and we're back...

I got back state side after a long journey. Longer than your typical trip and definitely way longer than the trip there to begin with. Once again, Chicago decided not to cooperate and be really chilly with perfectly slick runway conditions. O'hare decided not to play nice and decided to ground a ton of planes at the last minute and I got stuck in Chicago after sitting in Terminal 3 for about 3 beers. You see, I had it down on how to beat the jet lag and time difference. I would stay up on most of the trans-Pacific flight and then sleep on the trip back to KC after nursing a couple local brews. Instead I had to run to the little boys room when they made us go to the rescheduling desk and by the time I made it back there, the next available flight aboard United was 2 days later. I made it back after hitching a ride on a fellow KC'er rental car and agreeing to driving. My luggage made it back almost 2 days later. Awesomeness indeed. Yea, I beat the system, sort of.

I'm writing my reflective narrative about the trip now and taking a side detour to blog. In general, it was really amazing. All amazing for the experience to go, the experience I gained, and the knowledge I gained from meeting others and sharing our experiences. Maybe I'll get around to sticking some of the cooler pics up. I wish I had a nicer camera though. yes, the travel bug in me is definitely awake.

I may not necessarily blog for a while now. we'll see though...

local flora...

I think I have become one with the local flora. The phases "look out for the local water" and "watch what you eat" were slightly ignored this past weekend, actually Sunday and I was feeling the effect by midmorning. It's still going on, but tolerable for now. We'll see what happens. I should have called in some antibiotics for myself before I left the country. I can see why little kids get really annoying when they get a stomach flu. Unfortunately, I don't have the cat I can kick around now. (just kidding about the cat!) I also saw a lot of chicken pox today in the ID clinic. cool. roughly translated, it means water raised spots. that makes a lot better sense than chicken pox. (you know, dew drops mnemonic/buzzword)

culture clash

I'm glad the culture is the way it is in the U.S. it doesn't always make sense, but then again, I'm biased. there is more argument here, less personal space. Rounds and check out are a little loud in the morning. Patients barge in during rounds and during other patient's clinic visit to ask questions. I think we had 15 people in one smallish 6 by 10 foot clinic room. They take a 2 hour lunch break. Sounds cool, but I'd rather gulp down some caffeine and get my stuff done early and go home on time. There is more of a class/hierarchy system in the hospital. There's a lot of barging and shoving in the subway during rush hours, although I'm pretty sure it's like that many times in NYC too. the retirement age is 55, although I'm pretty sure they will have to change that at some time in the near future. There was some talk about making it mandatory for kids to take care of their parents. There's a heavy emphasize on textures in food and I didn't realize that a chicken/pig/cow had all these textures depending on which part you ate. Patients and physicians (along with all other health care providers) should be extremely happy in the U.S.; we have a pretty decent system setup, partially due to trial and error, and still full of errors that will require a lot of patching in the near future.

I still love being here and having the opportunity to come, but I miss my bed/non-smog air/ability to drink water from the tap/ and car.

madness

the inpatient ward is a bit crazy at the old hospital. up to 5 beds crammed next to each other. the old hospital can accomodate about 350 or so kids plus PICU and NICU beds, which vary according to how close they cram the beds together. and then there's the bunch who can't afford to be hospitalized immediately and instead get antibiotic infusions in the ward next to the ER and sit out in a courtyard area. I'm pretty sure I saw at least a handful of kids getting TPN out there too. in a sense, a lot of it is similar to our system with diseases and short comings. They have just 4-5 times as many as we do of each disease and then some rare ones too. They have great expectations for each child from the parents, especially since they typically just have that one kid. Most of the time, even if nothing is wrong, they get a prescription - either for some oral rehydration solution, antibiotic for 2 days, or some relatively benign Chinese medication. They don't have great follow up, so a lot of the even somewhat sickly kids are admitted. There must have been a special on HSP, because the old place had at least 30 or so HSP plus a lot of HSP nephritis. and your typical RSV as well.

the new hospital is pretty nice, with flat screens in all the rooms. i didn't ask about cost differences. once again, the parents do a lot and are typically always in the rooms with the kids. the parent is almost everything except drug admin and IV venipuncture. RT, child life, nurse tech? check, check, and check. actually since the parents don't know sometimes, the doctor doubles as all of those too. they have the same and more interesting monitors in the ICUs. I just feel like some of their knowledge base is lacking from Western medicine, b/c the required texts aren't always the newest U.S. ones. like the Nelson's and Harriet Lane, both Chinese versions, are available, but they aren't widely used. part of the problem is the delay in some translations to Chinese in the latest journal articles. They have to take PALS q2yr and they read Peds in review, just that those are in English.

another interesting thing is that docs typically know the prices for meds and such. why? the patient has to pay up front first and very few patients have private health insurance. even if they did, they know the cost upfront.

