It’s been awhile since my last writing and it will probably be awhile more before I’m in that thinking frame of mind again. But there have been so many poignant moments so far in residency that each one deserves its time to be savored. It is for me as true as ever that medicine is a labor of love for the beautiful rawness of humanity.
As the intern, lowest of the low and even more so because it’s surgery residency, for me to be in the operating room is no small feat. Even if all I’m doing is removing a catheter (the procedure takes five minutes tops), I’ll take it. The other day, we had three such cases scheduled. Having become nonchalant about these “surgeries”, I was somewhat annoyed—after you yank the catheter out, you have to hold tight pressure at the neck so the punctured vessel can clot off. For fifteen minutes. In fifteen minutes, I could complete 5 other necessary tasks! Instead, I’d be pressing on a neck in a sterile field for a total of 45 minutes. What a waste of time.
The first case was an elderly African American lady wearing a grey sweatsuit and shiny crocodile shoes. After completing all the preoperative paperwork, I positioned, cleaned and draped her neck to make sure the field was sterile, and called my attending before injecting the lidocaine and starting the dissection. The catheter came out easily. The attending left swiftly, and I was left sweating in my mask under the bright lights, holding pressure. Five minutes went by in silence. The OR nurse, Jean, asked me what dressings I wanted. They were retrieved. The patient lay quietly, patiently awaiting her reprieve. The fifteen minutes finally ended and I checked for hemostasis, placing a neat pressure dressing on her wrinkly neck. Jean and I transferred her from the table to a wheelchair while she muttered about wanting tea and pancakes. Then I ran off to complete other tasks before the next case.
The next patient was another elderly man with a heavy Caribbean accent. He was with his wife, who was sleeping next to him in the holding room. He had a good-natured disposition and a long grey beard that ended in a sharp point. I did his paperwork and interrogated him at rapid pace to make sure his blood pressure was controlled (it wasn’t), that he was not on a blood thinner (he was), and that if he was on a blood thinner that he knew why (he didn’t) and his most recent INR (ditto). I wanted to get this done as soon as possible. The attending didn’t answer my phone so I called another attending on service, who agreed to supervise. We waited ten minutes. The attending finally showed up. The case went the same, with the exception of the patient needing extra lidocaine for the pain.
When the catheter came out, I braced myself for another fifteen minutes of emptiness. I wanted to take my mask and sterile gloves off and pull my phone out for entertainment, but that would violate our sterile field. To my surprise, the patient broke the silence. “Ah, what I wouldn’t give for some fish and grits right now,” he said. My eyes, previously glued to the clock, turned to the wispy tufts of hair on his chin. I didn’t like grits at all. The OR tech laughed and chimed in, “It’s always a good time for fish and grits!” They shared a slow and hearty chuckle. “Ya, it is,” my patient said. “I got a granddaughter who live across the street. I make her fish and grits every day and she call me Papi and don’t let no one else call me that.” I asked him how he makes fish. “Well, I had one of the dialysis nurses at me house the other day. She said she never had such good fish. You got to steam it in lemon juice with some dry onion and cumin and butter. If you do it right, ain’t nothing better.” We all shook our heads, imagining a perfectly steamed fish. Our time was up and I put the dressing on. We helped Papi up from the table. “I want a hot coppa tea,” he sighed.
I signed his paperwork and walked back to the floors, back to checking boxes off my to-do list. It was a slower walk and I felt more human. I had been transported into my patient’s world for a few moments, a world that was abstract and foreign to me, but real and wonderful to him. Holding pressure was the perfect time to step into his life outside his disease, with no responsibilities other than mechanically achieving hemostasis. Hard to remember in a field where you are always under pressure, but so worth remembering.
My dad always taught me that there are many ways of seeing the same thing, and it’s up to each person to see what’s in front of them in the correct way—the correct way being the way that is most beneficial to you and everyone around you. Residency is tough: there are rude people, unfair hierarchies, rough hours and inequalities. But medicine is a privilege: we are privy to everything in a person’s life for a critical slice of time. To isolate the body and ignore the human in front of us would not only do a disservice to the patient, but cheat us of the best part of this profession: its humanity.
Thursday, December 1, 2011
Sunday, October 16, 2011
Truth Unfolding
When I was a medical student, I loved surgery because it stood for truth in my mind. There was no lying or covering up or giving 50% or even what you thought was 100%. Whatever you did had to be exactly precisely accurately 110% correct.
Now I am realizing that demand on a whole new and sometimes frustrating level. As a resident, I am not just pretending to care about patients while I try to pass exams. I am actually responsible for their care. There are times when I'm the only surgeon scrubbed on a case (simple ones, of course) or the only one writing and reviewing admission orders on a patient, or seeing them on discharge when they leave the hospital. Am I giving 110%?
Surgery is truth. You can't cover up a bleeder--you have to fix it right then and there before you move on to any other step of the operation. Your sutures have to be exact--if they aren't, the fascia will dehisce and the patient will wind up at your door with a complication. Or if your skin sutures aren't good, the skin will bunch up and heal with an ugly scar--your fault. There's no hiding, there's no room for error, your mistakes are like a mirror staring back at you.
So how does one go about being perfect if there's no room for error? No one is perfect but God. I have been frustrated with this thought recently, wanting to do the very most excellent best for my patients in the OR and on the floor, but my ignorance and lack of experience make that feel nearly impossible. I haven't seen or done or practiced or been taught enough. I am reading with a renewed vigor; for the first time I truly believe that my studying pancreatic cancer will make a real difference in someone's life. I never felt that way as a student--it was much more nebulous.
The answer is always the same of course, it's just my mind that runs in circles back to the same conclusion after running the mill of my silly human emotions. The only thing to do is work as hard as I possibly can to learn whatever I can, squashing ego and laziness.
The beauty of this formula is that it's good for my soul as well as my profession.
Now I am realizing that demand on a whole new and sometimes frustrating level. As a resident, I am not just pretending to care about patients while I try to pass exams. I am actually responsible for their care. There are times when I'm the only surgeon scrubbed on a case (simple ones, of course) or the only one writing and reviewing admission orders on a patient, or seeing them on discharge when they leave the hospital. Am I giving 110%?
