Week 2: Universitas

5/19
Universitas was a bit more demanding than I anticipated, but the atmosphere has forced me to move rapidly and think rapidly. The hospital is very large, and holds a lot of patients that were referred from various other hospitals to receive specialist care. It has ten floors and a couple elevators that are always ridiculously full, so most of the doctors, surgeons, dietitians, etc. take the stairs (the nurses and patients opt for the elevator). I thought Sunday was leg day, but apparently every day is leg day. There are 5 dietitians, each in charge of a different ward. There are so many wards and units on each of the ten floors that I struggle to remember where anything is at all. Yesterday began with Marli making her rounds in the cardiovascular ward with a group of other doctors huddling into each room to review each patient's status. It was excruciatingly long and was likely very awkward for the patients. I also saw a lot of diabetic patients with calcified toes, black and stone-like. In fact, there were very few diabetic patients at the hospital who did not have calcified or amputated toes. I then followed Monica around the ear, nose, and throat ward as well as the pancreatic and gallbladder diseases section. She informed me about Whipple's procedure, a surgery designed for those with cancer to remove the head of the pancreas, the duodenum, the gallbadder, and the end of the common bile duct (because they are all so tightly integrated) and then reconnect the intestine, bile duct, and remaining pancreas. We sat through a brief presentation from a Fresenius Kabi (supplement company) rep speaking about the importance of including glutamine in the feedings for critically ill trauma patients in order to consistently maintain blood glucose levels. I then followed Will around what I guess was either a geriatric unit or a surgical unit, but he sat down with me and introduced me to the application of estimated energy and protein calculations to nasogastric tube feeds and which feeds he typically prescribes for diabetics, cardiovascular patients, those with decreased renal function, malnourished patients, patients recovering from surgery, etc. He also noted that it is important to note the amount of fluid a patient is getting through the drip in order to prevent oedema. Mariechen briefly showed me some dermatology patients, some with Stephen-Johnson syndrome, a severe skin rash caused by an adverse reaction to medication. In this hospital, it is usually found in patients with HIV or TB due to a bad reaction to an ARV or antibiotic. It is a really nasty disease that causes a lot of painful, bleeding, blistered rashes that can even spread to a person's GI tract, making eating incredibly painful. Mariechen said she treats these patients much like burn victims due to the increased protein needs to repair the skin, not forgetting to include glutamine supplementation (an essential amino acid). She also checked in on a few babies who were suffering from malignant brain tumors and were severely malnourished. When I first saw the babies, I thought that maybe I was looking at conjoined twins, because the tumor was about the size of the infant's head, and the skull had formed to accommodate such. She said that she struggles with charting the infants' growth due to the weight of the tumors, and that she hopes to collaborate with a hospital near Cape Town soon. One of the infants was 2 years old, yet only weighed 17 lbs, much of which accounted for the tumor weight.

A couple of years ago I could not have handled this kind of constant exposure to gruesome deformities, but I think that I have reached a point where I am no longer appalled by the abnormal, but compelled to improve the patient's condition in any way I can, even it it just means smiling and talking sweetly to the babies that don't receive enough social stimulation.

We also visited some patients on nutropenic diets, immuno-compromised patients who must reduce bacterial exposure, so bacterial culture in foods such as yogurt and unprocessed fruits and vegetables must be avoided. We also noted that patients treated with steroids have greater appetites, so they are often fed according to diabetic guidelines (low fat, low added sugar). Tuberculosis patients are typically placed in the sunniest rooms of the hospital in rooms that also have blue lights, as light kills a lot of harmful bacteria and somehow contributes to recovery. Heidi showed me around the dialysis center, which is definitely one of the most interesting but most depressing units in the hospital. If I was ever diagnosed with end stage renal failure, I think I would just eat whatever I wanted and die quickly. In the end stage, there is no hope for ever regaining renal function or qualifying for a transplant. Even the patients with higher renal functionality who qualify for a transplant may have to wait a while remaining on the chronic program. End stage renal failure patients do not qualify for the chronic program, so if a patient wants to continue dialysis, he or she must pay out of pocket. I know the wait list for a kidney transplant in the US is at least 7 years. In the public sector of SA, there are so few donors that Heidi couldn't give me an estimate. Certainly longer than 10 years. On hearing that, I was introduced to an end stage renal failure patient that also suffered from diabetes.

After that depressing prognosis, Will brought me to the kitchen to meet the foodservice manager, Thelma, and to retrieve the nasogastric feed that he had prescribed earlier. At this hospital, there is some form of a computerized system. The dietitians input general diet orders for patients receiving something other than the house diet. Listed options were endless and included diets order such as "Diabetic 7000 kJ" or "Low fat low sodium cardiac diet 8000 kJ." If the dietitian really wanted to, they could fill out diet cards with specific menus for every meal and snack that a patient receives and submit to the cafeteria, but that would be insanely time consuming. He fills out a diet card every now and then for a patient with mild renal failure. All of the items prepared come from Cook-Freeze, a foodservice company right by the university that prepares foods six months in advance and freezes it with nitrogen before distributing. Hannelise has actually been stationed there for the past couple of weeks. Will also explained the "Kangaroo Mothers" initiative for breastfeeding. Mothers are encouraged to hold their babies skin-to-skin for at least 2 hours following the birth, along with all the other breastfeeding guidelines that I've talked about previously. All of the hospital's nurses are required to be trained in breastfeeding and bottle feeding is heavily discouraged. When a baby is given a bottle or a pacifier, the sucking reflex is encouraged, rather than the suckling reflex needed for breastfeeding. Once the baby learns to suck, the ability to use the whole mouth and tongue to suckle is reduced, and the baby may refuse the breast. If the baby cannot be breastfed, cups are used in feeding, because cups still require the infant to lap up the milk using the tongue. Apparently in many grocery stores, you must request infant formula from behind the counter, because it cannot be found directly on the shelves.

