South African braai (barbeque) to the subconscious and not-so-subconscious deliberate reasons why a girl actually allows you to notice she’s checking you out. It was fascinating stuff, and a good laugh all the same time.

It's just over 2 years now.  Meryl has added a special spice to my life...

It’s been just over 2 years now. Meryl has certainly added a special spice to my life…

This statistic may or may not be anecdotal but apparently there are more churches in Grahamstown than can be found within the limits of any other town/city in South Africa, a curious fact considering it is effectively a student town, built around Rhodes University.  This particular church is the Anglican cathedral, named after both Saints George,  and Michael.  Also curious,  I thought 😌

This statistic may or may not be anecdotal but apparently there are more churches in Grahamstown than can be found within the limits of any other town/city in South Africa, a curious fact considering it is effectively a student town, built around Rhodes University. This particular church is the Anglican cathedral, named after both Saints George, and Michael. Also curious, I thought 😌

An eerie bell tower on the grounds of St Andrews College, an 'uppity' institution according to a friend of mine :-P

An eerie bell tower on the grounds of St Andrews College, an ‘uppity’ institution according to a friend of mine πŸ˜›

On the weekend of 10 July we were in Knysna. I ran the Knysna marathon, an interesting experience. One has to be in Knysna the Friday night before the race to register and get a race number. The next morning from about 4.30am runners are taken up by minibus to a point up a mountain where we gathered wrapped in cozy red blankets (that were subsequently given away to charities) around little fires, waiting for the 7am and 8am marathon and half-marathon starts. When the starters gun was finally fired we set off on a route that seemed to ascend incessantly through the Knysna Forest.

I couldn't resist getting a couple of shots of the mountainous scenery along the route

I couldn’t resist getting a couple of shots of the mountainous scenery along the route

What else is there to do early on a Saturday morning? I mean surely shuffling along a dirt road on the side of a mountain is at the top of that list, no? :)

What else is there to do early on a Saturday morning? I mean surely shuffling along a dirt road on the side of a mountain is at the top of that list, no? πŸ™‚

4hours 12 minutes wasn't too bad a return for what was a very tough hilly course, I feel...

4hours 12 minutes wasn’t too bad a return for what was a very tough hilly course, I feel…

Lunch at the waterfront afterwards

Lunch at the waterfront afterwards

We drove across to Jeffrey’s Bay after the race.

Jeffrey's Bay

Jeffrey’s Bay

Leaving Jeffrey’s Bay to go back to Port Elizabeth we didn’t take the N2 highway as we would normally have. Instead we drove along the R102, one of the old national roads. It turned out to be an inspired choice…

An old single carriageway bridge that goes over the Gamtoos river

An old single carriageway bridge that goes over the Gamtoos river

I've been asked why I'm still in the Eastern Cape. What is there to love about this place? I mean look, you take a wrong yurn around here and look where you end up

I’ve been asked why I’m still in the Eastern Cape. What is there to love about this place? I mean look, you take a wrong turn around here and look where you end up

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Same old brain, same old heart…

Down and around on Sparrow drive, left onto Villiers, right onto 14th, right onto Water rd, all the way down untill it turns a sharp right into 5th, then left onto Prospect rd, right into 4th, left into Fordyce, right into 1st then left into Heugh rd. It eventually becomes Walmer Boulevard drive and I have to decide between taking a right onto Forest Hill rd which will take me past the airport then back toward home for what ends up being a 16km run. Alternatively I could keep going on Walmer Boulevard and eventually turn right onto Humewood road and run along the beach front into Summerstrand for what ends up being a 24 or 25km run. Either way I usually end up back on Villiers pushing along the last 3 or 4km, a very slight uphill to the end of my run.

I live in Walmer now, still in Port Elizabeth. It is July and effectively the 3rd month of a new year for me. So new beginnings, new running routes, new legs (kinda feels like that 😌). Same old heart…

