Saturday December 27, 2014

Today was my second 24 hour call day.  This time, it was on a weekend, which meant that I would need to round and write notes on all the patients in the wards, Nursery, NICU, PICU.

Tangra was taking care of a very sick kid in the ICU who started out as a fever of unknown origin, which then progressed to decompensation, respiratory failure, upper and lower GI bleed, DIC - presumed to be from a serious infection.  He was intubated after coding.  Tangra had been on the telemedicine site with doctors from the Tripler Army base in Hawaii discussing his case. 

Without going into great detail about his case, there had been several setbacks - including the hospital running out of his sedation medications and the patient waking up.  It was also discovered that the hospital's CT scanner, which was rumored to be "broken", was actually still sitting in a shipment container in the harbor - where it had been for several weeks due to ?the holidays (nobody seemed to really know).  This case is a good example of how much the hospital needs resources - both in trained nursing and physician staff, and equipment.  It is crazy to think that this actually happens on US soil.

Throughout the week, the patient improved on the vent and then was extubated.  His respiratory status was tenuous, but stable.

Anyway, my call that day was again very interesting.  I ended up sitting in the ICU almost all night watching the patient and adjusting medications, monitoring machine settings... something WAY outside of my comfort zone (since we had literally one month of MICU in residency, and most of the actual management of those patient are not done by residents, but by critical care attendings).  I took for granted the excellent nursing staff we have at HCMC - namely that you can trust them to call you when a patient's vitals change, or even trust them to correctly use lines, administer medications, etc.  While I don't blame the nurses here (they are wonderful people, but  way overworked and the acuity of the patient population is ridiculous), it seems that you have to explicitly double and triple check everything that goes on in the ICU.

I was also called away to the ER for admissions and consults.  There was also a couple of C-sections that Dr. Marrone ended up coming in to help on.

Throughout the night, the ICU patient's respiratory status and cardiac status remained stable... until about 6am, when he became tachypneic and started desatting... long story short, he ended up getting reintubated, which made me feel absolutely terrible (though, after talking to Tangra and Dr. Marrone,  I don't think I made any gross errors in his management... I definitely am not cut out to be an intensivist!).  Thankfully, both Dr. Marrone and Dr. Shushunov were in the hospital at the time and took over care of the patient.

All in all, it was an exhausting call, though an amazing learning experience.

Friday December 26, 2014

Went to the hospital for AM rounds with the team, then rounded by myself on my patients. Then it was off to clinic for the day - which was slammed, since the clinic was closed on Christmas.   Finished up at clinic around 4pm.

Christmas Day 2014

 Christmas morning, we all woke up early.  I went out on the back patio and made phone calls to Carlyn and my family from the cell phone (still no access to Skype, but by this time I wasn't really missing it).

Here is a photo of the Broge family in front of their Island Christmas tree.  Pictured from left to right - Matt, Noah, Tangra, Nolan, Linda (Grandma), and Neeli.

 We watched the kids excitedly open their presents....

 I bought the kids a set of Chinese guns that shoot plastic darts - which was awesome. They had a good time shooting each other (and me)... I'm sure their parents were thrilled.

Later that morning, Matt, Tangra, Noah and I decided to go for a swim out beyond the break.  The water was at high tide, so you could swim out beyond the ledge without much difficulty.

It was a bit tricky at first, due to the waves, and there were the occasional cracks in the reef that dropped ?? depth (you couldn't see the bottom).  I was a bit concerned about getting my foot caught in one of these holes while walking out to the break (visions of compound fractures danced in my head as the waves crashed over me), so I treaded slowly.

Once over the break, the reef dropped instantly into the void.  There were huge fish.  The waves were quite large, and we were lifted up and down 15-20 feet like ragdolls.  I attempted to get a video of the waves, but my camera ran out of battery halfway through.  You can still notice the power of the ocean.

 Here is a photo of Matt, Noah and Tangra swimming.  Noah and Tangra had life vests on, which was clearly the smart thing to do.

 Noah acting cool in the water...

It was difficult to conceptualize the depth with the camera (was about 50-75 feet deep).  Here is a photo of Matt swimming about 10 feet below me.

