Closing and Calling

I have now been back from Africa for a week. It's amazing how fast this life will suck you back in. I didn't think I would struggle much with reverse culture shock. I have seen and worked in poverty stricken countries before. I realize it is OK to own a car, make rent payments, and spend money on luxuries like meat. What I didn't anticipate being so hard was transitioning back to the role of a US medical student. I went from rounding on 30 patients a day in Africa to having seen exactly 1 patient for the entire week on Neurology. There were so many patients in Africa to be seen and so few doctors that what I did actually mattered. Here, my one neurology patients is cared for and seen by a nurse, a nurse aid, a medical student, an intern, a resident, and finally the attending. This is not to mention the speech therapist, ultrasound tech, and physical therapist. I'm not needed here. I do realize that my role isn't primarily to care for these patients, it's to learn. And having realized my medical knowledge is so incomplete while in Kenya, I have a heightened sense of responsibility to learn as much as possible the next few years. Still, it's frustrating being here when I know I could be doing so much more somewhere else. I have a good story to illustrate my point.

My last week in Africa I worked in Casualty, or the Emergency Department. It is a 10 bed room, with limited supplies, one thermometer, one automatic blood pressure cuff, and very few staff. My last day working there started off much like the others. It was slow in the morning, but picked up as the day went on. By evening, when I was supposed to leave and join some friends for one last dinner in Kenya, the ED was overflowing. There were at least 25 patients, some sharing beds, laying on the floor, or sitting in wheelchairs outside. I couldn't leave yet. Patients were dying of organophosphate poisoning, diabetic ketoacidosis, sepsis, poly trauma victims, malnourished kids with gastroenteritis, a man in shock who had acute urinary retention (eventually requiring a supra pubic catheter), and the list goes on.

I will always remember standing in the middle of that room in Kenya, feeling overwhelmed by the need. The lack of resources, training, and physicians. One of my mentors, a US trained Family Practice physician walked in about that time. He looked at me with a knowing smile; I'm sure he had seen bewildered look on a numerous medical students faces over the years. I tried to convey to him what I was feeling, experiencing. He understood. What he also realized was that in a few short hours, I was getting on a van, leaving the hospital, then flying back to an entirely different world. In this other world, things aren't always so clear as they are in Africa.

What he has witnessed time and time again is young medical professionals see a real need, want to make a difference, but eventually lose that vision. Residency, families, debt, and life have a way of making you forget. It is with this realization in mind that I make this post. By sharing my experiences and convictions with many people, I hope to be held accountable.

The hospital I worked in was mostly staffed by Western trained physicians. It served as a tertiary referral center for Western Kenya. We even had referrals from the bordering countries of Uganda and Sudan. It was likely one of the best staffed hospitals in Eastern Africa. And still, I was overcome with the need and lack of resources. If I was this overwhelmed at this hospital, I can not imagine what the need is like at other hospitals.

I have shared this thought with a few people here in the US, and a response I occasionally hear is, "Why would you travel so far when there are underserved areas here in the US?" Sure, there are many underserved areas here, but in other parts of the world, there are NOserved areas. Take Zimbabwe for example. In a country of 13 million, there are 37 OB/GYN docs, 2 neurosurgeons, one dermatologist. The doctor:patient ratio is 1:12000 compared to the United States 1:390. And Zimbabwe doesn't even compare to the worse countries such as Tanzania and Malawi boasting a ratio of 1:50,000

That night, I walked out of the hospital with tears in my eyes. These were not tears of grief or tears of frustration. I was overcome by the realization that I could not turn my back on what I had just experienced. I think many of us expect a sign from God, clearly spelling out his divine plan for our lives. Perhaps I was expecting a bright flashing neon sign in the sky. But God does not often work that way. In Matthew 22:36 Jesus was asked what the greatest commandment is, and his response was to love God, and love others. By loving God, our heart becomes closer in line with His heart. And He loves his children. The best way I now know to love others is by sharing with them the gift of medicine. It has been said by people far wiser than me, that God’s will for our lives is where our greatest joy intersects with the world’s greatest need. From what I have experienced so far that intersection, for me, lies in Africa.

