A Drop in the Bucket?

Today I attended a lecture on an OB/GYN physician's experience in South Sudan promoting and teaching family planning. She spent 4 weeks teaching local healthcare workers, midwives, and doctors everything from basic anatomy to how to implant an IUD. Her talk highlighted many of the difficulties in global health work such as financial obstacles, language obstacles, and cultural obstacles.

One hospital (term used loosely -- a few 1 room/1story buildings on the same property) where she worked didn't have much/any materials and medication. The hospital pharmacy and THREE small bottles of antibiotics. They didn't have sutures, speculums, or a constant source of power. If a family needed/wanted a c-section, they would somehow have to find their own supplies to bring to the hospital and hope that there is a doctor there who knows how to do it (not to mention traverse horrible, unpaved road for hours upon hours to get there)

Another barrier she faced was 1) the lack of education on why family planning is important (ex -- why can't you have 11 babies starting when you are 14?) 2) the acceptance of physical abuse as a form of aggression in households. This creates problems when you are trying to provide contraception to a women without her husband knowing (ex -- concerns about husband feeling IUD strings). She would have to start from scratch explaining how baby after baby after baby (especially at a young age) increases the maternal mortality rate and decreases the country's productive output.

Although her lecture was extremely informative and enlightening, I couldn't help feeling discouraged as I left. People like this doctor and my medishare team going to Haiti do their best to make a difference, but in the end, what is really accomplished? She left South Sudan with not a single medical professional up to competency to provide contraception (such as IUD and the arm implant). However, they are about a million miles closer than before she arrived and are continuing training in her absence. What about that hospital that can't even function due to lack of supplies? It just makes me really sad about the whole global health picture in developing countries. I know there are NGOs and non profits trying to fill the gap, but it almost seems like trying to put a bandaid over a gushing wound. What would happen if no one did anything though?

I guess I can only hope that all the drops in the bucket eventually add up to make a significant impact. I also know that I am extremely privileged to live in this country with all these resources available to me when I just as easily could have been another person born in South Sudan, seemingly without hope.

A Caveat on Psychiatric Diagnosis

—"If a man does not keep pace with his companions,
perhaps it is because he hears a different drummer.
Let him step to the music which he hears,
however measured or far away"

. -- Henry David Thoreau (1817-1862)

90 Seconds in Heaven?

Today was another eventful day in the Grady ER:

An elderly lady with a possible stroke, a middle-aged man who overdosed on tylenol in a suicide attempt, a young man in diabetic ketoacidosis because he can't afford his medicine for his diabetes, and lastly, the miracle patient who came back from the dead.

____

We got a call from EMS, "We're about 5 minutes away with a patient that is unresponsive and losing a lot of blood through the oropharynx(throat). We can't intubate him because he's clamped up." The physicians hurried into the CPR room to prepare the intubation equipment along with airway drugs (to paralyze and anesthetize the airway for intubation). As EMS wheels the patient into the room, the paramedic reports the patient lost about 2L of blood in the ambulance and went into ventricular fibrillation (vfibb) and they tried to shock him, but he was still in vfibb.

There about 10 people in the room at this time (interns, residents, attendings, nurses, medical students). Everyone got busy working on the patient. Someone cut off his shorts, the resident started a central line in his femoral vein, an intern started chest compressions, another resident worked on intubating him, another resident was getting an ultrasound of the heart, another resident was giving epinephrine injections, a nurse was standing by ready to shock when needed. People kept switching turns doing chest compressions. Every two minutes, they would stop compressions and check for a pulse. Every 6 or so minutes they would give a shock. After 20 minutes of working on the patient, the resident in charge of the code asked if anyone else thought that they could do anything to bring this patient back. No one said anything, and time of death was declared.

A chill ran down my spine. Through this whole process, I had been standing in the corner, trying to stay out of the way, watching everyone trying to desperately to bring this man back to life. I felt like crying (but I didn't). He was a stranger, yes, but the loss of another human life is hard.

As people were leaving the room, the resident I had been shadowing came over and asked me if I had any questions. As we were discussing the patient, we hear someone say, "He has a pulse!" With this, the activity in the room picked up again as the patient was ventilated and given more blood and fluids.

After having no pulse for about 20 minutes, the patient's heart had started to beat again on its own...a few minutes after he was declared dead.