It takes me a little over an hour and a half to run a half-marathon (1hr 35mins is the best I’ve ever done). By contrast it took about a year and a half of studying before I felt ready to write the College of Medicine Part 1 exam (Primaries). It wasn’t a full on effort for that entire period of time. I made the decision to start preparing a year and a half ago. Deciding is one thing, executing is another thing altogether, but I did translate mentation into action, albeit intermittently at first. I spent the first two months of 2014 (the end of my time as an intern) studying like my life depended on it. The renal and endocrine chapters of Ganong’s Review of Medical Physiology were put away with aplomb. I then ran out of steam and seemingly motivation. I did continued, though at a more measured pace. I was on and off over the next few months, days and weeks went by when I was very studious, and other days and weeks passed when I was less so. I finished my internship at end of April 2014 came down here to Port Elizabeth for my year of community service. I continued to study intermittently. In about November of last year I pressured myself into making a decision about when to actually sit for this exam. ‘When I’m ready’ was no longer adequate. A definite time line would also serve to put me under a bit of pressure. After the new year I became a little more consistent, measuring my time more and more by what the amount of reading I had or hadn’t done.

On 31 April in the early afternoon I walked out of the medical ward at Dora Nginza hospital for the last time, having completed my one year of community service. I have now done my ‘Zuma years’ as some would say. I no longer owe the government anything in the way of being fully recognized as a medical practitioner. Nice I suppose, and following that, if I wanted to tomorrow I could open my own private practice. Naturally I’ll do nothing of the sort. No I have a much less comfortable, far less glamorous future in mind. Picture a medical registrarship, long hours and an unreasonable work load at Chris Hani Baragwanath hospital. Picture having ample time to read but way too much material to have to cover and master. Picture HIV and TB, and more HIV and TB. Picture me being able to conjure up obscure spot diagnoses in response to a long convoluted set of signs and symptoms blurted out by a fellow medic on a grand ward round. Picture that. That’s my kind of life.

I had a week-long holiday of sorts at the beginning of May. I spent the first weekend in Johannesburg with my girl, Meryl. We set up house so to speak, at a cool little backpackers on Doris Street in Kensington for 4 days. We spent the days studying believe it or not, she for her midyear exams, the first of which was the following week, and I continued to slog through Ganong’s. I then went across to Centurion, Pretoria to spend a couple of days at my parents’ house.

10 May, 8.05am. I was up. Much earlier than I normally like to be out of bed on a Sunday morning. There were church bells ringing (literally) not too far away, the sun was out and beating down hard. If Long street was a person he, or she (we’ll settle on ‘she’) would be elderly, not frail but hardened and somewhat jaded, with that seen-it-all thousand yard stare. On this particular morning she looked calm, expectant. Breathing easy after the shenanigans that she’d played host to the previous night. I was standing on the corner of Long street and Longmarket street waiting for an Uber. The car pulled up and I jumped in.

Long street, Cape Town

Long street, Cape Town

Grote Schuur Hospital, Cape Town

Grote Schuur Hospital, Cape Town

I had been in Cape Town since the previous Thursday evening for a refresher course for the Primaries organized by the University of Cape Town (UCT) department of medicine at Grote Schuur hospital. A friendly summarized version of ‘everything medical physiology’ with a sprinkling of pharmacology, microbiology, statistics and some other need-to -know stuff. All squeezed into 3 days of back to back two-hour lectures. What we do for kicks eh! 😌

#geekmode

#geekmode

Difficult thing to get used to again, sitting in a lecture hall and having to maintain concentration. It took me right back to medical school, dosing off every now and then, not due to lack of interest but just sheer inability to pay attention for such long stretches of time. “Let’s hope something something sticks…” Dale had said on Friday morning as the first lecture had started. He and Alex, my Dora-mates and fellow Witsies had made the trip down too.

Seagull. Harbour.  V n A Waterfront, Cape Town

Seagull. Harbour. V n A Waterfront, Cape Town

Caught a little bit of comedy on one of the nights

Caught a bit of comedy on one night

Back in Port Elizabeth after that weekend I started a new job, in the ICU at Livingstone Hospital (LVH). It has been a continuous, seemingly non-ending learning curve this last month or two, and I’m really enjoying it, surprisingly. While being quite challenging, working in the critical care unit at LVH has not been as scary as I had thought it would be before transferring across.