Statistics and Stories

One of the unique traditions of medicine is what we refer to as M&M conference, or morbidity and mortality conference. I'm unaware of any other profession that conducts such a humbling practice. Once a week, all the physicians, residents, interns and medical students meet to review the unfavorable outcomes. The walls are lowered, the defenses are dropped, while a medical professional stands before a group of peers and admits a mistake or an unforeseen complication. It is generally a supportive environment where everyone learns from a mistake and hopefully next time a life is saved. Sometimes, it turns ugly.

While on my surgical rotation in the US, I have seen physicians rip a resident to pieces for a negligent mistake leading to the death of a patient. As if it isn't hard enough for a person to admit a mistake in front of their peers, especially a mistake leading to a human death, they are sometimes grilled for their actions. At times, the resident is presenting a mortality they had nothing to do with; one that occurred before they came on the service. They humbly accept the criticism and don't mention the fact they had no knowledge of the case until they were asked to present the day before.

Overall, I have found these M&M cases extremely educational, and I think most physicians would agree. Africa is no exception. Once a week a different service (Medicine, Pediatrics, Surgery or OB/GYN) presents their statistics and then a few cases with unfavorable endings. Last week I heard a startling number. 22% of patients admitted to the medicine service end in mortality. That's nearly 1 of every 4th person on their service dies. This is not a reflection on the quality of medicine practiced here; there are many reasons for such a high death rate. Almost 50% of patients on the medicine service are HIV positive. This immunocompromizing disease leads to many complications. Patients here also present much sicker than they would in the US. If someone got a deep cut in the states, they might clean it out and go to the ER for stitches. That costs a lot here. First there is the transportation, usually to a hospital that is not so near. Then there is the time they can't work while seeking medicine. The hospital bill is all out of pocket. And why should they seek expert medical advice when they have herbal medicine? They have always got better before. A few days later, after working in the field, the wound seems to be a bit more painful, and they notice this funny numbness in their hand. The next day, they can't contract their muscles as well. It must be that they didn't take enough herbal medicine, so why not just double it? A few days later, the infection has nearly incapacitated them, and the tetanus bacteria has spread proximal, now threatening their ability to breath. Now seems like a good time to go to the hospital.

I found it interesting that the busiest time in the Casualty or Emergency Room here isn't the same as in the US. Typically, Monday evening is the busiest in the US. This is because no one wants to be sick on the weekend, so they deal with it. Come Monday, when it's time to go back to work, suddenly being sick doesn't sound so bad. Maybe they try to tough it out for a few hours, realize how sick they really are, then break down and go the the ER.

Not so in Kenya. A day off work means the cows don't get milked, the chickens don't get feed, and you don't make it in to get paid for the day. Translation... you and your kids don't eat. This is probably why working in the casualty here is so exciting. Surprisingly (or not) there isn't a high prevalence of fibromyalgia here... (I apologize to those who do suffer from this, I'm not meaning to belittle this disease)

I have also been surprised by what is considered an elective surgery here. Apparently, osteomyelitis is not an emergent, or even urgent surgery. People live for years here with a fistula connecting their bone to their skin which drains pus from the infection. This is one of the few exceptions to the rule of only emergent surgeries for the orthopedic service. There are just too many emergent cases to worry about hip replacements, ACL repairs, etc.

The last few nights of call have not failed to live up to expectations. Last week while taking call for pediatrics, I was admitting patients in the casualty. A nurse came up to me and with a frantic look on her face, asked who was the attending physician for surgery. It seemed like an odd question. There is a very well established hierarchy in medicine. At the bottom of the totem pole lies the medical student. Above them comes the intern, then resident or a chief resident, and a the top is the attending physician. When a patient is to be admitted or worked up, it is always the medical student or intern to see them. Then, after working up the history and physical, they present to the resident. They may ask a few questions, add a few lab tests, and then when everything is in order, you make the page to the attending. At this point, you want all your ducks in a row if you will. Everything should be ready to present when the attending is called. This nurse wanted to bypass the whole system. Surely she was familiar with the hierarchy.