Surgery is truth. You can't cover up a bleeder--you have to fix it right then and there before you move on to any other step of the operation. Your sutures have to be exact--if they aren't, the fascia will dehisce and the patient will wind up at your door with a complication. Or if your skin sutures aren't good, the skin will bunch up and heal with an ugly scar--your fault. There's no hiding, there's no room for error, your mistakes are like a mirror staring back at you.
So how does one go about being perfect if there's no room for error? No one is perfect but God. I have been frustrated with this thought recently, wanting to do the very most excellent best for my patients in the OR and on the floor, but my ignorance and lack of experience make that feel nearly impossible. I haven't seen or done or practiced or been taught enough. I am reading with a renewed vigor; for the first time I truly believe that my studying pancreatic cancer will make a real difference in someone's life. I never felt that way as a student--it was much more nebulous.
The answer is always the same of course, it's just my mind that runs in circles back to the same conclusion after running the mill of my silly human emotions. The only thing to do is work as hard as I possibly can to learn whatever I can, squashing ego and laziness.
The beauty of this formula is that it's good for my soul as well as my profession.
Thursday, August 18, 2011
New Moves
Five months ago I was sitting on a couch in the dean’s office of my medical school in Irvine, California, five miles away from my favorite beach. It feels like a couple weeks ago. It was about an hour after every fourth year medical student received an email from the central body that matches students to residency positions. That Monday match email is succinct: either “congratulations. You matched.” Or “you did not match”. I received the first, my husband the latter. Hence the couch.
“Well, you matched in Philadelphia,” my dean said, looking straight at me. He probably knew it would blow me away. Worse things have happened. To me, even. Much worse. But somehow this felt really big. In that moment, I saw my gracious dad lose a few pounds of muscle, a few hairs, and another couple of inches. I saw my beautiful mother gain a few curves, muscle aches, and fine lines. I saw my sister struggle with her post-stroke husband without my help. I saw her two beautiful little boys growing up without Farah Aunty there to do the airplane and a million other little things they’ll probably never remember but mean the world to me. My world would go on without me.
Two months into residency in Philadephia, that will all probably come true. All of it except the part about my world going on without me. Initially, I focused too much on what I was leaving behind, and not enough on what I was going to. I have a wonderful marriage I’m only beginning to discover, new friends and old ones to connect with and keep in touch with, and the job of my dreams to pursue. There’s a whole new city to explore, a whole new body of homeless people to serve, so many new opportunities to be at peace with God.
More senior residents at my hospital and others are weathered and weary. I don’t know what it feels like to be a resident for several years (or even several months!) but I pray that I wake up every day feeling like I’m living the dream. I hope I always think drawing an arterial blood gas is a cool procedure, and prepare for it with similar attention (but not trepidation!) years into my career, carefully positioning the patient and examining the operative site. I hope I am soft around the edges, turn around to make sure I didn’t miss something someone said, and remember to smile. It took a long time to come to where I am, a lot of blessings strung in a long row. Philadelphia might have been a blow, initially, but in the end, I can’t help but feel that much more motivated to be the best person and surgeon I can be here—it is literally the singular reason I find myself on this side of the country. Naïve and idealistic? Sure, let that be me.
I’m on my way back home to California just 6 weeks into residency; my assigned two-week vacation happened to fall in August. My nephews will no doubt have learned all kinds of new things and I can’t wait to see them and all my family and friends. But I’m also at peace with life in Philadelphia. The geography is ancillary; the real work of life is simply to constantly seek out ways to be better. And there are many.
“Well, you matched in Philadelphia,” my dean said, looking straight at me. He probably knew it would blow me away. Worse things have happened. To me, even. Much worse. But somehow this felt really big. In that moment, I saw my gracious dad lose a few pounds of muscle, a few hairs, and another couple of inches. I saw my beautiful mother gain a few curves, muscle aches, and fine lines. I saw my sister struggle with her post-stroke husband without my help. I saw her two beautiful little boys growing up without Farah Aunty there to do the airplane and a million other little things they’ll probably never remember but mean the world to me. My world would go on without me.
Two months into residency in Philadephia, that will all probably come true. All of it except the part about my world going on without me. Initially, I focused too much on what I was leaving behind, and not enough on what I was going to. I have a wonderful marriage I’m only beginning to discover, new friends and old ones to connect with and keep in touch with, and the job of my dreams to pursue. There’s a whole new city to explore, a whole new body of homeless people to serve, so many new opportunities to be at peace with God.
More senior residents at my hospital and others are weathered and weary. I don’t know what it feels like to be a resident for several years (or even several months!) but I pray that I wake up every day feeling like I’m living the dream. I hope I always think drawing an arterial blood gas is a cool procedure, and prepare for it with similar attention (but not trepidation!) years into my career, carefully positioning the patient and examining the operative site. I hope I am soft around the edges, turn around to make sure I didn’t miss something someone said, and remember to smile. It took a long time to come to where I am, a lot of blessings strung in a long row. Philadelphia might have been a blow, initially, but in the end, I can’t help but feel that much more motivated to be the best person and surgeon I can be here—it is literally the singular reason I find myself on this side of the country. Naïve and idealistic? Sure, let that be me.
I’m on my way back home to California just 6 weeks into residency; my assigned two-week vacation happened to fall in August. My nephews will no doubt have learned all kinds of new things and I can’t wait to see them and all my family and friends. But I’m also at peace with life in Philadelphia. The geography is ancillary; the real work of life is simply to constantly seek out ways to be better. And there are many.
Tuesday, May 17, 2011
The Malek Diaries - 5/17/2011
California. :)
We're back in California, recovering from jet lag and finishing up some very important conversations with contacts in Juba. The trip was a very fulfilling experience despite the myriad challenges we faced and the many issues that are still unresolved with the clinic. To provide a service like medical care in such a needy community as Malek in a country so overrun by NGO's and international bodies is really tough. South Sudan has been in civil war for so much of the past 60 years, and has depended so heavily on outside aid for sustenance and decision-making, that the government itself is incapable of providing any essential services for its own people. To fit into a model like that is a challenge for any NGO, and even more so for a small, family-operated one like us.