After about 30 minutes, the waves began to get rougher & we noticed the tide was going out.  This was problematic because without the high tide, there is no way to safely get back onto the break.  We swam over to the edge of the wall and literally timed our approach with one of the large waves, which carried us over the wall and crashed us down onto the reef.  I ended up getting my snorkel ripped in half (the bottom was still in my mouth), and I cut my hand and arm on the reef. We managed to get back without any broken bones - it was quite the adventure.  (I can see now why the Samoans have a healthy fear of swimming... I don't think I will swim out past the break again).

Back at the house, we all changed and made preparations for dinner.  The power went out for about 3 hours.  During this time, I decided that I needed to learn how to crack a coconut the "Samoan way".  

Basically, you slam the coconut on top of a sharp, pointed stick.  Eventually you make a big enough hole to rip away the husk so that you can drink the coconut water.

My first attempt was an utter failure... (Matt had a great time poking fun at me. I swore at the time that nobody would ever see these embarrassing photos!)

Eventually, I got the hang of it...

This is me with my mangled coconut. 

 

Which I cracked open and used the coconut scraper to get out the meat. (Much easier than actually cracking the darn thing open)...

Later that evening, once the power came back on, we had dinner and relaxed out on the patio. There was another awesome sunset... truly paradise.

 

Wednesday December 24, 2014 - Amanave and Cape Taputapu

Today, we arrived at the wards for rounds.  I presented my patients to the team - very straight and to the point - but very thorough - which was again a refreshing change from residency (although I do understand the value of anal-retentive rounding with regards to training and safety).

Dr. Marrone was on call the night before, and he admitted another kid < 1 month with concern for sepsis.  He let me do the lumbar puncture by myself this time, which I was surprised to say that I got on the first try! (Dr. Marrone is a great teacher).

After rounding on my patients, I spent the day in clinic until early afternoon.  Afterwards, I went back out to the Broge house.  The weather was warm, about 87 degrees.  The water was absolutely amazing - the clearest I have ever seen.  Even more so than the Caribbean.

Part of the reason why the water is so clear is that there is very little sand on the island.  It is mostly coral and volcanic rock.  The coral is very colorful, and there were more fish in one spot than I have seen anywhere else (including Mexico and the Caribbean).

Prior to coming to American Samoa, I splurged and purchased an underwater camera (Fujifilm Finepix XP70).  I tested it out in the water, and the results were incredible.  Check out this video that I took just 20 feet from the shoreline in about four feet of water:

The water is very shallow for about 50 yards, then it hits the "break", a sharp dropoff of about 50-100 feet that was formed during the volcanic eruptions that formed the island.  The coral is almost razor-sharp, and you cannot go into the water without water shoes designed for coral reefs. (Thank you, Andrew, for your Christmas present - the shoes came in handy!)

Despite my best efforts, I did end up falling and hitting my knee on the coral (hurt like heck).

Matt, Nolan, Noah, and I walked out along the rocks to one of the break points - just below an island called "five palms", named after the five palm trees that grow in the top.

Photo I: Matt and Noah just prior to our trek to the rocks

 Photo II: The view of the 5 palms

Photo III: Balto, the family dog (adopted stray from the island) decided to join us!

Photo IV: Another view of the five palms

Photo V: There were numerous crabs and lizards (too many to count) crawling all over the rocks

Video II: Here is a view from beyond the rocks (really does not do the size of the waves justice... they were huge!)

I spent the night over at their house.  The next day was Christmas, and a holiday - so no clinic!  I had the whole day off.

Tuesday December 23, 2014

Today I was post-call.  I ended up having a little difficulty getting to sleep due to the "high" I was on from the night's excitement.

As I was finishing up rounds prior to going home, the First Lady of American Samoa paid a surprise visit to the Pediatrics Ward - complete with a Television crew and several AS dignitaries.  Being the only peds doc around, I was pulled and interviewed on TV with the First Lady.  She had brought large platters of food and gifts for all the children, a very generous gesture.

 Read the story (and see the clip) here: First Lady & elves visit children patients

"First Lady Mrs Cynthia Moliga, members of the Governor’s Office staff and employees of the Department of Youth and Women’s Affairs delivered gifts to children hospitalized at various wards of the LBJ Hospital this morning.