As it turns out, there was a head on collision involving two matatus, the main form of transportation for most Kenyans. Supposedly these are 14 passenger vans. Traditionally, matatus are blasting rap music, being driven by a teenager who is high on miraa (similar to amphetamine), and have names like Homeboyz, Blood Fist, and You Are Lonely When You Are Dead. I actually choose not to get in one matatu base on the name, "14 Black People." I didn't want to upset the balance. My personal record for most people in a "14 passenger" matatu, is 25 people. See below.


Back to the story, the traumas started rolling in, and you better believe that I gave her the name an the home phone number of the attending physician. (I still couldn't bring myself to call the attending, I made the nurse do it. I guess some things are just too ingrained by this point in my medical education.) I was pulled off Pediatrics call that night while we simultaneously ran three OR rooms throughout the night. At one point, my chief resident, Dr. A (see post on Perspective), asked me if I wanted to place the chest tube on our patient with a pneumothorax. Of course I did, so he briefly explained to me how to do this procedure I had only seen once and never actually preformed, while he went to the next OR to elevate a skull fracture. A crazy night, but finally the morning came and the traumas stopped pouring in.

I mentioned the high mortality rate here. I don't think I have been on a call yet where we didn't loose a patient. Last call was no exception. While admitting 11 kids from casualty, my resident grabbed me as she was running to the nursery. She was just paged, one of the quadruplets (the local tribe has a high number of multiple births) had a falling O2 saturation. This one survived the night. Two other kids in the nursery were not so fortunate that night.

Books about medical missionaries don't sell very well if the dwell on the bad outcomes, so I'll conclude with a few happy cases. I've been rounding in the Peds ward during the morning, then the nursery in the afternoon. The nursery is full of premature babies, many suffering from neonatal jaundice, sepsis, hypoxic ischemic encephalopathy, etc. After rounding there for the past 2 weeks, I was able to discharge 4 patients on Friday.

Picture of an incubator in the nursery.

Another of my Peds patients I admitted while on call was very sick. We were unsure of the diagnosis, and I was afraid the paralysis he was experiencing would soon compromise his breathing. After praying with his sobbing mother, I assured her I would do all I could. Unfortunally, we didn't have a spare ventilator to aid his breathing if he required it. Good news: this morning after church I stopped by to check in on him, and he was doing much better. I believe he has acute disseminated myeloencephalitis. I expect him to improve over the next few days with few if any neurologic deficits. Pictured below is me supporting him and his concerned brother beside us.

T.I.A.

Every once in a while I have those moments where a situation takes me by surprise and I realize, This Is Africa.

Here are a few.

Working in the Casualty (ER) writing a note and the power goes off. Black out. Fortunately there is a backup generator that kicks on within 12 seconds. The ICU is grateful for that, especially when they have patients on the ventilator.

Here's a picture of the hydro where we get our power.

I'm used to traveling in the third world. The overcrowded matatu, near misses while passing 3 cars going up hill around a turn, sharing a seat with chickens on the bus, holding a baby on my lap for 3 hours (not quite sure where the mother was) etc. However, I witnessed a new sight. The hatchback was about 10 people over its capacity (not a new sight) but what I didn't expect was to see the cow in the back seat.

No anesthetist in the OR for an hour while our patient is under general anesthesia...

Six people on a piki piki (motor bike)...

Treating a patient who was gored by a buffalo.

Doing a below knee amputation with this...

The Emergency Department is called "Casualty"

Working in Casualty and realizing there is no blood pressure cuff, or normal saline, or gloves, or suture, or monitor...

No soap on the second floor of the hospital.

Being laughed at every time I call a patient's name.