Having said that, some real progress has been made. The building will God willing be complete in 30-45 days, and we have solid staff onsite to supervise and take ownership from the very beginning. The people of Malek and surrounding bomas (aka village areas) are on board. We have blessings from the county and state officials, and are in the process of partnering with the national government and other agencies that work with NGO's to ensure sustainability over time.
One of the most important things I learned in this process was how essential an exit strategy is to a project proposal. Our proposal was 15-20 pages long, depending on the version, and had many details in it. It did not, however, have an exit strategy, as Dr. Baba requested from us in his Juba office two days ago. He explained very patiently that many NGO's, including those working in Jonglei State building clinics, have failed because they want to be completely private, and run out of funding after awhile, or contact the government when they are running out of funding, by which time it is too late for the government to sustain the clinic because they have not provided for it in their budget. By this time, the community has become accustomed to receiving care, and is left with nothing. We have heard this story too many times. According to Dr. Baba, the best way to avoid this is to involve the government early on, which we are in the process of figuring out how to do. We all have one goal: to provide sustainable, high quality, affordable health care services to the people of Malek and surrounding villages.
We are nowhere near the end of this project, a fact that is intimidating but exciting. Even with government participation and ownership, our close involvement, especially in the first year of operation, will be crucial. We have many ideas, including setting up a rotation at the clinic for health care workers from home, expanding the clinic to include more services such as a maternity ward, an operating theater and more beds, and endless other possibilities. It is easy to build a building. It's keeping it going in a sustainable, functional way that's hard. God willing, we will keep learning along the way.
Thanks for reading, and thanks to my amazing mom for being the best part of the trip!
We're back in California, recovering from jet lag and finishing up some very important conversations with contacts in Juba. The trip was a very fulfilling experience despite the myriad challenges we faced and the many issues that are still unresolved with the clinic. To provide a service like medical care in such a needy community as Malek in a country so overrun by NGO's and international bodies is really tough. South Sudan has been in civil war for so much of the past 60 years, and has depended so heavily on outside aid for sustenance and decision-making, that the government itself is incapable of providing any essential services for its own people. To fit into a model like that is a challenge for any NGO, and even more so for a small, family-operated one like us.
Having said that, some real progress has been made. The building will God willing be complete in 30-45 days, and we have solid staff onsite to supervise and take ownership from the very beginning. The people of Malek and surrounding bomas (aka village areas) are on board. We have blessings from the county and state officials, and are in the process of partnering with the national government and other agencies that work with NGO's to ensure sustainability over time.
One of the most important things I learned in this process was how essential an exit strategy is to a project proposal. Our proposal was 15-20 pages long, depending on the version, and had many details in it. It did not, however, have an exit strategy, as Dr. Baba requested from us in his Juba office two days ago. He explained very patiently that many NGO's, including those working in Jonglei State building clinics, have failed because they want to be completely private, and run out of funding after awhile, or contact the government when they are running out of funding, by which time it is too late for the government to sustain the clinic because they have not provided for it in their budget. By this time, the community has become accustomed to receiving care, and is left with nothing. We have heard this story too many times. According to Dr. Baba, the best way to avoid this is to involve the government early on, which we are in the process of figuring out how to do. We all have one goal: to provide sustainable, high quality, affordable health care services to the people of Malek and surrounding villages.
We are nowhere near the end of this project, a fact that is intimidating but exciting. Even with government participation and ownership, our close involvement, especially in the first year of operation, will be crucial. We have many ideas, including setting up a rotation at the clinic for health care workers from home, expanding the clinic to include more services such as a maternity ward, an operating theater and more beds, and endless other possibilities. It is easy to build a building. It's keeping it going in a sustainable, functional way that's hard. God willing, we will keep learning along the way.
Thanks for reading, and thanks to my amazing mom for being the best part of the trip!
The Malek Diaries - 5/11/2011
Malek.
On Monday, we went to SCOM to buy the rest of the block for the dividing walls. SCOM's office is very near Malek; the company is using land formerly owned by an oil company that moved out when war broke out in 2008. SCOM is run by a group of unfriendly Maldovians producing block at $2 each and making a hefty profit.
After we got our block loaded onto a hired truck, we transported it to the clinic site and unloaded it as a community. This week, Anyuen and Alier will move to the clinic site as their living quarters are also in the process of being built.
Later in the day, Deng told us that the women in the community had some concerns they wanted to share with us. We had specifically wanted to meet with them, too, so we were excited about the opportunity. It has been difficult to meet with the community as a whole because they are at work planting maize and sorghum in preparation the rainy season. They were concerned about not having a woman employee at the clinic to confide in. There was also a traditional birth attendant at the meeting who was eager to learn more skills as she has no formal training. Their worries were real and helped us understand their needs. We are working on addressing them through a community elected female liaison and considering formal midwife training through a nurse contact we met in Bor. We assured them that primary health care can only be achieved with healthy women and children, so their active participation is crucial.
Talking about health opened other doors. One elder woman told us they are powerless in their culture--they have no say in important decisions and are beaten if they disobey the men in their families. Girls are married early in life because their marriage brings their family a dowry of 100 or so cows. Their fathers are eager to trade them for the cattle, attempting to regain what they lost in marriage (their family had to pay cows to marry the women who became their wives). If the women refuse, they can be killed by their own brother, father or uncle. A 17 year old girl was beaten to death by her father last month for deciding to marry a man with no cows. A similar story was later relayed.
The women said they confided in us because we came as two women with so much independence. It gave them hope. I asked them if they thought educating their daughters was important. They all agreed, but said school is too expensive and fathers want their daughters to marry as early as possible--after primary school if there's a suitor!
The burden of these cultural barriers is catastrophic. The only thing I can think of to lift these women up is an education for their girls. They agree. The majority of their daughters will not go to high school. They will be married/traded for cows,have a baby every year, and raise poor children who are also uneducated.
It also occurred to me that microfinance might empower the women of Malek. I asked them if any of them make anything to sell. Only one of them answered yes. But the market is so far away, several hours by foot. They have nothing to sell and no one to sell it to. I learned about microfinance in my MPH training but the sense of powerlessness of these Sudanese women made me understand their desperate need for financial independence in a much more immediate way. Microlending won't solve all the problems these women face, but maybe it will empower them, and cultural changes take time.
