falling in love

Yes, Its true. I've fallen in love.... with a 6 year old boy with the sweetest smile. LOL don't worry I'm not gettin all Mariah Carey on ya, I saw this boy in clinc the other day and he just wowed me. He has a chronic illness. He could tell me why he was coming, and could name his problem. He was initally shy but became very chatty. Like many boys his age, he was asking all kinds of questions and kept practing saying the word stethescope. His grandmother was as sweet as can be too, asking me if I would see him again when they come back for follow up. I assured her that she would see another pediatrician but she kept asking if it would be me. I felt really honored that she wanted me to see him again and then got a little sad knowing that I wouldnt. I got excited that I'll be seeing my kids from home again soon but then I remembered that I only have 3 months left of residency and all the kids I've fallen in love with up to now I will have to give to another doctor.

I'm really privledged to have a job that I love, where its OK to love my patients (in that non-creepy don't sue me kinda way of course!), where I feel truly fullfilled. When I first chose medicine, I chose it because I saw the need for medical personnell in the world first hand. Though I consider that as real a reason as any, I was not any less nieve about what it meant to be a physician than any average budding med student. I thought my mere presence would save lives! LOL. I would have this fantasy that I am driving and there is an accident before my eyes. I would spring from my vehicle and magically by my mere presence the mangled would get up and be healed I thought I would save the world. As the meaning of doctoring has gone from being fantasy, to tangible, to my real daily existence I have gone through many changes. Primary care has become my passion. But what does it mean? I realized that what I like about my time here with Issa Trust most is that it is very similar to a clinic month back home. I see them, assess as many things as I have time to, introduce interventions, help them navigate the system, see them back. As I would at home I am essentially trying to build some trust and provide the best care I know how to. Im doing that, mostly from the clinic, because I believe in prevention, monitoring for occult disease so it may not cause more significant illness or premature death later in life, and mostly (to be honest about my personal intentions), so that these young folks can have the best quality of life with fewer days of illness or complications. Primary peds is not sexy. Diagnosing a 3 yr old with a urinary tract anomaly and providing interventions to prevent long term kidney damage is not going to wow your grandparents at the dinner table. Preventing a case of rheumatic heart disease by treating a strept throat, or treating a teenager with chlamydia to decrease her odds of having complications that might involve her ability to conceive later in life… those things are not ‘your favorite doctor show exciting’ but they are vital. As I reflect on them it reminds me of why what we do matters and why offering pediatricans to a place where there are so few, is a significant contribution to this and any population where access to a pediatrician is limited.  The icing is that loving and caring for your patients makes you better at your job and leads to the kind of relationship that, though short term and minimial in the grand scheme of all the relationships people have, is still in some way significant.

Dont get me wrong sometimes it is like an episode of ER. A mom deliveries a baby thats very sick, significant interventions have to be done to help that baby breath, keep enough blood circulating to keep the heart pumping and treat whatever infections may have been brewing. This happened last week at one of the hospitals. I wanted one of the awesome pediatricians as she resusitated and stabalized a baby in prep for transport to a hospital that has a ventilator (which they do not at Annatto Bay). They team took turns bagging the baby and safely delivered her to a higher level of care. At home that would be the realm of the neonatologist. Here, where specialists are so few, the pediatricians do as much as they can and deliver the babies to one of the few neonatologists when they don't have the right equipment or it is beyond their expertise.

Overall though the thing I love most about my job are the patients. I snuck in an 18 year old the other day and she was so great and made me miss the teens. I've seen a 14 and 15 year old here and there and they just fill me up with joy. The babies are so beautiful (most of them lol!) the children so fun (except when they really don't feel good and then they're likely cranky. You look around in the world and you realize that some have nothing that brings them joy. They hate their jobs, they live alone, they aren't close with their families. They struggle to make it, they work 7 days all day because they have to to eat (met a man like that last week). I like the whole "first world problems" joke thats going around. You know the " i had to wait 3 min for that webpage to load" lol.  My patients here wait all day to see me on clinic days. They get a number at around 9 am and if there are many patients I may not see them until 2 or 3 pm. I apologize for their wait and they are still so friendly and patient and glad a pediatrician is seeing their kid. I get first world annoyed just as much (maybe almost as much) as any American, but I'm always glad to gain some perspective.

a regular day...

