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.