Today, we met with another physician at Bor Hospital, Dr Samuel, who answered a lot of our questions regarding some of the challenges of working in South Sudan and particularly in a rural area. It felt strange asking him questions like "what do you do for diarrhea?" and "what prenatal/perinatal care can be offered in a rural health care setting?" but the practice of medicine is so different here.
Next, we held a clinic for the community. It was clear that many problems were related to basic hygiene. The most heartbreaking cases were the babies with diarrhea. We did some counseling on basic hygiene, but the lack of sewage and running water make it so tough. We saw another patient with complications resulting from a combination of poor dental hygiene and dehydration (ill spare you the details). Public health interventions are definitely going to be crucial to the clinic's success.
On the way home, we shared a matatu with one of Deng's cousins Aton who works with a microfinance company in Bor. It turns out they are already lending to groups of women in Malek. Surprisingly, the default rate is high, and when the clients don't pay, the company may take the money from Aton's salary. Then she is left to fight for her money with the women.
Today was our last day as a team in Malek. It was far too short and I can't wait to be back again, God willing. Tomorrow Mom, Mayen and I will go back to Juba and meet with the Ministry of Health for registration and licensing of the clinic under our nonprofit. Then it's back to Nairobi for me and Mom, and back to Bor for Mayen.
On Monday, we went to SCOM to buy the rest of the block for the dividing walls. SCOM's office is very near Malek; the company is using land formerly owned by an oil company that moved out when war broke out in 2008. SCOM is run by a group of unfriendly Maldovians producing block at $2 each and making a hefty profit.
After we got our block loaded onto a hired truck, we transported it to the clinic site and unloaded it as a community. This week, Anyuen and Alier will move to the clinic site as their living quarters are also in the process of being built.
Later in the day, Deng told us that the women in the community had some concerns they wanted to share with us. We had specifically wanted to meet with them, too, so we were excited about the opportunity. It has been difficult to meet with the community as a whole because they are at work planting maize and sorghum in preparation the rainy season. They were concerned about not having a woman employee at the clinic to confide in. There was also a traditional birth attendant at the meeting who was eager to learn more skills as she has no formal training. Their worries were real and helped us understand their needs. We are working on addressing them through a community elected female liaison and considering formal midwife training through a nurse contact we met in Bor. We assured them that primary health care can only be achieved with healthy women and children, so their active participation is crucial.
Talking about health opened other doors. One elder woman told us they are powerless in their culture--they have no say in important decisions and are beaten if they disobey the men in their families. Girls are married early in life because their marriage brings their family a dowry of 100 or so cows. Their fathers are eager to trade them for the cattle, attempting to regain what they lost in marriage (their family had to pay cows to marry the women who became their wives). If the women refuse, they can be killed by their own brother, father or uncle. A 17 year old girl was beaten to death by her father last month for deciding to marry a man with no cows. A similar story was later relayed.
The women said they confided in us because we came as two women with so much independence. It gave them hope. I asked them if they thought educating their daughters was important. They all agreed, but said school is too expensive and fathers want their daughters to marry as early as possible--after primary school if there's a suitor!
The burden of these cultural barriers is catastrophic. The only thing I can think of to lift these women up is an education for their girls. They agree. The majority of their daughters will not go to high school. They will be married/traded for cows,have a baby every year, and raise poor children who are also uneducated.
It also occurred to me that microfinance might empower the women of Malek. I asked them if any of them make anything to sell. Only one of them answered yes. But the market is so far away, several hours by foot. They have nothing to sell and no one to sell it to. I learned about microfinance in my MPH training but the sense of powerlessness of these Sudanese women made me understand their desperate need for financial independence in a much more immediate way. Microlending won't solve all the problems these women face, but maybe it will empower them, and cultural changes take time.
Today, we met with another physician at Bor Hospital, Dr Samuel, who answered a lot of our questions regarding some of the challenges of working in South Sudan and particularly in a rural area. It felt strange asking him questions like "what do you do for diarrhea?" and "what prenatal/perinatal care can be offered in a rural health care setting?" but the practice of medicine is so different here.
Next, we held a clinic for the community. It was clear that many problems were related to basic hygiene. The most heartbreaking cases were the babies with diarrhea. We did some counseling on basic hygiene, but the lack of sewage and running water make it so tough. We saw another patient with complications resulting from a combination of poor dental hygiene and dehydration (ill spare you the details). Public health interventions are definitely going to be crucial to the clinic's success.
On the way home, we shared a matatu with one of Deng's cousins Aton who works with a microfinance company in Bor. It turns out they are already lending to groups of women in Malek. Surprisingly, the default rate is high, and when the clients don't pay, the company may take the money from Aton's salary. Then she is left to fight for her money with the women.
Today was our last day as a team in Malek. It was far too short and I can't wait to be back again, God willing. Tomorrow Mom, Mayen and I will go back to Juba and meet with the Ministry of Health for registration and licensing of the clinic under our nonprofit. Then it's back to Nairobi for me and Mom, and back to Bor for Mayen.
The Malek Diaries - 5/7/2011
Malek.
We are very excited to finally be in Malek. The Juba Bor highway is much improved, and the journey was beautiful, full of plants and animals. The acacia trees and neem trees are amazing, and the Nile is awesome. I have to admit though: Sudan is incredibly hot!
The first thing we did after our sweaty four hour trip was to stop at the clinic, where community members were unloading the truck full of building materials, including 215 bags of cement! When everything was unloaded, it was time for a soda break. Deng, Mayen, Mom and I headed back in the Land Cruiser to securely store all the meds and supplies near the primary school. Then we went to Bor, the nearby town and capital of Jonglei State. While walking, we ran into Garang, another Californian Lost Boy setting up a small business in Bor. It was good to see him in Sudan, carrying a paintbrush on his way to oversee workers at his shop site. Bor really needs more independently owned businesses.