Today I was in Annatto Bay. After being in Port Maria where we see tons of kids and am busy all day Annatto bay is a nice change of pace. There are 2 pediatrics trained folks consulting and a whole team of pediatric focused medical officers. I wasn't very busy but I learned a lot from rounds and from a presentation one of the interns gave about pediatric UTI. We got to discuss the standard of care for UTI here as far as imaging is concerned and I got to hear how it differs from the US and what kind of studies that have been done to inform the recommendations. I feel like I help the least here because there are so many other amazing people seeing the kids, but I'm sooo glad we come here for my education. I got to run some cases that I saw in clinic yesterday by the pediatricians and learned a lot about hospital care. They were saying they have never had to put a child with asthma on continuous or bipap or anything like that in the 8 yrs since of the peds has been working there. And the kids get better. If I had come here but not had these interactions then I would not be up to speed on the local standards so I'm grateful to have the Annatto Bay experience. I went to the Emergency area after ward rounds and saw a few really good cases. 

I have seen clinic patients alone with "attending backup" at home for many months now. But this experience really helps build my confidence when no one is there to just "run things by". I have been here long enough to have some patients come back and have been pleased by the results I have seen. I'm also getting better at seeing patients faster. I'm still in awe at just how specialized it is to be a pediatrician and how valuable our knowledge base is even among very experienced practitioners. I had a really sick kid in A and E today that myself and 2 other doctors helped stabilize. I felt really good about our efforts. I was nervous but once I calmed down I realized that I know stuff lol and we worked together. There was an ER trained doc there for support and she thought we did great and just added a few recommendations. 

I'm also really having fun at work. The docs and nurses are just as awesome as they are back home and its been easy to joke and have fun despite working hard. Thats like the icing on the cake. Anyone who comes from one country and practices in another abroad should have to spend at least some time with local docs learning the recommendations. It also helps build overall comfort in my opinion because you get to relate on the medicine. Its like a group of instant friends.

I have also met some wonderful kids. Kids that don't eat there vegetables and then grin at you when you tell them they should. Kids you have to negotiate to drink water instead of juice. Amazing girls who play net ball, and run track, and play soccer whose parents beam when they talk about their accomplishments. They are all impressed that I used to run the 400 meters... "the long one!" I tell people I was always getting smoked by the Jamaican girls and we make a joke about how my legs are too skinny.

I also went shopping a few days back and made some good deals. I didn't get you anything. Yes you. Nothing. I got one person one thing and then commenced to buying things that I needed/wanted for myself. Perhaps I will get you something later, but don't count on it... unless you are my grandma... in which case, Grannie your doll is on the way!

The other doc her for the month arrived yesterday and shes amazing! After my own heart and totally living the life I want to live with respect to global health stuff. Shes wise and experienced and we have such great conversations. She gives me space to reflect in our convos and inserts excellent stories. Shes also just a fun person to talk to. Although I have my favs here at the hotel, I realized how much I've been waiting to decompress with someone that knows what its like to be doing this thing, away from home, because its immensely meaningful to me. Good times. 

after my own heart ....

I first studied abroad as a 20 year old undergraduate in 2004. I volunteered at a hospital while I was a student at the University of Ghana in Legon just outside of the capital city Accra. This was a small hospital, with a few words and a few doctors. The only specialist there was a pediatrician, and every day she saw all of the children. Everyone else was a general practitioner with 1 year of internship then on the job training. I remember watching the long queues of people lined up every morning to see the 4 doctors and could only imagine what it would be like to be that one pediatrician.

Today, I got goose bumps when one of the other 3 doctors at Port Antonio health department told me I was the only pediatrician there today.

Since I left Ghana 10 years ago, I have thought a lot about global health. I thought about how to make a real impact, I’ve thought about the ways that sometimes well intentioned people with resources such as myself can sometimes be a burden as we try to help. This program is truly done well. My stay is not a burden on any person since no one has to feed me and house me. I am working under the auspices of the public medical system, so if I get Dengue fever and am down for the count there is always a doctor who can see the babies and we are reiterating continuity and the importance of using the medical system. Since Diane tries her hardest to get 1-2 pediatricians here every month there is some consistency and I can make a plan for 3 months from now that I can pass on to another team. There is bi-directional learning. I’m so proud to be here, and to be a part of this program.

I met two people this week after my own heart. One was an ambulance driver. We got to talking about some things that he has seen and he began to tell me his opinions on health care. He believes that health care is a right, and something that should not be withheld because someone cannot pay. He states that life saving medicine should be the priority of the ministry of health and that anything less and the ministry is not doing its job. Next I met a Cuban doctor who is sort of my hero now. He is Cuban and had his medical training there. He does an amazing job with patients and they love him. Part of what makes him great and that he takes the time to explain things to patients, is really smart and thoughtful about them, and takes the time to show them that he cares. He told me that this is how he was trained and it was reinforced by his lifestyle. He said in Cuba, where physicians are just as poor as everyone else, the pride of the poor physician is knowing the diagnosis, having patients want to see you, and explaining things to them well. I'm sure the are many things that are not great about the system there, but training that mentality is truly special. I have no beef with folks who want to make a lot of money, or who argue that we have to make a lot of pay our debts. But the more I do things like this the more I know that no matter where I am or how much I'm paid, this here medicine thing is my calling.