Today (Tuesday) kicked off with a visit to the plastic surgery ward with Will, a unit usually host to patients with cleft palettes and breast cancer survivors. There was however, one outstanding patient who came in for a sex change, because he had previously visited a sort of village wizard called a "sangoma" who had given him funky tea and and then advised him to cut off all of his genitals. Unsurprisingly, the home operation was unsuccessful and landed him, who is now a her, in the hospital due to infection of the wound. He was referred to the dietitian due to increased protein needs while recovering from surgery. Village sangomas have the potential to be quite problematic for the health of rural communities. In addition to infections caused by primitive surgeries, some pregnant mothers are given strange teas and herbs that may cause fetal deformities. We also visited the CVD ICU unit and the cardiothoracic ward.

Monica and I visited the prem clinic again and checked on some babies who suffered from the blinding effects of congenital rubella. Then Marli took me to the gastrointestinal ward and pop quiz roasted me about paraenteral nutrition, total gastric outlet obstruction, ulcerative colitis, Crohn's disease, refeeding syndrome, Billroth 1 and 2 procedures, and the Roux and Y procedure. I haven't yet taken medical nutrition therapy or nutrition counseling, but I did my best to infer and maintain a minimum level of dignity. One thing I learned that really stuck with me while in that ward was the importance of maintaining a positive attitude and what I like to call 'doctor etiquette.' Doctor etiquette usually means avoiding habits like standing by a patient's bedside and saying to the intern, "Very few people recover from a condition like this," or "Hopefully the nurses don't forget to flush the tube this time." It kind of frightens the patient into thinking that they are not receiving adequate care and that their illness is terminal, which doesn't quite improve the odds of recovery.

5/24 
So I am trying to document all that has happened since Tuesday, and I finally just gave up on trying to describe everything in detail. Let's just sum up the week by saying that Universitas was a difficult place to work. The workload was heavy and individualized patient care was often compromised for the sake of time. Not to mention the poor students Johanrè and Shannon are always stressed, always working on blue books for the patients that the dietitians assign. Wednesday was a bit more relaxed as I visited National hospital, specifically the branch associated with Universitas' oncology patients that were referred here but still classify as Universitas patients. Rianna showed me around the oncology department and I noticed that most of the inpatients had esophageal, mouth, or lung cancer due to excessive alcohol consumption and smoking. A lot of patients smoke sketchy things rolled in newspaper and drink homemade brews, which increases the exposure to toxins and carcinogens even further. I try to be very good about greeting all of the sisters because otherwise they get very offended. But of course, the one time I forgot was on my way to the bathroom. I noticed one sister outside the bathrooms intently reading, so I thought it best to not disturb her, but afterwards when I was trying to exit the bathroom, the door was locked. I voiced to the sister my concern and she said she locked the door because I didn't introduce myself, to which I responded, "Oh sorry! Hi, my name is Jordan. Nice to meet you. Can you please unlock the door?" Her name was Gladys, and I picked on her later in the day when she couldn't remember my name, "...even after all we had been through together." We laughed about it and all was good at the end of the day.

Thursday was an easier half day at Universitas. After going through the ward rounds with Heidi, Monica, and Marli, we went to a guest house for a seminar on polycystic ovarian syndrome and insulin resistance, an interesting combination, though we also sat through a drug representative's presentation for Inositol and a presentation about PEN, a dietetics database of evidence-based research compilations. It was actually quite a relaxing event as there was abundant tea, milktart, salad, and quiche prepared by a catering service that Carlien was stationed at this week. I am beginning to understand why companies like interns so much. Unpaid, obedient employees that desperately seek your approval and positive evaluation are stellar for workplace efficiency. I stayed with her until the place closed up, which wound up being around 5:30 pm. Afterwards, I went to learn some field hockey moves from Hannelise and got some sushi with her and some friends after the hockey game. 

Friday, I went to the department presentations just like last week, but Marli wanted me to come in afterwards. When I arrived, she handed me a thick textbook and a couple pages of questions that I was to look up and define. I did about a page before it occurred to me that I was at the hospital for clinical experience and I was not receiving grades from the distributor of said busy work, so I asked Marli if we were going to do any more clinical work such as ward rounds or counseling sessions. I had not planned on staying past 1:30 pm anyways, because our daily itinerary that I had received at the beginning of the week said that I would stay no longer than 12 pm on Friday. She didn't have any other work for me, so she let me leave, and I was thanking my lucky stars that I did not need her evaluation. She doesn't seem to favor the other two students despite their desperate efforts to appease, so I'm not exactly sure how fond she is of the American who couldn't even remember the difference between a Billroth 1 and a Billroth 2 procedure. I was just proud of myself for knowing what a Billroth procedure was, because we've not yet discussed it in any of my classes.