Not uplifting?!?!? / Fauna of JFK

So, thanks for the emails and the comments on the blog and the general well-wishes. I also want to thank my Jacobi friends (ok, mostly Chertoff...) for all the pictures from Graduation. Wish I could've been there. I'll miss my Jacobi buds.

And, thanks to Schultz for the pictures from the Kenyon 10 year reunion! So good to see you guys-- sorry I couldn't make it!

It has been commented that the postings have been “depressing.” While likely true, this is mostly my fault. You'll notice pictures are primarily of things and situations and cases. I think this is partly because I'm taking, and therefore not in, most of the pictures. And, probably also because I don't imagine people who aren't here are going to be interested in random pictures of people. And maybe it's because my personality is such that I focus on situations and goals and “the work” and less on “the relationships.” That probably is true of me, but I also hope some of it is because the good stuff I like to live while I'm there having it, and the pictures of it sort of fall by the wayside. I'd like to think that's true, anyway.

So, this is a wholly positive posting to counter the "not uplifting" naysayers...

The kid in the bed smiling was hit by a car, a pretty common reason kids come in. While I was examining his leg, he actually sat up in the cot, grabbed my elbow and bit me. I looked at him, attached as he was to my arm, and said “Really? You're biting me now? I can't believe you're biting me.” He laid back down. But now we're friends, because pictures don't lie.

He also introduced me to a phrase I've been hearing a lot with these kids. Introducing the concept of pre-examination analgesia/sedation, I often draw up a bunch of meds in front of them. To a toddler, they all scream out “White Man, don't juke me!” I have learned this means not only “trick” or “get the better of” but also very specifically “Don't stick me with that needle,” it's most common usage. I enjoy that this verb has evolved to serve so specific a purpose. I'm reminded of the verb enratonar, which Chris Stoltz from high school and I found in one of the Marlows' old Spanish dictionaries. It is a verb (regular conjugation) meaning “to become sick (vomit) from eating too many rats.” I'm pleased not only to imagine that this was a common enough occurrence to warrant an entire dedicated verb, but also to think that there existed such a thing as eating an appropriate number of rats...

Speaking of which, the two mice in my room (I've named them “Lassa” and “Hanta” for reasons close to my heart-- don't worry, hemorrhagic fever is mostly a late rainy season phenomenon. Mostly...) recently finished off the rest of my trail mix (thanks, Dorrit II). They are pretty acrobatic in that they enter the room by climbing down the window-side of the 7 foot dark red curtains that hang over and next to my bed. I would hear this progressive scratching on them at night and used to wonder, but then I hit the noise with a flip-flop and one of them, Hanta I believe, fell from the other side. So now it's kind of reassuring to know they're there.

And while on the topic of interesting fauna, the biggest example of the common Hobo or Aggressive House Spider I have ever seen, Nemesis, is no more. He's documented here, living in the supply closet designated for HEARTT equipment.

The other day I was looking for c-collars because the President of the country was going on a trip and one of the admins thought it'd be a good idea for us to lend them some (I'm not kidding), and Nemesis jumped out of a box of cardiac monitor adhesive leads (We have no cardiac monitors). And maybe I screamed like a little girl. Look, I'm wearing my Keanes, which offer no protection, ok? So one of the patients on the trauma side of the ER came over and killed Nemesis for me, as I cowered in a corner. Not really cowered-- I was trying and failing to squash him with an old Harriet Lane handbook. Still, this surgical patient thought I looked like I needed saving. Score one for manliness, USA.

Oh, and the reason I'm giving a talk about rabies to the medical students is because this little beast was in the common lounge in the medical dorms the other night when I'm trying to post to this blog. It's not enough to hope there's power and signal and time, now I have to hope there are no bats.

Ok, soldiering on...

Picture fest

So, back at the restaurant with good internet. Hope a few pictures upload. The first is of me next to the medical incinerator. :)



This next is of the crack JFK rapid response fleet. My assumption is that they have not had tires for about 5 years...









Dr. Toomey, one of the Residents who stayed on at JFK after her internship year there, is hugging Marcia Glass good-bye here, as Dr. N'jo (I think that's the spelling...) looks on. This room is the site of morning report.

Here is how the Rads department brings new meaning to the term "wet read." Problematic with the films is sometimes they dry with streaking or there's wrinkling of the film, so some pretty wild artifacts are created, making them tough to read. Also, more than one view is hard to get (it also costs the same per view!) and they are often put on the same sheet to save film. Try telling the Pt that the film is inadequate and they have to buy another!A few shots from the ED, including Louis leaving the HEARTT closet negotiating the "off-road" wheelchairs of JFK, and the trauma side "resuscitation area." Note the portable O2 compressor and suction (oomph-poor suction...) pump. They are donated from separate sources and one always needs a converter, depending on where you wheel them...