This is like a refresher course is why I became a doctor. I want to be a smart caring doctor to people who barely have a doctor at all. I want to be the kind of doctor to this obscenely under served people, that people who good insurance in the states simply expect. I want to be the kind of doctor that all people deserve to those who don't have the money and voice to demand it. 

First Day

Way back when I was in Summer Scholars prior to medical school, a wise older student said "get comfortable being uncomfortable". Medicine forces you to do that because if you don't you will be a ball of stress rocking back and forth in the fetal positions whimpering "why me". Today was my first day in the clinic. It was amazing and a little overwhelming to be the pediatrician. Then I realized most of this stuff is universal kids stuff and that there are other docs around to assist if I'm stumped. I was supposed to get an orientation but no one was available to do it so I just decided to start seeing patients. I made a few faux pas's like ordering a medicine that per the pharmacist that called me quite perturbed "hasn't been seen on the island in months!" (cephalexin), though my orientation guide stated that it was available, it must not have been updated lol. Also I don't "write" perscriptions anymore (magical computer land) and so writing them was hilarity. Thank goodness the pharmacists that work next door were patient (unlike the one from above). i forgot to put the patients name on one, forgot the dose on another, dispensed a tube size that doesn't exist a different time. LOL. Again, just like nurses, these pharmacists saved my butt and I'm so grateful.

I got an "urgent" consult from the ED equivalent {accident and emergency} and it was a girl that was really not so bad. I thought, part of the beauty of being a pediatrician is not over treating children. I met a few kids with asthma today who have no albuterol at home. nothing. parents aren't even taught how to do a treatment. sooooooo yeah. I made them go to the pharmacy (right next door) pick up the albuterol, bring it back and teach how to do the inhalations. It took a few tries but we worked it. spacers are hard to get but I'm thinking of how to use water bottles.

Just when I was ready to move in I realized why I am thankful to have my training in the US. There are a few pediatric sub specialies that dont exist at my hospital and I just send my patients on across the river or to private docs out of our system. Here, there are no peds hem-onc, peds ID, etc. I have a pt that really needed a specialist and can't get it and will literally have to go to another country ASAP to get life saving, long haul treatment. Her mother is ready to go all in, but the expense is going to be enormous. I'm looking into how to get her to Cuba since that is probably the most cost effective option but I'm exploring any and everywhere. I still may move somewhere but I gotta get over the anger I feel at the gross inequity involved with being a poor kid. You think, working in Camden, I'd stop getting all worked up about it, but no. Still makes my blood boil.

Despite this and my mistakes it was pure joy taking care of these kids. toddlers still toddlering (ughhhh toddlers! we all know I loves the toddlers). pre-teens still refusing to eat vegetables or take medicines. babies still cute as ever. I'm just sad i don't see over 13. Eventually I will try to schmooze and convince the GP's to give me the teens as well. We'll see. The waiting room was full of adults so they may gladly hand them over.

New Passport New 10 years...

In a few days I head to Jamaica for a 1 month rotation. I've been looking forward to this for over a year. I will be working with another pediatrician and we will be consulting on pediatric problems. In Jamaica Pediatrics is more like a sub-speciality and most kids are taken care of by general practitioners. So if those practitioners are scratching their heads they send them to us. There are very few pediatricians in the country and most live and work in the metro areas *much like everywhere else in the world* so the ministry of health will be transporting us to less populated areas.

The foundation I'm going with is the Issa trust Foundation. Please do look them up and make a donation if you can. I'll try to blog a few times while I am there. http://issatrustfoundation.com/

I really look forward to using my new fancy microchip passport. I had the old flimsy paper one without enough pages that just expired last november. I am so excited to be going to work with the global underserved. For the first time EVER I will actually have skills and expertise to provide care that is actually helpful. This is what excites me most. I have appreciated working the front desk at Legon hospital in Ghana, and organizing impromptu clinics in Ecuador, and observing HIV care in Botswana. But this is something I have had to get specialty training (that as hard as it is, is truly a gift; I'm very lucky and in a very small minority of people world wide)  to be able to do and now at the end of my residency, I finally have something to offer.

On Concerns About Vaccines

I have started doing the research for a project I will be doing on reasons that parents give for not vaccinating their children. It is a very good example of medical technology that has to be translated. Who cares how great the technology is, if everyone is afraid to use it?