Camping at the top of a 7,000ft peak 60 miles south of the equator with 20 African children in 50 degree weather and one 10 year old boy named Petunia saying, "This country I come from is very cold."

Washing my hands in brown water coming from the faucet.

Cleaning surgical equipment that is generally thrown away in the US.

In the middle of a rectal exam when the power goes off. (No picture for this one)

And treating patients who otherwise would have no access to quality medical care. These T.I.A. moments make life here exciting and interesting.

Mourning and Contemplation

At times, it seems the hospital is bursting at the seems. It's not uncommon to have 2 patients to a bed. Occasionally I've seen people sleeping on the floor, but I'm pretty sure these were family members who didn't want to leave their loved one alone. Currently, there are a lot of visiting staff here. A radiologist, pediatric emergency physician, ENT head and neck surgeon, a maxillofacial surgeon, and a neurosurgeon. And it seems as if the whole country knows about it (people are lined up all day to get into clinic). In fact, the ENT doc has had cases scheduled for more than a year, cases he wasn't able to get to last year when he was here.

This is great for individuals getting procedures, however patients literally spend all day at the hospital. It's a full day event (and sometimes multiple days). My last patient of the day had taken public transit from hours away, and due to the long clinic wait, wasn't able to get the ultrasound she needed. Instead of going home, I think she is sleeping on a bench somewhere near the hospital. This was after we had to negotiate what tests to order. She couldn't afford a TSH level, a simple test we order in the US without even thinking about it. In fact, we order a TSH, T3, T4 and then maybe even a free T4 just to be sure.

I wonder what Americans would say if a simple clinic visit was an all day event? I guess this is why there is so much fuss over the health care reform bill. People are afraid of change, and for good reason. In Kenya however, you wait all day and then still have to pay for everything out of pocket.

I took call last night. The intern presented all his cases to me before calling the attending. I was able to teach him how to read a chest and abdominal XRay. A weird role reversal. Today I rounded in the morning, ran back and forth between clinic and the ED during the day, and finally scrubbed on the OR cases I had booked this evening.

Perhaps it's a good thing that doctors are so busy. You don't have time to think about what you just experienced. In clinic today, I told my first three patients they have terminal cancer, and there is nothing we can do. This was after my patient introduced me to his newlywed wife. He was 29. I looked another man in the face who just realized his mother was going to die of starvation in months due to her constricting esophageal cancer. I offered chaplain and hospice service, but he wanted more; he asked me to pray with him. Despite feeling that prayer was the only thing I could offer this man and his mother, I have to remind myself that prayer is a powerful thing.

A question I think many people ask themselves while working internationally is, "Am I really making a difference?" Is there any lasting impact, or would the hospital here continue to function without me? For me, this question isn't as relevant. Sure, I may make a small contribution here and there, but my role is fundamentally different than that of a long term physician. I'm a student, and while I'm here to serve, it is also a learning experience.

But, it's interesting to hear the other staff deal with grief. The death rate here is high. I'm sure there are many reasons: patients present very late in the progression of their disease, there is limited preventative medicine, resources aren't available, etc. After a while, it makes you start to wonder if you are making a difference. Here, I have seen many short and long term physicians mourn the loss of a patient. In a way, it is refreshing to see.

I guess if what they say about 7 positive comments being needed to make up for one negative comment is true, and can be applied to medicine, then I'm in need of some reflection.

1) I operated yesterday with a neurosurgeon on a 10 year old with an open skull fracture. He'll likely have epilepsy for life, but he wouldn't have survived without the operation.
2) I treated a Catholic nun with a GI bleed. Her admission hemoglobin was 5. (see picture below)

3) I admitted a child with a gastric outlet obstruction (according to Mom, he hadn't passed stool for 2 months) due to a duodenal stricture secondary to H. pylori. I didn't believe the mothers story until I saw how cachectic he looked.
4) I scrubbed on a case where we released a muscle contracture caused by a burn on a 3 year old girl. She will now have a lifetime of normal function of her arm, and not be a cripple.