12 Steps to Freedom

1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

________

As part of the psychiatry/neuroscience II module, we are required to attend an Alcoholics Anonymous meeting. I went to one tonight about 10 minutes from where we live.

I was apprehensive about attending the meeting. I wasn't sure how to act and if I should introduce myself. "I'm Lindel and I'm not an alcoholic?" That didn't seem right. I didn't want to be perceived as judgmental. I didn't want them to think "Why is she here?."

As I walked into the building, I saw a room where a few people were gathering. Unsure if it was the right room, I stepped in and sat down. I then saw that everyone had the 12 Step Book with them and I was assured that I was in the right place. As I sat there waiting for the meeting to start, I was unsure of what to do. So, I started reading the 12 step book that was in the chair next to me, listening to the conversations around me, and contributing to them when I could (The extent of which was naming Simon as the third chipmunk of Alvin and the Chipmunks and remembering LaLa as one of the teletubbies.) Everyone was friendly and no one seemed upset that I was there. As I looked around, I was surprised at the amount and variety of people who were at the meeting. I had expected less than 10 people, and honestly, I had expected them to look...different. I'm not sure if I could have told you before this experience what I thought "an alcoholic" looked like, but I (ignorantly) expected them to be identifiable-- maybe a bit disheveled? looking like they've seen the harder side of life? I don't know. The people around me looked like people you would see in the grocery store, in church, at school. On other words...like ordinary people. I should have known better since I have a friend who is an alcoholic, but I guess I always thought that he/she wasn't your typical alcoholic. There were old, young, men, women, black, white, rich, poor....all different kinds of people.

The meeting started off with people around the room taking turns reading alternating paragraphs from chapter 11 of the 12 step book. This chapter/step is concerning prayer and meditation to gain the insight into God's will for you and how to accomplish His will. After the reading, people around the room would take turns giving their impression and thoughts of the 11th step. Some people spoke directly about how their thoughts on prayer and meditation. Others spoke about other issues tangentially related to Step 11. A lot of times, people spoke around their issue, never directly addressing it, which made it more difficult to understand.

Something that struck me was that no one directly spoke about their problems with alcoholism. Before anyone would make a statement, they would say "Hi, I'm ______ and I'm an alcoholic." However, none of them spoke directly about their problems with alcohol in the past, temptations they face in the present, or how they ended up in AA like I expected they would. It was a lot more focused on the individual step they were discussing for the night.

The meeting closed with recognizing people who's "anniversaries" of sobriety fell on today's date. There were two women -- one who had been sober for 1 year and one who had been sober for 5 years. The group then gathered in a circle, held hands, and recited the Lord's prayer.

This assignment really provided insight into who are alcoholics. By going to this meeting, I got the chance to see "the face" of alcoholism. It really can be anyone.

OPEX Reflections

Yesterday was my last day at OPEX (out patient clinical experience).

Yesterday I worked with Dr. X, a resident. We saw a wide variety of patients -- an 8yo boy with pink eye, a russian woman with migraines, a U.S. health service worker with an infected finger, and a mom wanting her 7 yo to be evaluated for ADD.

There were several things that struck me as we saw each patient--

1) It was so refreshing to see a child -- a talkative, friendly, outgoing 7yo boy at that. You don't realize you are missing anything working in a primary care adult clinic, but seeing that boy yesterday made the appeal of family practice care clear to me. You see a greater variety of patients. It was fun to take care of an enthusiastic little kid that talked about baseball, his best friend in school, and playing outside.

2) Cultural, communication, and social barriers. Our patient with migraines was an middle aged woman from Russia whose second language was English. My preceptor was also an immigrant whose second language was English. There were several times that I witnessed communication breakdown between them.

Dr. X -- "Was your head trrrobbing [throbbing]?"

Patient -- "What? No, I had a migraine."

Dr. X -- "you know? pulsating? what did it feel like?"

Patient -- "the pain was just on my right side"

Ai yi yi...and so it continued. The problem wasn't just the communication though. I really didn't like the way the interaction was going. Dr. X was acting very paternalistic and started lecturing her on how she shouldn't be taking ambien because it continues the insomnia cycle when she mentioned that she wasn't sure if she could take ambien and imitrex(migraine medication) together. Whenever she asked a question, he would continually interrupt her and say "now, listen to what I'm saying." Lastly, he kept touching her knee or her arm or hand when he was talking to her. Now...I like my personal space, and I know if I was that patient, I would have felt very uncomfortable about the doctor continually touching me while we are speaking. Ultimately, the doctor had the best intentions -- he wanted to educate the patient and help her get control of her migraines, but the approach was not for me.