I don't think that U.S. patients realize how lucky they have it in the U.S. at least we treat first and worry about payment later. same for docs - we don't have to worry about the financial burden. I think that was the response given when I asked back in med school for why our CPOE system didn't just have costs for all the tests and meds listed in each row. the costs might bias us and our primarily roles are supposed to be health first.

next is culture and maybe life outside the hospital.

not my clinic

clinic is interesting. the patients typically do what you say and listen pretty intently, unlike a lot of places in the U.S. of course, the private practice clinic I followed a couple months ago had some excellent patients (follow advice, good payer source). in the tertiary care hospital, there are a lot of specialists and even more patients. 60-80 in a day is typical. I think I saw more diarrhea and constipation in a day than I have all year. they all come home with some form of prescription. sometimes it's an antibiotic, well, a lot of times. some WHO approved oral rehydration source (apparently you can make your own in a pinch 1/2 tsp salt, 1/2 sodium bicarb, and 4 tsp of sugar in a 1liter of water), and sometimes some racecadotril (a seldom used drug available in the U.S too), and some Chinese medicine. I'm not sure if the antibiotic resistance patterns are much worse here than the U.S. It would like the case since antibiotics here seem worse than th ER docs giving vitamin R shots (rocephin).

the manners here are different than the U.S. you have patients barging in to check on their status to be seen and no sort of specific order. the nurse is no where as helpful in triaging patients in. they are really good at lab draw and getting the ultrasound done super fast. they don't even takevitals. some of this may stem from the fact that Western medicine is still relatively new here and their med school still emphasizes a lot of Chinese medicine. I know I would get burn out seeing 60+ cases a day though. There is still a big hierarchy system and the older attendings do not see much clinic and never take any sort of call. They do a lot of admin stuff. Some of the same stuff still occurs here though - parents bringing their kids in for basic common sense stuff (diaper rash, diarrhea when it's not really diarrhea, etc), over utilizers of the systems, and people using the ER during holidays as their clinic. I haven't been able to figure out how many people have a primary care doctor.

next is maybe inpt

setting

the hospital is really nice. it is set up sort of like our own in KC, with the Hospital and Clinics sort of model. It is a Women's and Children's Hospital. Like I was told before I came here, a lot of their stuff, like equipment and facility, is nicer than ours. It's about an 850 bed place with full tertiary care options for all. There is an older hospital too in the older part of town with another few hundred beds. They even have a separate ob/gyn ED. A hospital like this in the states would cost probably several times more for labor and land. The entire place is draped in white marble. Inpatient now is pretty light due to the holidays. All of their inpatient doc is via a computer system except for some areas in the ICUs. and of course , their heart cases are at a standstill too due to the holidays.. Radiology is a separate system and they do not have PACS. The patients take a lot more responsibilities like administrating their own meds by the parents. oh, and they also pay up front if the docs decide they need to be admitted - like a lot of other countries in the world. they pay a 3000 RMB account from which meds and other charges like nursing get deducted from. the family typically finds ways to get this and if not on the first night, they spend it in the ED under observation status. oddly enough, they even had a case of MSUD. their newborn screen is only 3 diseases though. it was pretty hard to understand everything, since unlike HK, everything is in Chinese, including the culture results and MIC/resistance patterns! plus, I really don't speak Mandarin at all, which a lot of docs use since they are from elsewhere in China and my Cantonese medical speak is horrible.

new post will be about the clinic

differences...

I guess this will be own journal for myself too, but here goes.