5) I took the H&P of a child with likely Burkett's Lymphoma.

6) I helped wash out a septic wound, then a few days later assisted in the amputation of his leg. Without this operation, he would have died.


7) I'm helping CRUSH AIDS!


So, in the end, I think the answer to the question, "Am I making a difference?" is rather simple. It depends on your goals. Am I, or is anyone going to single-handedly save the world? No. Will I make a difference to an individual, where there would have potentially been no medical help? Yes.

Perspective

Today I completed one of my goals while in Kenya: I ran with a Kenyan! Actually, I ran with about 30. I got out of clinic a bit early today, and needed to go for a run. So, naturally, I ran to the highest point around. It was beautiful. After taking in the scenery, I started to run down. However, the path went by a primary school. Not being used to seeing a mzungu in shorts running by, they started shouting with excitement. The next thing I knew, I was running with 30 barefoot Kenyans running behind me. Despite not being able to speak the same language other than greetings, I started to yell with excitement. They would repeat me. Then I stuck out my arms, acted like an airplane. They repeated. We carried on like that for 3 miles. I'm sure they will be talking about the crazy mzungu for days.




Clinic, like always, was crazy today. You never know what is going to walk in. My first patient had a mandibular mass half the size of her head. (Never mind the skeleton in the background, I was examining this patient in a storage closet)






Next I saw a patient with elephantiasis. It was classic. She was a Massai woman, decked out in her classic African wardrobe. This is an infectious disease, where microscopic worms named, wuchereria bancrofti, (awesome name, right?) live in the lymphatic system. They are spread by mosquitos, which I recently learned are the most deadly animals in the world. Many diseases are spread by them.



Working in a foreign country can be frustrating for many reasons. The cultural differences in concepts of time, appropriate clothing, and food are a few. Usually I feel pretty comfortable traveling, and don't have any issues adapting. The issues above haven't been an issue. However, the language barrier is starting to get to me. After the time-consuming process of bugging a nurse to interpret for nearly every patient, and all the cultural misunderstandings of translated words, I was getting a little unnerved by the end of the day. So naturally, when a 23 y "confused" male walked in, I wasn't happy. He was talking nonsense, even before his words were translated. At first I thought it was a psych patient and my frustration with the situation increased. Then I looked at the vitals (yep, having to rely on them a lot when you can't communicate) and noticed his pulse rate was 40. (Cushing's reflex- a response to increased intracranial pressure) I started to take him more serious. It turns out, he had a history of head trauma three days ago, had projectile vomiting, but no focal neurological deficits. Of course in the US, you would get a head CT immediately and consult neurosurgery. Here you rely on the physical exam skills. Being unable to assess for papilledema, (I would have killed for a PanOptic) I had to assume there was increased intracranial pressure. I ordered a head xray. He had a compound depressed skull fracture. Whelp... teachable moment. Thanks God.


Perspective:

The past year or two, I have been almost bitter at times towards medicine. Why do physicians work so hard? Why am I expected to work 6 days a week, round on patients 7 days a week, have my call shifts be LIMITED to 30 hours in the hospital and an 80 hour work week is normal? It's especially hard when most of my college friends are working a 9-5, making money, and moving on with their lives. One of my med school friends surveyed our class with the following question, "Would you do medical school again?" The overwhelming majority said no. Not exactly the best attitude to have as residency draws ever nearer.

I feel the need to tell you about one of my surgery chief residents, Dr. A. While serving here, I have had the opportunity to work with incredible physicians and residents. They work as hard, or harder (no 80 hour limit here) than in the US. My senior resident Dr. A is from Ethiopia, and a PAACS (Pan-African Academy of Christian Surgeons) resident. He went to medical school and completed his internship in Ethiopia before the hospital was closed. He then spent two years in Cambodia training until that program ceased to exist. His last year was spent here, and with one year to go, he's looking forward to returning to Ethiopia. His future? To take over for the only surgeon at the hospital serving a catchment of 800,000 people. The current surgeon is leaving the day Dr. A gets there. He will be on call 24/7. No weekends, no vacations.