Next, we met with Mayen's cousin Dr. Mabior, a doctor at Bor Town Hospital. Dr. Mabior trained in Cuba as part of a group of students who went there for medical training. I got the second biggest shock of the day when he greeted me in Spanish and proceeded to speak it fluently! (The first biggest shock of the day was finding gyros in Juba at Konya Konya market.) He arranged for us to meet with a contact who can give us some insight on how private clinics in the area are run, and specifically how services and treatments are priced. We want our clinic to be accessible and affordable, as well as financially sustainable, God willing.
The next day was a very important day, as we planned to meet with the community to formally discuss the clinic, introduce John Alier (pharmacist) and Gai Anyuen (nurse), and manage expectations. The meeting was held in the open air in a large circle, and community members came to the center to speak. Jacob Malual (UU alum helping with the clinic since 2010) translated. Women attended and spoke as well, some of them simultaneously shelling peanuts. Children played with cow dung figurines nearby. It was a community affair.
The meeting went very well, despite my apprehensions. We came to an understanding that the clinic will not be free, but will be affordable. The emphasis was on sharing responsibilities and ensuring quality and sustainability. We also made an agreement that the clinic will be named Universal Unity Health Clinic, not to reflect our organization but to acknowledge that health is a universal need that unites us. Tribal warfare is a big problem in South Sudan. We envision the clinic treating "the Dinka, Murlee, Nuer, Mundari, black, white and purple all the same." The community responded in agreement, saying they welcomed all except those who wished the clinic harm. It felt like a true meeting of the minds, and the feedback I received from attendees was thankfully very positive. Phew!
At the end of another long day, we met with our Kenyan engineer, Daniel. We negotiated with him to reduce his charges and finish the building in 30 days, God willing. Now that we have brought all the materials, work will start immediately. The rainy season is coming, so time is precious.
Today, we are going to get more blocks to finish the inner dividing walls of the clinic. We are also planning some health education sessions for the community that should be a lot of fun, including eliminating standing water, disposal of nonbiodegradable trash, child nutrition, and methods of birth control.
My dad always said that communication is one of the most challenging things in life and he was definitely right. It has been an extreme challenge on this trip, even within our own UU team. But when people come together and share ideas, something amazing happens. Our minds open up to endless possibilities and we learn some fundamental truths about life.
We are very excited to finally be in Malek. The Juba Bor highway is much improved, and the journey was beautiful, full of plants and animals. The acacia trees and neem trees are amazing, and the Nile is awesome. I have to admit though: Sudan is incredibly hot!
The first thing we did after our sweaty four hour trip was to stop at the clinic, where community members were unloading the truck full of building materials, including 215 bags of cement! When everything was unloaded, it was time for a soda break. Deng, Mayen, Mom and I headed back in the Land Cruiser to securely store all the meds and supplies near the primary school. Then we went to Bor, the nearby town and capital of Jonglei State. While walking, we ran into Garang, another Californian Lost Boy setting up a small business in Bor. It was good to see him in Sudan, carrying a paintbrush on his way to oversee workers at his shop site. Bor really needs more independently owned businesses.
Next, we met with Mayen's cousin Dr. Mabior, a doctor at Bor Town Hospital. Dr. Mabior trained in Cuba as part of a group of students who went there for medical training. I got the second biggest shock of the day when he greeted me in Spanish and proceeded to speak it fluently! (The first biggest shock of the day was finding gyros in Juba at Konya Konya market.) He arranged for us to meet with a contact who can give us some insight on how private clinics in the area are run, and specifically how services and treatments are priced. We want our clinic to be accessible and affordable, as well as financially sustainable, God willing.
The next day was a very important day, as we planned to meet with the community to formally discuss the clinic, introduce John Alier (pharmacist) and Gai Anyuen (nurse), and manage expectations. The meeting was held in the open air in a large circle, and community members came to the center to speak. Jacob Malual (UU alum helping with the clinic since 2010) translated. Women attended and spoke as well, some of them simultaneously shelling peanuts. Children played with cow dung figurines nearby. It was a community affair.
The meeting went very well, despite my apprehensions. We came to an understanding that the clinic will not be free, but will be affordable. The emphasis was on sharing responsibilities and ensuring quality and sustainability. We also made an agreement that the clinic will be named Universal Unity Health Clinic, not to reflect our organization but to acknowledge that health is a universal need that unites us. Tribal warfare is a big problem in South Sudan. We envision the clinic treating "the Dinka, Murlee, Nuer, Mundari, black, white and purple all the same." The community responded in agreement, saying they welcomed all except those who wished the clinic harm. It felt like a true meeting of the minds, and the feedback I received from attendees was thankfully very positive. Phew!
At the end of another long day, we met with our Kenyan engineer, Daniel. We negotiated with him to reduce his charges and finish the building in 30 days, God willing. Now that we have brought all the materials, work will start immediately. The rainy season is coming, so time is precious.
Today, we are going to get more blocks to finish the inner dividing walls of the clinic. We are also planning some health education sessions for the community that should be a lot of fun, including eliminating standing water, disposal of nonbiodegradable trash, child nutrition, and methods of birth control.
My dad always said that communication is one of the most challenging things in life and he was definitely right. It has been an extreme challenge on this trip, even within our own UU team. But when people come together and share ideas, something amazing happens. Our minds open up to endless possibilities and we learn some fundamental truths about life.
The Malek Diaries - 5/3/2011
Juba.
After many unforeseen challenges and small but precious victories, we finally got everything loaded on the 20 ton truck. Thankfully, we found almost everything we needed in Kampala for the clinic. What we were not able to get (32 Y8 bars!) we will find here in Sudan. After the past five days, I know more about barbed wire, carpentry, and how to tell if you're getting a good product or being taken for a ride than I ever imagined would be necessary!
Gai left last night to accompany the truck to Sudan. There are two border checkpoints to cross, and we are praying for their safe journey.
As far as the rest of the team, Mom and I just arrived in Juba, the capital of South Sudan, this afternoon. We met up with Mayen, who brought all the medications a few days ago. Deng and Mario will arrive in Juba tomorrow and we will all set out to Malek together on Thursday, God willing. Kuai, who has been instrumental in our UU scholarship program, will meet us in Malek. We are very eager to get on the ground and start the work of finishing up the construction, setting up the clinic, and meeting with the community to discuss their concerns and priorities as we move forward!