It's been really nice there thus far. It makes me apprecriative of the differences, however subtle or varied, they are of the two cultures. For those who are unaware, I'm spending the month of February in Guangzhou, Guangdong Provience, China for clinical rotations. I'll have to continue to thank my residency program for sponsoring me here. For starters, I happened to arrive during the New Year's. Chinese New Year is a full week long celebration and people seem really surprised that the U.S. only gets 1-2 days off for their Christmas/New Years. In general, everything stops. The construction zone that is the city halts since everyone goes back to the country side. In the hospital, even the patients that can go home do so, as long as they aren't hooked to an IV for anything. The hospital runs on a partial staff too. Once the week is over, things kick back to full gear. They follow traditions a lot and like many Asians, tend to be a bit too superstitious. The class distinction between elders both by age and job role is more marked as well. Everyone also tends to welcome guests a lot more than in the U.S.

Every day, both here abroad and in the U.S., I try to pay attention to something cool. What's cool to me is different than someone else, but for me, sometimes it's funny and sometimes it's an "ah-ha" moment and makes me more apprecriative of life and nature. Typically you can't quantify it and I hope that it's something can never be programmed into a computer code. Anyway, today I was walking around and heard John Mayer, except that on following it, it was being sung, not too shabby, by a Chinese kid. There are a lot of street performers around, he definitely stood out. I'm not sure how many others around knew what to make of him though. Guangzhou does not have a lot of non-Chinese visitors compared to other cities in China. I listened for a bit and gave him to what amounted to about 1 US dollar.

this is a note to myself, but I'm supposed to spend a little time in the hospital tomorrow, so I'll post about that next.

my schedule

wow, I can't believe it's been over a half a year since I said anything here. I guess this sort of mimics my silent life. my time management skills are definitely better, and I can prioritize stuff better too! unfortunately, road bumps keep sneaking onto this odd journey to an unknown place. it's nice to be over half way done with this part though. back to my hectic schedule at least until I think of a more definite path to take this diary. in the meantime, I'll just read my brother's log, although he wishes to be anonymous for now due to work conflicts. mood - strangely lackadaisical

my procastination

between work, work, and oh yeah, more work, this blog has sort of gotten the through shaft. I know I should write a bit - I enjoyed it back in undergrad years ago, and I often looked for a chance to write for the paper. It sort of sucks that there's deadlines and reading to be done, because, yes I do want to be good worker bee. I really have no interest in writing about every little tidbit about life, as I really have no purpose for doing so. In a selfish sort of way that I think I mentioned a while back, my audience is really myself in a certain number of years away. Like a teacher once told me, all writing is for an audience and should be for a specific purpose. My next big project will be finished, hopefully, in mid to late February. Until then, I will keep my half-finished, mid thought articles buried in some searchable form on my hard drive. One of life top 10 aspirations is still to have some form of my work(s) published - there is certainly some degree of coolness to that. besides work, I'm trying to organize a garage band. I realize that it's certainly something I should have done years ago, but damnit, I missed that part in the 80s and I have no qualms about re-living that part of it. sarcasm totally intended there...

speaking of life in general, I like facebook for keeping in contact with some friends both from now and the past. But, if I have had no direct contact with you in the past, don't expect me to be your friend. I have absolutely zero aspiration to have the most number of friends on there, which the same goes with myspace.

my year, almost

it's almost been a year of this mayhem, and I guess my mood would be fairly undecided. yes, the story of my life thus far. I've been meaning to compose a blog, oh, maybe once a month or something like that. Unfortunately for these pages, I've picked up some toys, including guitar hero, a piano, and some books. Good stuff. I'll try to beat those kids at GH next time at Walmart. addictive too, sort of like kiddie crack, except you get better finger dexterity. I like it.

I say undecided because I get asked quite a bit about med school and residency by the fellow med students. It gets me thinking, since about 90% of my answers during med school and the interview trail were fairly contrived and routine. I guess by the time I recited them so often, I sort of believe them myself. I still try to convince people to go into medicine, but I try to make sure they do so for the right reasons. boring? never. rewarding? occasionally. challenging? daily. I hope these reasons are still true 1 year, 5 years, and even 10 years from now. maybe I won't be too cynical then, but I am an optimist.

I will blog more later. these articles are literally sitting on the desktop, partially completed, partly funny, and poorly worded thoughts...

my patient's patience

"we should get those results to you today"

as soon as I heard those words from another resident, I knew it was too late. we were explaining some test and the approximate time frame when the results of said test would be known. I turned to my med student.