Speaking of vacations, I live for them. That's what allows me to work hard; knowing that I have something awesome to look forward to. Last year, this Dr. A got one month vacation from residency. He went home to Ethiopia to see his parents. Before he even arrived home, the only surgeon at the hospital near his parents house heard he was coming, left for the month. My resident spent 27 straight days and nights operating, rounding, and staffing the hospital by himself, until he had to return to Kenya. For him, residency is a vacation. Next year, he will be it. No backup. When he decides to sleep, or rather, nature forces him to sleep, people will die. The weight of responsibility that awaits him is unfathomable to me.

So, a little reality check, with my residency match rank list due in a month. Sure, I'm going to work hard. But suddenly, and perhaps just when I need it, God provides a bit of perspective.

Daktari?

In Kenya, I'm daktari. What have I done to deserve this title? Well, not much. I could be a white guy with a high school education, and when I walk through the halls of a hospital here, I would be referred to as daktari. I would feel a bit guilty about this, if I hadn't trained for the past 3 1/2 years. And the fact that anyone here who works in a hospital, whether Kenyan or western, is called daktari. Still, it doesn't feel quite right. Sort of like trying on a new shoe that's a little too big. I guess I better get used to it soon...

As this is my first post in over two years, let me make a disclaimer. You will find a stream of reflections on my experiences at a mission hospital in Kenya. I don't claim that my thoughts will make sense, or that I will even agree with them a day after posting it. Just a stream of jargon, with a story or two for entertainment.

I have now been here a week. I'm rotating on the surgery service; days
are usually from 5:30am until 6:30pm. I feel like I'm actually really
contributing to the care of the patients here. As opposed to the US where
medical students are pretty limited by what they can do, and the fact that there are a number of
residents and other students all fighting for the same procedures.
Here it is often just me caring for the patients. I have seen amazing
surgeries that I would have never got a chance to see in the US. And, I am
usually the First Assist on every surgery I scrub into, or they will
actually let me do the surgery and they will be my assistant, directing my
actions.

I'm not sure exactly how this happened, but I have taken over the
female surgical ward, which I round in every morning and evening. I'm
taking care of about 20 women with complicated wounds, pancreatic cancer,
bowel obstructions, trauma injuries from drunk husbands, etc. Most of them
are HIV positive, a real problem here. (And a little scary for me after I
splashed blood in my eye while suturing a massive head laceration of a
motorcycle accident victim) However, since former president Bush's PEPFAF
initiative, HIV has changed from a death sentence to a chronic illness that
people can live with for years. Before this program, no one here even
wanted to be tested because they didn't want to know they were going to
die. Now, people want to know their status and their first question is,
"Can I get the medicines?" Obviously, this has huge implications in
terms of public education and in spreading the disease. There is still a
large social stigma associated with the disease however.

One of the comforting things in the US is that now mater how sick a patient
is, I know that I'll always have back up. I can call my intern, resident,
senior or attending if I had to. Here, there is no back-up. I've had a few
experienced now where I was called into the "Casualty" (the equivalent of an
Emergency Department in the US) to encounter a patient who was comatose.
The casualty here is staffed by a nurse, who determines whether the patient
is sick or not. If not, they will be sent home. If they are sick, they
determine if it is a medical or surgical problem. Then the intern will be
paged.

Now, no mater what reputation interns have in the US, we have pretty
good training. Two years of clinical medicine may not be much before
becoming an MD, but it is far more experience than what a Kenyan intern
gets. With only one month of required clinical rotation left before I graduate
medical school, I have quite a bit more experience than the interns here. And, I'm gaining more experience all the time.