The presentation also included big trays of fruits and yummy treats for the hospital staff.

Mrs. Moliga’s first stop was at the Pediatric Ward and she and her group were welcomed by Family Medicine Resident Dr. Justin Michael Corbin and Mrs. Tofiga Tufele."

The visit was an unexpected surprise, but I thanked her for her kindness on behalf of the hospital.  The interview later aired on Samoan television and radio. 

I ended up getting back to my apartment at 11am (so much for duty hours... shhh nobody will know!).  I ended up sleeping most of the day.

Monday December 22, 2014

This was my first 24 hour call day.  The call schedule here was q5.  This was a learning experience for sure, as the on-call person covers the Pediatric wards, NICU, PICU, does admissions, and attends Cesarian sections to do infant resuscitations.  While I did have current NRP and PALS certifications, my only real experience with either of these in residency was with mannequins.  I must have reviewed the PALS and NRP algorithms in my head 50 times that day.

From 9am - 3pm, I was in the clinic.  It was very busy.  We see an average of 15-20 patients each during a clinic day.  A lot of viral syndromes, crazy strep/staph skin infections, genuinely sick kids.  The clinic here does no primary care, as the well child checks are all done at the department of health.

I was surprised to find that American Samoa also has one of the highest incidence of Rheumatic fever in the world, so a lot of kids coming in for screening and their bicillin shots.  Despite what I learned in medical school (strep throat leads to rheumatic heard disease, and strep skin infections lead to glomerulonephritis), most of the physicians believe that the high incidence of Rheumatic Fever/Heart disease is due to a very virulent strep skin infection.

That evening, I had three admissions, plus a lot of phone calls from the ED with questions about management, drug doses, etc.  It was also very refreshing to be in a place where the ER physicians do not admit the patients - I think HCMC has to be one of the only places where ER physicians admit and the team actually taking care of the patient cannot refuse the admission.  Of course, with this being my first on-call, I played it safe and admitted most of the kids.  After all, many of these kids come from well over an hour away, and their parents may not bring them back if the doctor tells them their kids are "fine".

My admissions included a two week old with a fever, concern for sepsis.  Dr. Marrone came in and taught me how to do a lumbar puncture on a baby.  There was also a kid with a bad pneumonia, and a little girl with seizures. I also had a straightforward "emergent" cesarian section that I attended as the NICU pediatrician.  The baby required some active resuscitation with PPV, but APGARS were 8 at 5 mins, and the baby did fine.

All in all, it was a very busy call.  I got maybe an hour of sleep, but the learning experience was worth it. The three kids I admitted became "my patients", and I would round on them every day before clinic, write the orders, and discharge them home.  It was awesome having the autonomy, but also a little out of my comfort zone - since up to this point, most of the medical decisions in residency are micromanaged by attendings (especially when it comes to kids).

Sunday December 21, 2014

Today (12/21/14) was another free day.  I spent the night over at Matt and Tangra's, and went to church with them in the morning.  They go to Calvary Chapel, an open-air non-denominational church.  The church location is absolutely stunning, with amazing panoramic views of the mountains, palm trees, and circling tropical birds.  The worship style is contemporary, with three vocalists, keyboard, and the pastor on the acoustic guitar.  The pastor, Oscar, gave a very good sermon from the book of Isaiah.  Almost everyone came up and introduced themselves to me - and many gave me hugs.  It was very refreshing to be in an environment with so many wonderful Christian people.

We spent the afternoon back at the Broge's house. I had the chance to pick and drink from one of the many coconuts growing on the palm trees around their home. Neeli showed me how to scrape out the coconut meat with a special "coconut scraper".

That evening, the kids had a Christmas program back at the church.  It was an elaborate event with songs and choreographed numbers. The songs were in both English and Samoan, and it was incredible to see the talent that these kids have to share.

T

 

Photo I: A view of the outdoor church

Photo II: The banner above the stage during the Christmas program

Photo III: The kids during the finale of the program (Nolan and Noah are on the front left, first and third kid respectively)

 On the way back from the church program, we drove past a very unique house of worship nicknamed the "Santa church" - mainly because it is decorated with dozens of glowing statues of Santa.  There is also a big glowing Mickey Mouse out front.