It is a high pressure environment with a neat set of rules and regulations. If A happens then we must respond with B. If C happens then the patient must receive D, if X then Y etc… Protocols. Know what to do, how to do it and when it is appropriate to do so. Not so intimidating when looking at it like that but the thing to do obviously, is to determine why or how X happened isn’t it? That is the real art of what we do as medics. The lady is in low output heart failure, she has a valvular lesion. She has had it for many years, so what is different now that has caused her to tip over, caused her to decompensate…? There is a lobar pneumonia and she is in sepsis. What is the offending organism? What is the appropriate antibiotic? If we decide to initiate… Can we wean her off the inotropes? Get her well enough to get off the ventilator? The gentleman in bed 5. Severe pancreatitis, most likely due to years of excessive alcohol. Now a couple of days post-op, and in respiratory distress, tachycardic. Septic markers inconclusive. Antibiotics? Nope. No real temperature spikes, blood cultures haven’t yielded anything. Is there a fungal infection, maybe…

I’m only a few weeks in and am admittedly a slow learner. The goal is to get to a place where one understands rather than just knows the protocol, why do we do B when A happens, and Y when X etc… I have the rest of the year more or less, to get comfortable and to get better. I am definitely enjoying myself and who knows, perhaps I’ll become an intensivist one day after I deal with this minor detail of qualifying as a physician that is :-P. Oh and while we’re on the subject of my current situation, regarding Eazy in the EC: ‘One year in the Eastern Cape’ has turned into two…

In between all of this new learning at work I continued plugging away at the material for the Primaries. I finally got down to doing some statistics (my favorite! 😦 ) Research is how medicine and hence patient care moves forward these days. One can’t be a medic and not have at least a basic understanding of statistics, to my chagrin.

Towards the end of May and through most of June my life seemed to become ever more streamlined. Simplified if you will. Life became work, eat study, study, study, sleep. In that order, in ever repeating cycles. I went through an eerily familiar phase towards the end of June. Everything other than what I was supposed to be studying became interesting. On numerous occasions as I was about to sit down at my desk I would think “What was that thing they said on the radio earlier? Lemme google that, I can’t believe Kanye West would…” or I’d realise that I hadn’t been on Instagram for a little while and before I knew it I’d have spent a whole half-hour of my life perusing through images some pretty, and inspiring but mostly bland pointless and entirely non-contributing to my ambitioned future life as a specialist physician… Then I would eventually sit to study and I’d be quite productive for a while until I would think: “What if they ask a question about this…?” I would fret, and quickly look through my notes again, or “What if there’s question on this…?” and I would stop what I was reading and have a quick look at that too. All these questions about these little things. These little molecules, ligands and receptors, these pathways. “My brain is tired, my backside is sore, my back is aching… ” “My everything is everything!” I said to Meryl over the phone one night (insert sad, self-indulgent emoji) “Maybe I should stop studying and download a movie…” There’s a good way to spend this precious time!

This is not dissimilar to my pre-exam behavior back when I was at medical school. In fact the mental merri-go-round, emotions and sense of subdued-yet-bubbling-over stress I was going through felt exactly like it did when I was a hapless student. “That exam is quite soon isn’t it, you look so calm” my colleagues would say. It is most definitely just a look. People also said that about me at medical school, alas it is very different to what I’m going through on the inside. The older I get, I realise the more I still stay the same. “I wish I could redo the last year and a half with a different brain!” I found myself saying to a friend.

I still ran, but only about twice a week and when I did run I seemed to be squeezing it in between the studying. I’d get home from work and put in a couple of hours at the desk and get out onto the road quite late, knowing full well that it would be dark by the time I got back if I covered 15 or 16km as I felt I had to. I felt sluggish, barely ever able to push myself very far under 5min/km pace. Healthy body, healthy mind, a teacher once told me back in high school. But when the mind is preoccupied the body can but to follow suit.

On Saturday 20 June I ran the Heartbreak Hill 21.1km, organized by Charlo running club. 1hr 44mins and a few seconds. Not a time to rave about but I was coasting mostly. I didn’t hang around after the race, briefly said hello and cheers to some of my running club mates who I hadn’t seen in what seemed like for ever, and promptly went back home and kept at the books. On the following Wednesday myself, Dale and three other aspiring physicians sat in a classroom upstairs from the library at LVH and each of us worked our way through the 150 questions on physiology mostly, some statistics, some microbiology and pharmacology. I walked outta there at 12h02pm having handed in my completed paper, after using every single one of my allotted 180 minutes.

That afternoon I was to the airport to pick up Meryl. It had been 6 long weeks since I last saw her and she looked gorgeous!