Surgical laundry day is awesome. I keep meaning to buy the ED flystrips-- I assume the same is relevant to the OT (operating theater)...




Lastly, this is where I spend most of my time. It's a desk on the medical side of the ER. The AC is nice, but note the condensation streaking down the curtains into the fuse box and out to the floor. Yeah, I'm thrilled by this. Fortunately, every day we have a different administrator come into the room, see the problem, and say they'll take care of it. This recurring situation will be featured prominently in the upcoming feature "WTF @ JFK."

Anyway, hope to have more up soon. No big news-- the clinical issues continue, and I continue to be confounded/astounded by the whole payment prior to service thing here. Working on working on it. Small small ("a little bit").

Slaughter house 9-to-5

Re-read the below recently-- pains a fairly grim picture, but from the folks who have been here, things have been worse. So progress is happening. A favorite quote from Robert E Lee...

"My experience of Men has never disposed me to think worse of them, nor indisposed me to serve them; nor, in spite of failures which I lament, of errors I only now see and acknowledge, or of the present aspect of affairs, do I despair of the future. The truth is this: The march of Providence is so slow and our desires so impatient; the work of progress is so immense and our means of aiding it so feeble; the life of humanity is so long, that of the individual so brief, that often we see only the ebb of the advancing wave and are thus discouraged. It is history that teaches us to hope."



It's pretty impressive here. I'd say the “pathology” is “interesting,” but most if it doesn't live long enough to become so. It's a pretty standard occurrence to be called out to the drive-up receiving area by the triage nurse to pronounce a patient dead in the car. That way, the family isn't charged for the ER visit. Often a relatively young person will arrive in extremis, clearly a few days into the process, and all I can really do is watch them die. Sometimes not even that, depending on how busy things are. Usually they were recently seen (hopefully at another clinic/institution!) and sometimes have been taking some mystery pills for unknown reasons. So the family asks me at least for answers, if not hope. Why? What? Who's next? I don't know what to say. We have little ability to check basic chemistries, beyond a BUN (2 day turnaround), no microbiology, no functioning autopsy service. DOA, 2/2 BIA (dead on arrival secondary to born in Africa...?).
Often they appear gaunt, occasionally minimal responsive to noxious stimuli. More often than not I write for an HIV test (HIV, malaria smear, hemoglobin sometimes come back the same day...), whether or not I think they will last for the results (or the sampling). To a person, the family complains of them “Not eating.” A week is average.
So I write the standard orders for first dose quinine, ceftriaxone (or amp/gent, or benzylPCN or ampicillin, depending on review of systems and ability of the family to pay, as well as D50, fluids, paracetamol (please stop giving malaria patients NSAIDs IM! Platelets, platelets platelets...). Maybe I'll catch a septic patient right when it could matter. Maybe I'll put my hand on a belly and get the patient to OB or surgery. Maybe the social worker will approve emergency surgery so it can happen now, and not after sitting on the medicine ward for two days, filling with blood or pus. Maybe the kiddo will perk up, complete a quinine course po and go home. Maybe.
But the worst days are when I'm wrong. The baby looked ectopic to me on sono; the spleen suspicious for abscess. I thought that TB patient was stable to go back to chest clinic, where they had his meds and chest x rays and records. But I was wrong. Or I still don't know. Patient sat on the wards, and died a few days later-- no feedback, no closure. DAA 2/2 BIA (died after admission, secondary to born in Africa).
I guess I sound melodramatic, but perhaps blogs are supposed to be evocative? The truth is, I start out in morning report, trying to make something useful out of them. I'm then in the medical ER 9-5, w/ a PA on the surgical side during that time (I wander over now and then and try to suture or reduce something). The interns/residents here haven't really taken to signing in or out the ER patients. I track them down and tell them if there's someone critical in the ED. Any spare moment I have I try to teach something to the PA students. Anyone who will listen, really. Take my book, take my pen, look at my video on splinting from the NEJM! I've said before to a med student here, if there's anyone taking care of anyone in Liberia in 40 years, it's going to be from the group of people who are training now (or people they have trained). They are the reason I came to Liberia. Maybe if I inspire someone to try harder, learn more, be upset when people die, then maybe I'll have done something with my time here. And that may be the real hope for those of us BIA. For any of us, really.

Video diary...

Sorry to take long between posts. The internet is very slow and now, over the weekend when I don't go in as much, the power will be out in the dormitory compound until Monday... So, I've started to collect "post thoughts" and will upload like crazy when I can. I've also started to put together a video diary of sorts-- ala “Grizzly Man” I can only hope, though, that Werner Herzog narrates... For Lee-- "That's Sirius, the dog star. That's some serious stuff." And "Grape Soda Strategic Night Maneuvers."