Last night I staffed casualty for several hours without much support. I had 4 trauma patients come at nearly the same time. They were bleeding profusely. One had been beaten with a metal pipe by her son. One man was in a land dispute with a Maasai warrior, narrowly dodged the arrows shot at him, only to have his ear and half of his face sliced off by a "panga" or machete. Another man was bitten and beaten by his neighbors who heard him drunk and hitting his wife. Good thing I have completed a few months of Emergency Medicine this year. The unfortunate part is, when I wanted to start the two large bore IV's and run fluids wide open, I had to start them myself. Then, when I ran out of fluids later that night, I realized I need to be a bit more judicious in medical resources. I also ran out of sutures, lidocaine, gauze, gloves...

Another story. I was called into casualty while on call. I encountered a 80
year old patient, unresponsive, laying in bed. One leg had been amputated, the
other clearly had necrotizing fasciitis (a very serious infection that
requires surgical cleaning). I had seen several septic patients in the past
few months while in the ICU. In my head I began to recall my training,
"Airway, Breathing, Circulation, IV, O2, Monitor..." The only problem was,
in the casualty area, there are no blood pressure cuffs, no monitors, etc.
Vitals are NOT nicely displayed and recorded every few minutes on an electronic medical record that can be dropped into your pre-formed templated note. I had to
run to the ICU to find a Oxygen saturation monitor. Turns out it was 65%.
Not really compatible with life for very long... Anyway, the guy needed
immediate surgical intervention after being stabilized. He was sent home to
die, being unlikely to survive even the anesthesia required for the
surgery. People here don't come to the hospital until they are on deaths
doorstep. Whether it is because they are stoic and the people in general
don't show much pain, or they don't want to have to pay for the care, they
often present in very late stages of their disease.

No matter what you think about health care in the US, I'm coming to
realize it is very good. You can argue whether health care in the US
is a privilege or a right. In Kenya, it is defiantly a privilege. I
saw a 3 month old in clinic this week with a meningocele
(a protrusion of part of the spinal cord through the spine). Essentially,
this baby had a 30 cm mass protruding from her lumbar spine. This was the
first time she had seen a doctor, as the mother had given birth at
home, and much to her surprise, the mass did not go away. Unfortunately, she did not
have the money to pay for the surgery.

Despite working at a missionary hospital, the patients still have to pay. What they pay
covers only their operating cost. The missionaries salaries,
all building projects, and many of the medicines are provided by
outside resources. However, by making the patients pay, even just to
cover costs, the hospital can keep running, and the Kenyans aren't
becoming dependent on handouts. Instead, they are owning their health
care and perhaps are more appreciative. The hospital is actually
staffed almost entirely by Kenyans. The majority of the economy in
the surrounding area is fueled by the hospital.

The drawback? People like this 3 month old girl bear the burden. I'm
not sure how much longer she will survive without the surgery. The
skin separating her spinal cord from the bacteria that could end her
life is paper thin. So, we sent her away to find the money. Many
times the village will try to pool their money, sell a cow
(literally), and take care of their own. I scheduled her to return to
clinic on Tuesday. Hopefully she will come.

I don't know if there is a "best" way to do health care, but what we
have in the US is pretty good. One of the nice things about going
into Emergency Medicine is EMTALA. While working in the US, I will
never have to worry about a patient being able to afford treatment.
If they step into the ED, I'll treat them. Wealthy CEO, illegal immigrant, drunk homeless person, it doesn't matter. Figure out payment later. You could argue that this might bankrupt US health care, but selfishly, it's nice to not have to worry about that.

The mission hospital's policy is that you don't leave the hospital
until the bill is paid. They have gates around the hospital, less for
our protection, but more to keep the patients in until they pay. I'm
not sure how well this would go over at home. Incarcerating patients
who can't pay hospital bills might go straight to the Supreme Court.
I had one of my female burn patients ask me to take her off the high
protein diet (of 1 egg with every meal) because she was afraid she
couldn't afford the bill. I guess she doesn't want to be locked in.

I have a million more stories and thoughts, but this is enough for now. Tomorrow begins another week. "Daktari" is expected to round early.