We could not be more thankful for your support. We are also humbled by the kindness and humility of the Ugandan people (with the exception of exactly one vendor). We pray for Gai's safety on the road with the truck, as well as for Deng and Mario en route to Juba.
After many unforeseen challenges and small but precious victories, we finally got everything loaded on the 20 ton truck. Thankfully, we found almost everything we needed in Kampala for the clinic. What we were not able to get (32 Y8 bars!) we will find here in Sudan. After the past five days, I know more about barbed wire, carpentry, and how to tell if you're getting a good product or being taken for a ride than I ever imagined would be necessary!
Gai left last night to accompany the truck to Sudan. There are two border checkpoints to cross, and we are praying for their safe journey.
As far as the rest of the team, Mom and I just arrived in Juba, the capital of South Sudan, this afternoon. We met up with Mayen, who brought all the medications a few days ago. Deng and Mario will arrive in Juba tomorrow and we will all set out to Malek together on Thursday, God willing. Kuai, who has been instrumental in our UU scholarship program, will meet us in Malek. We are very eager to get on the ground and start the work of finishing up the construction, setting up the clinic, and meeting with the community to discuss their concerns and priorities as we move forward!
We could not be more thankful for your support. We are also humbled by the kindness and humility of the Ugandan people (with the exception of exactly one vendor). We pray for Gai's safety on the road with the truck, as well as for Deng and Mario en route to Juba.
The Malek Diaries - 4/30/2011
Kampala.
The past couple of days have been action packed, thankfully with lots of headway being made here in Uganda. As some of you may know, Kampala has recently experienced a slew of riots due to an unbearable rise on taxes on gasoline. The Walk to Work campaign, championed by political figure Bisgeye, has incited a lot of disruptive fighting on the streets. Friday was particularly bad, as Bisgeye was violently attacked by police chiefs on Thursday.
As far as our work was concerned, after Friday's excitement, things cooled down quickly. By Friday evening some shops had opened again and we even set out looking for our generator. Today (Saturday) was an extremely productive, long, sweaty day, full of bargaining, starting at 7am and ending 15 hours later discussing prices in the dark! The good news: we got almost everything (and everything major) on our list. Incredibly good news!
Tomorrow, we'll visit all our vendors, pay for our wares, and make some last price comparisons. We hope to be en route to Juba in our 20 ton truck by Monday, God willing. Riots are expected to pick up again then, making it impossible to do anything. We are grateful to be safe and sound and on schedule. We are also very grateful for the help of Mayen, a UU alum who just arrived in Juba with the medications we purchased in Nairobi.
The past couple of days have been action packed, thankfully with lots of headway being made here in Uganda. As some of you may know, Kampala has recently experienced a slew of riots due to an unbearable rise on taxes on gasoline. The Walk to Work campaign, championed by political figure Bisgeye, has incited a lot of disruptive fighting on the streets. Friday was particularly bad, as Bisgeye was violently attacked by police chiefs on Thursday.
As far as our work was concerned, after Friday's excitement, things cooled down quickly. By Friday evening some shops had opened again and we even set out looking for our generator. Today (Saturday) was an extremely productive, long, sweaty day, full of bargaining, starting at 7am and ending 15 hours later discussing prices in the dark! The good news: we got almost everything (and everything major) on our list. Incredibly good news!
Tomorrow, we'll visit all our vendors, pay for our wares, and make some last price comparisons. We hope to be en route to Juba in our 20 ton truck by Monday, God willing. Riots are expected to pick up again then, making it impossible to do anything. We are grateful to be safe and sound and on schedule. We are also very grateful for the help of Mayen, a UU alum who just arrived in Juba with the medications we purchased in Nairobi.
The Malek Diaries - 4/27/2011
Nairobi.
Yesterday, we started the morning off by going to MEDS (Mission for Essential Medications and Supplies). Their office is a little fast from Ngong Road, where we are based here in Nairobi, but we used the missionary car to get there early so we could confirm our order. Our list of items is long, and we wanted to make sure we got everything!
When we got there we realized it was going to take longer than expected. Inexplicably despite three months of correspondence as well as having prepaid for our meds, the folks at MEDS were not expecting us! Over the next few hours we counted and recounted meds, made sure we had everything on our list, got some extra ranitidine and omeprazole for good measure (it seems like everyone had gastritis or ulcers, Kenyan as well as Sudanese!) and packed and labeled the boxes to our satisfaction. The delay notwithstanding, the people at MEDS were kind, good natured and helpful and we got it all sorted out.
We set off from the office in a matatu to go to lunch before visiting a local kenyan bank to open an account. Back when UU was working only in Kenya, we had little need for trans East African country banking. Now that we are in Uganda and Sudan, we need a bank account with a presence in all those countries. KCB fit the bill, so we took our business there.
Meanwhile, we finally got in contact with Garang. We were eager to speak to him after receiving his cost analysis to see whether traveling to Uganda for our purchases was a wise idea. His recommendation was to make the trip to Kampala since prices and availability were more assured there. He also told us some sobering news: his uncle was killed two days ago by a Murlee. His communication was delayed because he was attending the funeral. Our prayers are with his family.
On the bus ride home I saw two gentlemen dying on the street. Initially I was ready to yell to let me off the bus to do something to help, but I realized quickly how powerless I am, in so many ways. It also made me realize how much Kenyans themselves struggle to piece together a living. Over 50% of them are unemployed. This in arguably the most stable country in the region. How can we excite Kenyan med students and health professionals to work at our clinic when they themselves need a hand up? It's not the bleeding heart, champion of the poor mentality we have in our developed countries. Those ideals are a luxury here.
Over breakfast at Mayfield, I met a sweet Caucasian girl who I assumed to be American. It turned out she was born in Kenya, has lived here all her life, and is actually a junior in high school at a very well established school for missionary children in Kijabe, a small town with a prominent hospital staffed year round by foreigners. I wish our clinic can end up like that. Kijabe Hospital and Rift Valley Academy are deeply entrenched in the missionary community and culture, which keep it funded and running. In fact, I was surprised to read that Theodore Roosevelt himself commissioned the building of the academy back in 1906!