That was last week. The Grahamstown arts festival kicked off yesterday. There’s a marathon on next weekend. I’m not in very good physical shape at the moment but I’m gona give it a go

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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! πŸ˜“) 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! 😌 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! πŸ™„

A good day at the office

Aside

Not enough in the legs

I just got back to the flat in Port Elizabeth Central after a 30km run out in Seaview with Robyn, who I work with at the hospital and a few others from her running club Charlo. It was supposed to be 30km, but I only managed 28km. We went out quite fast I felt, for a long run, doing about 5 and half minutes per kilometer for the first 15km. The second half of the route was quite hilly, and I did a lot of walking. I just didn’t have the juice in my legs today, struggling from about 21km onwards. The last bit was a winding gentle uphill that went on for about 4km, which isn’t far by anyone’s standards (I don’t think) least of all a runner (I think I can call myself that 😌) but my state of mind at that point, having been running for over 2 hours with the sun bearing down almost directly at us (so it felt like) was not conducive to any sort of gritty put-your-head-down-and-work-it strategy that one would normally employ at that stage, in desparation. It had been dark cool and quite foggy at 6am when we’d started earlier…

The previous day I ran a 10km road race at Lake Farm, not far from Seaview. I did it in 48mins which isn’t too bad. I have definitely run faster 10km races before but this too was quite a hilly bugger.

 

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As you can probably tell hills are a problem for me. In road running, as in life though having to go uphill every now and then is inevitable. It’s all about one’s approach isn’t it? It makes sense that if you just put your head down and give it a good hard go you’ll get over it (the hill that is) faster. It’ll hurt (like a female dog!) obviously, but you’ll definitely be stronger for having gotten through it, as in life. All of this is very easily said, of course and I sound like I know what I’m talking about but that is so far from the truth that it is actually depressing and somewhat soul-destroying (if you will allow me a little hyperbolizing πŸ˜‹) In real life (or do I mean in a road race?) when I see a hill coming up I put my head down sure, but when I get to the hill a mental switch goes off and no matter how good I’m feeling or how hard I’ve been pushing I then proceed to put one leg in front of the other with the sole intent (it seems) to survive the hill rather than own it as my above described bravado would suggest. This makes for a slower pace, more akin to the resigned shuffle I have spoken about before.

 

Seaview is absolutely beautiful and even after almost a year here in PE, and getting out there every other weekend I still can’t get over that. The greens, browns and greys that make up the surrounding scenery are so vivid it is almost surreal. The never ending road on a long run though is somewhat less awe-inspiring methinks :-/ “Some people are lucky enough to actually live out here!” I often exclaim to myself. So if anything when one of the other Charlo club guys picked me up in his car at the 28km mark I was miserable because of how I felt physically and because I didn’t finish the planned distance but I was inspired (sort of) by the surroundings.

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I spent the last 30 minutes of the run fantasizing about buying a Vitamin Water after the run at the petrol station not far from the start/finish point. But when we finally got there (by car and not on tired but triumphant legs as initially planned) I bought the sweetest coldest drink I could see in the fridge, a Fanta! Not exactly the drink of champions but there you are. This along with the biggest bottle of ice cold water on sale and a chocolate, also the biggest one I could find. There are no rules and there is no conscience (at least not one I’m willing to acknowledge, guilty or otherwise) when you’ve been running for 3 hours!

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For a humorous,  if somewhat elitist attempt at a runner's definition of 'tired' check out http://caitchock.com/distance-runners-and-a-skewed-tired-scale/

For a humorous, if somewhat elitist attempt at a runner’s definition of ‘tired’ check out http://caitchock.com/distance-runners-and-a-skewed-tired-scale/

 

The author of The Oatmeal, a blog I read sometimes (theoatmeal.com/blog) is a keen runner. In an old post he talked about getting home after a great race and wanting to tip over the fridge and devour everything that fell out. I can certainly identify with that urge. When I got back a little while ago I had half a pizza left over from yesterday and having composed this latest post, the plan right now is to have a wee sleep before hitting the books for a couple of hours. I have to go in to work later, I am on call at the hospital tonight.

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Write when inspired?

 

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Yesterday was a long day 😐 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.Β 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! πŸ˜“…) 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 😐) 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.Β 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 πŸ˜› 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.Β 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. Β Average day in terms of inspiration, or more appropriately the lack thereof. To study I suppose, and to write…

 

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Fun times

I am never leaving the Eastern Cape… EVER!! Those were my sentiments on Saturday morning 2 weekends ago, mostly because I woke up to this view…

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That is what you see from the back of one of the beach houses at Island Vibe backpackers in Jeffrey’s Bay. Having been there once before a couple of years ago this is one of Meryl’s favourite places. She was over for the weekend and we had made the ninety minute drive out there the previous afternoon. Looking around from the moment we arrived it wasn’t difficult to see why she is so enchanted with the place.