3) The ADD epidemic. It is well known that ADD and ADHD are over diagnosed in children in the United States. It is no joke to put your kid on medication for life not to mention the psychological impact of "you have a disease that makes it harder for your to succeed" on the child. One of our patients was a mom bringing in her young daughter for ADD evaluation. She kept going on and on about how her kid refused to focus and how whenever she found something difficult she just quit or how she puts the wrong answers because she gets impatient with working out the problem. This child may very well have ADD, but I didn't like the way the mom was talking about her own child with the girl right there in the room. It just felt like she was being attacked and being told that something was wrong with her. It bothered me.

Looking back over the last year of OPEX experiences, I have learned so much. I can take a history and do a physical with ease now. I can come up with a differential diagnosis and a treatment plan for patients. I've seen the application of lecture material in real live patients over, and over, and over again. It has been a great experience and I am so glad that it is part of Emory's curriculum.

The Power of Positive Thinking

This week we have been learning about movement disorders in our neurology module. We've had patient interview almost every day, which has been great. The patients we had with Huntington's Disease and Multiple Sclerosis particularly impressed me. What stood out about them was not their severe, lifespan-shortening disease, but rather their positive outlook on life. Seeing these patients struggle to walk and move and describe their cognitive decline is difficult. It makes me sad for them, and I think about the struggle they and their family must go through. Yet, both of them were happy.

The multiple sclerosis patient was jovial and joked around with us during the interview, making fun of his doctor from New Jersey with a few Jersey jokes. "Did you ever notice the Statue of Liberty is facing AWAY from New Jersey?" and "Did you know they charge a toll to go out of New Jersey to New York, but there is no toll to go in?" At the end, he simply stated "There are people worse off than me. There are people going to bed starving every night. I think I'm ok."

The Huntington's disease patient described the judgement she encountered at the National Huntington's conference about having a child, and she said "I have ENJOYED my life." ...even having Huntington's.

I have so much admiration for these patients. I don't know if I would be able to keep a positive outlook if faced with such an incredible challenge.

"17 Degrees Ain't Nothing"

I am part of the planning committee for Homelessness & Healthcare Week that is happening this week at Emory. Last night was our first event -- a documentary screening of "17 Degrees Ain't Nothing" followed by a discussion with the filmaker and formerly homeless individuals. The documentary is about a group of homeless individuals living in an abandoned warehouse in Atlanta.

There are so many misconceptions and stereotypes about homelessness, and when we asked the formerly homeless men what they wanted us to take from the discussion -- they said to approach every homeless individual with an open mind, without stereotyping them first.

There are so many different reasons why people become homeless. For example, when I asked Joe* how he had become homeless, he proceeded to tell the audience the incredibly moving story of his life leading to homelessness. Joe was a proud, productive entrepreneur. He had just launched his own business when he had a debilitating stroke. He unfortunately didn't have health insurance and his hospital bills cost him his life savings. At the time, Joe had been in a relationship with a women for 15 years. They had a son together. After Joe's stroke, his partner started becoming verbally and physically abusive. As his caregiver, she would neglect Joe. He couldn't go to the bathroom by himself, and she would just leave him. Joe struggled with this because he knew he was in a bad situation, but he didn't want to abandon his son. After several years of the abuse, Joe knew he couldn't live there anymore, and he decided to leave even if it meant becoming homeless. Joe didn't have anything and he didn't know anything about living on the streets -- there is no guidebook to being homeless. It can happen to anyone.

________________

Day 2

Today we had a lunch time discussion about mental illness in the homeless population. As an introduction to the issue of homelessness, the lecturer presented some video/audio clips of how homeless individuals are treated in our society. There was the video of the "bum hunter," a spoof of the crocodile hunter where a man would sneak up on homeless people, tie them down, and try and force them to fight each other. He was doing this to other HUMAN BEINGS. What has our society come to that people think this is ok? Another homeless man on NPR talked about how "Friday nights were the worst nights to be homeless" because drunk teenage boys would pee on him, beat him up, and treat him like trash.

It just really saddens me that people would treat other human beings as less than human. They might have made mistakes to end up homeless or maybe just landed in a really unfortunate situation like Joe, but they are still people who should be treated with compassion and respect.

*Name changed