Ed's Work Day

First a correction about the charges I mentioned previously for imaging exams. Much less than I thought, CT cervical spine $88.20, Abdominal Ultrasound (includes a pelvis survey) $13.23, thoracolumbar spine $15.43. CXR (one view) $7.72, shoulder 2 view $13.73. I think these are all inclusive charges, and the physicians are on salary. These apply to the outpatient facility, where there is a three tier scale for payment, depending on patient resources. This is the first desk that patients go to when coming in. Ultrasound exams are used extensively, and there is a dedicated junior radiologist assigned to the two locations, one in the outpatient unit, which also has an inpatient ward, and another in the hospital across the street. Exams are performed when the patients appear with a requisition. There are no bookings for other than same day exam.

I gave my first lecture today, postponed from yesterday as the driver did not show up at 7:15, due to miscomunication. The conference is in an X-Ray room with most attendees standing (not enough seats). Today there were about 12 people, including the head radiologist, junior physicians, technologists, and secretaries. We had to cut the presentation short, because they needed the room to take radiographs. Unfortunately I was not able to bring cases from "home" because of technical  problems. I  found online lectures which I downloaded, and will be running through them as a commentator, describing what we do in my country, the differential diagnosis, and how this differs due to different patient populations, and the often delayed access to care. 

View of the wall outside our hotel room. First thing I see in the morning.  Cheaper than razor wire and more photogenic.

Following the conference I hover between the hospital and outpatient unit looking for work or teaching opportunities based on the case at hand. We sit at a desk in the same room as the exams are performed, looking in real time at the Ultrasound or CT monitor. Plain films are brought in for interpretation, or if no one is around, the exams are brought back to the ED or ward unread. There is no archive of any sort aside from the capacity of the CT or ultrasound hard drive, and exams are deleted as needed to make more room for new patients. I have not come across any teaching files yet. I don't think you can search for old reports, unless it is an inpatient, where the old report is in the chart. Exams are "filmed" with minimal numbers of images on thermographic paper and stapled onto the report page, which then goes into the chart.

At 10:00 I participate in medical rounds with the hospital physicians and other foreign volunteers. There is an attending from the V.A. hospital in Porland, OR, and a resident from the Mayo, near the end of his training. Cases I have seen this week include miliary TB, several cases of hepatocellular carcinoma with portal vein thrombosis, viral encephalatis, Lupus with terminal multisystem end stage disease, bacteremia often originating in the urinary tract, acute MI and hypertensive crisis, TB of the abdomen with massive ascites and mesenteric adenopathy, and SIADH from long term steroid treatment and adrenal suppresion. Steroids are frequently given in the countryside for arthritic pain. Everyone has diabetes. The teaching rounds are very good and they take the education of the physicians very seriously. Criticism is gentle. If there are imaging studies to review during rounds, I am available. The rounds reminded me why I migrated away from internal medicine, as we had discussed only six of the 15 patients in one and a half hours, reviewing all the lab data in necessary but excrutiating detail. I faded out as I contracted a cold for the last couple of days, and just didn't have the energy. The patients are complicated, and post discharge management is always a source of concern.

Medical Rounds. Families stay with their loved ones around the clock and bring food for them. Everyone is very patient and nondemanding, clearly appreciative of the services delivered.

After lunch I again rotate around seeing where my services are needed, and they call me to review cases as necessary, more as handholding rather true need, although many of the attending radiolologists are more comfortable with ultrasound than other modalities. They all have private practices outside to support themselves, usually involving ultrasound exams. I leave around 4 PM when the driver returns us to the hotel, leaving me tired and ready to recuperate. Big change from my retirement lifestyle.

Roasted nuts

The canteen outside the hospital. There is no cafeteria, but there are innumerable food stalls on the street.

Node of the information superhighway, local version. Hospital internet connection leaves something to be desired, and  hampers the style of medicine to which I have become accustomed.

Until next post. Yours truly.