But UU work is not missionary work. Our work is health and education: sound minds and sound bodies. While we don't subscribe to the missionary culture, one thing we would do well to adopt from them is the idea of really getting to know the community before proposing a change, even if we think we know better than they do about things like disease and hygiene. We need to observe and listen first instead of talk first. That requires humility and patience in just the right dose.
Deng arrived safely last night with his wife and is staying at Mayfield as well. Today, the plan is to make our travel arrangements to Uganda. Mayen will be going straight to Sudan with the 90 kg of medicines and supplies. In Uganda, Deng, Mario, Mom and myself will make all our purchases and hopefully make it to Sudan early next week, where we will finally meet up with Garang and Kuai, two other vital members of Team UU.
Yesterday, we started the morning off by going to MEDS (Mission for Essential Medications and Supplies). Their office is a little fast from Ngong Road, where we are based here in Nairobi, but we used the missionary car to get there early so we could confirm our order. Our list of items is long, and we wanted to make sure we got everything!
When we got there we realized it was going to take longer than expected. Inexplicably despite three months of correspondence as well as having prepaid for our meds, the folks at MEDS were not expecting us! Over the next few hours we counted and recounted meds, made sure we had everything on our list, got some extra ranitidine and omeprazole for good measure (it seems like everyone had gastritis or ulcers, Kenyan as well as Sudanese!) and packed and labeled the boxes to our satisfaction. The delay notwithstanding, the people at MEDS were kind, good natured and helpful and we got it all sorted out.
We set off from the office in a matatu to go to lunch before visiting a local kenyan bank to open an account. Back when UU was working only in Kenya, we had little need for trans East African country banking. Now that we are in Uganda and Sudan, we need a bank account with a presence in all those countries. KCB fit the bill, so we took our business there.
Meanwhile, we finally got in contact with Garang. We were eager to speak to him after receiving his cost analysis to see whether traveling to Uganda for our purchases was a wise idea. His recommendation was to make the trip to Kampala since prices and availability were more assured there. He also told us some sobering news: his uncle was killed two days ago by a Murlee. His communication was delayed because he was attending the funeral. Our prayers are with his family.
On the bus ride home I saw two gentlemen dying on the street. Initially I was ready to yell to let me off the bus to do something to help, but I realized quickly how powerless I am, in so many ways. It also made me realize how much Kenyans themselves struggle to piece together a living. Over 50% of them are unemployed. This in arguably the most stable country in the region. How can we excite Kenyan med students and health professionals to work at our clinic when they themselves need a hand up? It's not the bleeding heart, champion of the poor mentality we have in our developed countries. Those ideals are a luxury here.
Over breakfast at Mayfield, I met a sweet Caucasian girl who I assumed to be American. It turned out she was born in Kenya, has lived here all her life, and is actually a junior in high school at a very well established school for missionary children in Kijabe, a small town with a prominent hospital staffed year round by foreigners. I wish our clinic can end up like that. Kijabe Hospital and Rift Valley Academy are deeply entrenched in the missionary community and culture, which keep it funded and running. In fact, I was surprised to read that Theodore Roosevelt himself commissioned the building of the academy back in 1906!
But UU work is not missionary work. Our work is health and education: sound minds and sound bodies. While we don't subscribe to the missionary culture, one thing we would do well to adopt from them is the idea of really getting to know the community before proposing a change, even if we think we know better than they do about things like disease and hygiene. We need to observe and listen first instead of talk first. That requires humility and patience in just the right dose.
Deng arrived safely last night with his wife and is staying at Mayfield as well. Today, the plan is to make our travel arrangements to Uganda. Mayen will be going straight to Sudan with the 90 kg of medicines and supplies. In Uganda, Deng, Mario, Mom and myself will make all our purchases and hopefully make it to Sudan early next week, where we will finally meet up with Garang and Kuai, two other vital members of Team UU.
The Malek Diaries - 4/26/2011
Nairobi.
We arrived in Nairobi two nights ago and have been making progress on our plans to buy the medical supplies and materials needed to finish the clinic building. Yesterday, we met with many of our students to follow up with their issues, including school fees, paperwork and any medical illnesses. We met with Nhial and Jool, high school students (Nhial just graduated!), and Deng and Thion, both medical students. Deng is in his 3rd year, Thion in his 2nd. We also met with John Alier, who has a diploma in pharmacy and will be going to Sudan with us. We also met with the rest of our team, including Mario Bol, a Lost Boy from San Jose, CA, and Mayen, a Universal Unity graduate who has been invaluable in our education project in Kenya. Deng, who many of you remember from our fundraiser event, will be arriving tonight.
Today, we are going to MEDS, a warehouse for nonprofits that sells reliable medications at low cost. We will pick up the medications we ordered for the clinic there. We will also have a meeting to decide, within the next two days, whether we will purchase the generator, windows, plaster, doors and other materials to finish the clinic building from Kampala (Uganda) or Juba (Sudan). We have done an extensive cost analysis with the help of Garang, another Lost Boy currently in Juba, but we want to make sure we get the best value as well as the best materials for the clinic, so it's an important decision!
From the medical/clinical side, we have also got a hold of a malaria net distribution evaluation questionnaire to evaluate the 500 nets passed out during Deng's and Jordan's trip last year. Evaluation is a crucial component of any public health intervention and one we are trying to be particularly mindful of as we move forward. We also have a contact knowledgeable in latrine interventions and are planning community meetings to discuss the logistics and community readiness for a dry bathroom vs. pit latrine project. Communication is everything!
We arrived in Nairobi two nights ago and have been making progress on our plans to buy the medical supplies and materials needed to finish the clinic building. Yesterday, we met with many of our students to follow up with their issues, including school fees, paperwork and any medical illnesses. We met with Nhial and Jool, high school students (Nhial just graduated!), and Deng and Thion, both medical students. Deng is in his 3rd year, Thion in his 2nd. We also met with John Alier, who has a diploma in pharmacy and will be going to Sudan with us. We also met with the rest of our team, including Mario Bol, a Lost Boy from San Jose, CA, and Mayen, a Universal Unity graduate who has been invaluable in our education project in Kenya. Deng, who many of you remember from our fundraiser event, will be arriving tonight.