I'm learning how to use the camera I got recently, so hopefully this video will load up. The internet is a little speedier at the restaurant down the road from the hospital. So, I braved the weather in my boy scout poncho and made the trek down. Rachel, another HEARTT doc, showed up yesterday to do some OB/GYN research, so I'm learning a little more about getting around Monrovia as well. Between the dark, the difficulty/danger in securing car transport, and the now torrential rain (Rainy season began 3 days ago-- nothing, then -BAM-, rain that would embarrass your mother) it's tough to get around.

Hope the video uploads. The following posts are for a few of the "in the know" JFK-ers...

IMCI = IMBM (“it must be malaria”)

Interesting evening tonight. You know your country is up a creek when the Haitian ENT doc says he's never seen anything like it before. “It is very very estrange.” “That was, zomething zpecial.” “It is very very curious for this to happen in a hospital.” “How can you do it without materiales?” "How do you dilate without seeing what you are dilating?"

The Security guys now have blue blazers and little yellow badges. They stop the Liberians and ask to see inside their plastic bags. What are they worried about them sneaking in or out? Seriously. I was stopped the other day and they looked inside my computer case. Am I stealing an African baby? Do I look like Madonna?

Of Hippos and Cheetahs....

picture of a quiet day on the trauma side...

So, www.ted.com is a great website full of a bunch of talks on various topics (a few of my favorites can be accessed through my Facebook page..) It's a meeting of a bunch of folks out in Monterrey who every year get together and discuss-- whatever. A few years ago, the topic was Africa-- basically all kinds of aspects. One speaker in particular caught my attention with his metaphor for the crisis in leadership in Africa. I believe he was from Kenya, but I'm not sure (and no, Kenya does not compete in lacrosse with Earlham and Dennison...). There are two types of leaders in Africa, he said. There are the young, hungry immediately post-student or student generation who are looking for things to change and change quickly. Who see the world forgetting Africa and are looking to catch Africa up to take its place among nations (though granted, this could take generations). He referred to them as the Cheetahs. Then there are the other African leaders. Concerned primarily with their own station, and therefore the status quo. Who take no initiative and at times block innovation to maintain their position. Who can only see the watergrass in front of them and do not look to the horizon of the future. These are the Hippos. More often than not, he observed, the Hippos tend to be in charge and entrenched (ever tried to move a hippo?). And it is their weight that is a part of the problem holding Africa back.
I found that observation to be interesting, and not just relevant to Africa. Leaders tend to be like parents-- the big challenge is knowing when to step aside and let what you've built or raised come into its own. Of being confident enough in yourself and your work to let it outlast you (and of ensuring that you are building something that will outlast you, that, in the end, will make you unnecessary). And that's the challenge. As we grow old and “experienced,” professionally, we are every more concerned with our own mortality or career longevity. Frailty begets conservatism and fear of letting go. This is probably adaptive-- you bounce back less when you osteoporotic (metaphorically speaking, of course).
In the end, I think it was said best by Lao Tsu: Go to the People. Live among them. Love them. Learn from them. Serve them. Plan with them. Start with what they know. Build on what they have. And when the best leaders leave, the people will say, “We have done it ourselves.”

What I find interesting is that it implies/assumes that the best leaders leave. What happens to them then? One can only hope they were able to be part of something that they are proud to see outlast them.

medical stuff

So, I was debating how much vs. how little of the medical stuff to put up on the blog. Both for patient confidentiality/respect (most of the "interesting cases" end up dead or disabled, and I feel awkward about taking the picture...), but also because some readers are friends/family who are not medical folks may not be interested in seeing it. So I've decided to be sparing and clearly label medical stuff posts as such.

Many docs back home said I'd probably see some "crazy sh*t." That's certainly the case. But mostly it's been the solutions, improvised or absent, to the medical issues that have been crazy. For starters, it had been common practice to diagnosis & prescribe, order labs, xrays etc. for a patient, and then have the patient or family pay for all that prior to it being dispensed. Even in emergencies. "Can't afford an appendix or SBO surgery right now? Ok, we'll wait until your relative shows up with the cash..." Even if that's 2-3 days! (of note, surgical emergencies, unlike wine & cheese, do not improve with "aging," though I have found them here to give me migraine headaches...) Luckily, that's improving.

The major burden of disease here is malaria for the younger ones, and trauma for young adults. As indicated by the stats posted earlier, I would not want to take my chances being born (infant mortality) or getting pregnant in Liberia either (though the latter might make for an interesting blog in and of itself...).

Uh-oh, late for morning report. The pictures will have to wait!

Ok, a quick one. Our differential was buruli ulcer (cutaneous mycobacterium) vs. traumatic ulceration of filariasis (elephantiasis) in a Pt later diagnosed with AIDS...

Def-con 5

This is a priority one alert: I have just been informed that the medical dormitory is out of toilet paper, and may not be resupplied until Friday. Emergency gauze pad and kleenex rationing will commence. This is not a drill, repeat.

Oh, and there are honest to God beach-sized crabs living in the storm drain. WTF.