"today! you realize that we have just doomed ourselves to finding out those results and letting them (family) know. actually, I think she just doomed you, because that kid is your patient."

and they say I'm too nice to my med student... In all reality, it really sucks that we setup these unrealistic expectations once a patient is admitted to the hospital. I thought for a second during my own medical school that such practices were limited only there, but it was really an afterthought. After all, what patient or parent would NOT want to be given the answers and solutions to everything once they set foot and set up camp in a hospital bed and room? after all, you are now in the big great academic hospital (which shall remain anonymous).

this sort of reminds of the movie Sicko, where one explaination I read somewhere suggested that our insane health costs are partially to blame on the expectation that the American people demand and our own culture of fast food medicine. we want answers to everything, and we want them fast. if we are discharged from a hospital stay, we damn well better give them a magic elixir to solve them, or else ligitation reigns supreme.

unfortunately, medicine is very much the opposite. in many cases, we are trying to undo the years of bad health and this is only where we know what is going on. many other times, we have no idea what the hell is going on with our patients. We rule out all the immediate badness like cancer, infections, vascular abnormalities, cardiac oddities, and other quick kills, and discharge you home to follow up with your general practitioner and specialists. if it's something possibly rheumatologic, then it will show itself in a few months, or maybe not. lab tests are sent out and if they miss a courier time, then it's another day wait. our lab vampires suck out several tubes of blood and leave the patient's arms and legs all bruised, yet no one gets a chance to fully explain that some of those tests may have to be redrawn tomorrow.

I'm still learning, but I do know what my expectations should be now. Fortunately for that patient, the MRI results came back later that evening. I think I'll start setting up false expectations now though. it's like the directv guy telling you he'll be there at 3pm and showing up at 2.

my workout

there's something to be said about a good day in clinic. unfortunately, those usually come later in the year; later, when I know where stuff is, how charting is performed, and what things to expect from the patients. the good thing is that I didn't screw up, not much at least.

the first day of medical residency is the start of many firsts. it's the first day after a tiring orientation, first day of the medical profession and practice, first day of doing something closer to what you ultimately like, first day of being paid, first day of calling yourself "doctor" and having it literally carry some weight, etc. although we still report to a higher power, being the attending, we do make judgements and decisions. this brings a new definition to the words "scary fun". unless you know the inner workings of the medical hierarchy, or follow one of the medical dramas out there on the tube, you may not be aware of the environment a intern faces. the worst of it can be comparable to being tossed in the deep end with a number of fresh cuts and bruises from before (medical school), while the opposite side is just a mild workout. fortunately, the institutes we work at have mostly gone the way of the latter, largely due to demands of a more humane working environment. I can take a mild workout, maybe some unblocked kidney punches and a handful of good uppercuts. after all, bruising is just bilirubin. bad pun indeed.

I started out in gen peds clinic, which is an awesome way to start, no sarcasm intended. I got another orientation of the clinic, a light load in the morning and a medium one in the afternoon. Best of all, a small flock of medical students were there to lighten the load. and did I mention pediatrics, which is somewhere on the opposite end of satan, er, surgery. along the middle of the day, some twins came in, identical in all aspects including chief complaint, history and exam. names differed in only a letter, and rhymed as well. oh, and other difference was slightly more severe otitis media, requiring a new antibiotic since the first line course had failed. Outcome? I wrote the script for the wrong twin. In the end, I tried to call the mom, but succeeded in talking to voicemail several times. she had a great metallic voice and I left her a message. To quote a great attending, a little bug juice never hurt and if the other kid was worse, they would come back anyway. Hell, there's still a chance it could be viral.

I don't think my jaw is too sore, besides, I have another 8 hours tomorrow and 40 opponents.

my "n"-th attempt

once again, I will attempt to chronicle mild bits of life fused with bits of comedic fiction and sprinkles of fact. while this will serve to help others who know me to keep in touch, it is primarily a selfish act to keep a digital version of my life. I've tried it in the past and now it serves to give me a good guffaw every time I read it and realize how much I've learned. Yet everyday of work also reminds of how much more I still should know.

enjoy this semi-updated blog.