Today, we are going to MEDS, a warehouse for nonprofits that sells reliable medications at low cost. We will pick up the medications we ordered for the clinic there. We will also have a meeting to decide, within the next two days, whether we will purchase the generator, windows, plaster, doors and other materials to finish the clinic building from Kampala (Uganda) or Juba (Sudan). We have done an extensive cost analysis with the help of Garang, another Lost Boy currently in Juba, but we want to make sure we get the best value as well as the best materials for the clinic, so it's an important decision!
From the medical/clinical side, we have also got a hold of a malaria net distribution evaluation questionnaire to evaluate the 500 nets passed out during Deng's and Jordan's trip last year. Evaluation is a crucial component of any public health intervention and one we are trying to be particularly mindful of as we move forward. We also have a contact knowledgeable in latrine interventions and are planning community meetings to discuss the logistics and community readiness for a dry bathroom vs. pit latrine project. Communication is everything!
Tuesday, February 1, 2011
Dr. Cynicism
I'm on my last heavy-duty rotation of medical school, spending four weeks in a surgical ICU in Southern California. It's hard to believe that four years has passed. I know that I've changed throughout medical school, but I can't cleanly delineate how, or whether it's a positive change.
I remember worrying about changing in the beginning of medical school. I didn't want to become cut and dry, lacking in human spirit. I know so many physicians who treat their work like it's a day job, and that's not why I worked so hard to get into this field. I was reaching for something larger than life, some sort of zen or nirvana or self-actualization that I believed could only be achieved by dedicating my life to healing others. To doctors, I know now that this reasoning sounds insufferably common. To me, it just sounded true.
As part of my training in the SICU, one of our professors suggested we read a recent article in the New Yorker on death and dying, and the trillions of dollars spent on heroic measures at the end of one's life. I see this firsthand every day on our unit: for instance, there's the 60-year-old man with terminal lung cancer, sedated and paralyzed, on a ventilator forcing a measured volume of air with a measured content of oxygen at a measured volume of pressure through his chest to keep him alive because he can't breathe on his own. He and his family wanted us to do everything possible to keep him alive. Last week, the surgeons decided to put a permanent breathing tube in his throat to make him more comfortable. He came out of the procedure retching and nauseous, inexplicably more uncomfortable now than before. He died the next evening.
Dr. Gawande's article spells it out nicely, with similar heart-wrenching stories of people choosing the illusion of an ugly life over the inevitability of a "more" peaceful death. Interestingly, however, Gawande hints that the onus is at least in part on health care professionals to manage patients' expectations. After all, they are not as equipped as we are to make treatment decisions. Then again, who are we to decide the course of their lives?
At the heart of this struggle is, as my professor declared, America's unwillingness to accept death as an inevitable outcome. I'm sure our nation's litigious tendencies, particularly fearsome in the field of medicine, don't help. Sounds pretty hopeless.
So as a fourth-year medical student entering a system plagued with staggering costs, wasteful practices, and complex social injustice, is there a role for optimism?
I have asked myself this question about optimism many times and no matter what situation prompts me to question my natural tendency towards it, I always come out with the same answer. Whether it's building a clinic in South Sudan, bringing eco stoves to the Chiapan mountains, being there for an ailing family member, or petting a lame dog, the answer is always the same: you must act.
But why? Why should you intubate the terminally ill cancer patient who has essentially no physiologic reserve, sedating and paralyzing him so you can have a machine breathe for him in his last days of living, robbing him from any hope of interaction with his wife and daughter? For the preservation of life? For the preservation of dignity, if you define dignity as honoring your patients' wishes in their darkest moments of dying?
And why should you spend $2,000 risking your life and future to travel to a war-torn village in Africa the world has no use for, to bring health care to a place struggling with far more basic provisions like peace and water?
For that matter, why tell anyone to quit smoking?
I am convinced, more than ever, at the risk of sounding egotistical, that the job of physicians is to bring hope to their patients. This is not an unbridled brand of hope, whereby an 80-year-old patient can take up salsa lessons after her bilateral hip arthroplasties. No. It is a measured hope, where the physician essentially counsels his patient, "This is what you can expect if you do this, and that is what you can expect if you do that, and I will help you understand what your decisions entail, how they will affect your life, and how you can get where you want to go." We give people choices by giving them knowledge. If you don't tell your diabetic patient what can happen if she doesn't control her blood sugars, how can you expect her to care? She didn't go to medical school. YOU did.
I'm sure the situation is not as simple as I'm laying it out here. It is far more complex. But at the heart of the matter is still the patient's best interests, and far too often, health care professionals forget this. As Dr. Gawande puts it, we often get swept up in their whims, making ourselves salespeople and our patients consumers. After all, this is America, and the customer is always right.
At the end of the day, it IS the patient that calls the shots. The gentleman who passed away last week had every right to demand mechanical ventilation in his last days. Or did he?
My dad always used to say that when you live in a society, whether you like it or not, you have to conform to certain societal laws. As taxpayers, whether we like it or not, we pay for certain civil services that we ourselves may or may not make use of. One of these services is government-issued health insurance for the destitute and the elderly.
In America, we are at odds. We buy into this sense of shared existence, but we also defy it by protecting our personal rights to all kinds of things. End-of-life care is the perfect example. We spend billions of dollars on one person's last week of existence, fighting the inevitable and throwing quality of life to the dogs. Meanwhile, somewhere else in the country, whole neighborhoods of children with potentially bright futures go unvaccinated, undernourished, underdoctored. Where's the justice?
When will things change? If history is our guide, only when they get so bad there's no choice but to make it better. Some would say, hasn't that already happened? Isn't medical spending sufficiently out of control to warrant acute efforts? Isn't health care access abhorrent enough? I'm not sure. What I do know is that the new crop of doctors entering the workforce should grow enough cynicism to be hungry for change, and enough idealism to fight for it. If the most salient thing we provide is hope, there is no place for apathy in this profession.
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