Island Vibe beach house

Island Vibe beach house

When you think of a backpackers you think: very basic four-walls-and-a-bed-to-sleep-in, and dirty traveller-type people around (as a friend of mine recently added πŸ™‚ ) This place is very far removed from that, think of something in between a cosy bed and breakfast and a fun island resort and you’re a lot closer to the Island Vibe experience. Now it sounds as I if I’m being paid to write this πŸ˜› No, that is most definitely not the case! We just both thoroughly enjoyed the place. It is situated on top of a small hill in Jeffery’s Bay, and when you’re standing in the reception area you can look down the other side of said hill and see waves crashing down on a beach barely a five minute’s walk away.

Girl and the beach...

Girl and the beach…

 

Perhaps it was just that particular weekend, or the crowd of young traveller-types that happened to populate the place on the night we were there, but the place had an energy about it, a party-like atmosphere. Meryl swears that is it’s permanent state. We (and what seemed like everyone else that was there) spent that Friday evening in the bar-restaurant area.

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We had pizza for dinner (as one does :-P), and met some interesting characters. At one point late in the evening I found myself on one side of the room playing pool with a Namibian guy I had just met and on other side of the room Meryl was playing beer pong with some other people.

 

We had a really good time and I recommend this place to anyone road tripping through the Eastern Cape or just passing through Jeffrey’s Bay for a night or two. We were not in fact on another roadtrip, we drove back to Port Elizabeth the next day but we have a definite plan to go back and hang a little longer, sometime soon.

 

Back in Port Elizabeth we met up with my friends Gareth and Nadisha. They had spent the previous 2 weeks in Cape Town with family and were spending a night in PE on their way back to Zithulele where they are currently living and working.

I don’t really like board games. Yes I know, who doesn’t like board games right? It’s just something about having a plan to sit around a table for an hour (or a few) focussing on the table bothers me. Just one of those things. It is alleged that I always enjoy myself when I’m dragged/forced to play. Of course I deny this, but apparently there is proof. I was up in Centurion with my family over the Christmas weekend, and there was one particular day when Meryl came over and we spent an entire afternoon playing 30seconds with my two sisters and my sister’s husband. I may or may not have enjoyed that, I dunno it’s difficult to say πŸ˜›

 

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Gareth and I settled down to battle Nadisha and Meryl over a game of Cranium. We let the entire male race down and got our backsides handed to us, by an embarrassing margin at that! It may have been my fault, I’ve never played Cranium before and it took me a couple of rounds to get into it. It was Meryl’s first time too but she seemed to catch on quite quickly. There is a theory that says that people couple up with partners of roughly equal intelligence. Based on how things went that night Meryl the law student is sharper than yours truly the medic. Looking at things a little closer though, Gareth’s wife and my girlfriend were two happy winners that evening, so perhaps it is us who were the smart ones… πŸ™‚

 

From left to right Gareth's arm :-P Nadisha, and Meryl

From left to right Gareth’s arm πŸ˜› Nadisha, and Meryl

We had to say goodbye late that evening, Gareth and Nadisha would be driving off again early the next day. I had seen them two weeks previously (again, briefly) when they had passed through on their way down to Cape Town. Our time together is always so short lately.

Gareth,  Nadisha and their two year old twins Jonah and Caleb.

Gareth, Nadisha and their two year old twins Jonah and Caleb.

Meryl and I with Jonah and Caleb.

Meryl and I with Jonah and Caleb.

Gareth mentioned that when they were down in Cape Town he kept asking himself why they don’t live there. It seems to be a serious option for them. This while I wrestle with my own little dilema. I have and am really enjoying my time in Port Elizabeth. My year is almost up. I am all but sold on the slower life, and relaxed atmosphere down here. Why go back up to Jozi? Meryl is in Johannesburg, oh and also Meryl is in Johannesburg. I have an apartment in Jozi. My family and best friend are all back there. Life will be faster. Work will be in a tougher, higher pressure environment. But that is what I always wanted isn’t it? Decision time. Fun times…

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