First I will disclaim that my training teaches me that vaccines are one of the most important public health innovations in modern history… up there with water and sanitation. I am both saddened are angered by vaccine access issues in the developing world, where lack of access to vaccines results in vaccine PREVENTABLE infections that cause sickness and death. I am an avid proponent of vaccines.Other disclaimer: I’m not a doctor I am a fourth year medical student who has read some stuff and seen some people.

That said vaccines are a medical therapy. I would feel like I was committing malpractice if I did not recommend them. They are equivalent to antibiotics, or blood pressure medicine, or clot breaking medicine for someone who has stroke due to a blood clot. The difference is they are prophylactic. Like antibiotics, or blood pressure meds, or clot busters there are benefits and risks to the therapy. Most people do great with antibiotics (minus some diarrhea), but sometimes people have really bad very serious allergic reactions. Are we going to stop using life saving antibiotics because this is a possibility? I would say that if we did that would be criminal, and given the choice most people do their own risk benefit analysis and choose the therapy. In a country where people often choose very dangerous chemotherapy drugs, given very low probabilities of success I am a bit surprised by the reactions of some to the anecdotes about vaccines.

One thing that upsets me about the vaccine conversation is when people refuse them for uninformed reasons. If you weigh the true risks, and true benefits and decide against it, that’s fine with me. The problem is when anecdotes fuel a person’s decision. I understand the fear that a news story, or a friends experience can place in the minds of parents and individuals. But the millions of people who get the flu shot and are fine the next day (minus an achy arm), will never make the news. When making your decision remember that serious side effects are very rare. Some of the factors that lead to serious side effects include, the person’s previous health status, the person’s genetics, and the person’s unknown allergy. No one can tell you for sure that you will not be one of those 1 in a million that have a bad reaction, but the odds are you won’t. The other thing is, not every reaction is due to the vaccine. If a person gets the flu after the vaccine maybe they are one of the people who the vaccine does not cause a sufficient immune response. Vaccines are tested in such a way that they have to result in a protective response in most but not all people that it is tested on. That said some people do not have the right combo of immune genetics to respond to the vaccine. With regard to the flu, the vaccine does not include all of the strains of flu just the mostly likely and/or dangerous. The other thing is sometimes, things were going to happen anyway, and the timing of the vaccine was an unfortunate interlude. Association does not automatically mean causation. Sometimes it does. Sometimes it doesn’t. I think we should be even in our interpretation of these sorts of things.

With regard to H1N1 it is important to know that if you are fine with getting a regular flu shot you should be fine with getting the H1N1 shot. They are made in the exact same way. (see CDC website)

I would like to say that I don’t think health professionals do the greatest job of allaying the fears of those who come to them with anecdotes or other fears about vaccines. Much like other realms of medicine, they often make the decision for the patient saying “you much get this… it is safe don’t worry… see you later…” You are injecting medicine in a healthy patient to prevent a disease. If after given accurate information about the dangers of the disease, and most importantly after understand the real risks vs. benefits, the patient should be able to decide. I think that if we have an outbreak of H1N1 and people are very sick and/or dying around them, then people will run each other over to get the vaccine. We in the US have the luxury of not having witnessed an epidemic from any of the vaccine preventable diseases.

So weigh the pros and cons for yourself. If you are ambivalent about the flu vaccine consider: If you are a health care worker, you will be exposed to flu, if you get the flu, you will expose it to sick people who are more likely to die from it. If you are a hermit that never leaves the house without a gas mask on, your odd or different from our health care worker example. If your kids in day care, her or she will probably be exposed. If your kid never leaves the house, if you can keep sick family members away your kids’ odds of not getting the flu are lower than say the day care kid. If you’re a healthy adult that lives a normal life, you may get the flu. Weigh whether you want to deal with it or not, but odds are you won’t die. If you go home to a older person or child, the odds are you will pass it to them and they could have a long critical sickness or die. There are hundreds of scenarios.

Lastly, if you believe in a government conspiracy to kill the masses by injecting people with deadly diseases through vaccines I have nothing for you. Apologies, but I don’t really have any evidence to support that, especially in light of the large number of people living fine after vaccines. I do know that people die and or suffer serious sickness from some of these vaccine preventable diseases.

Really Changing My Life... Part !!

I read a book called Confessions of an Economic Hitman and it really affected me. If you have an hour you can watch a free Democracy Now episode that is an interview with Mr. Perkins. http://uk.video.yahoo.com/watch/2375443/7418940 Basically, the book is about the way that he worked as an international consultant that manipulated lower income countries into taking so much debt that they can't pay back. They have 'professionals' like him intentionally 'forecast' economic possibilities that are overestimates so that people will agree to take the money... thus the inability to repay. The debt then allows the loaning country to have political clout and manipulate the country by pulling back on the debt. The thing that struck me most was when Mr. Perkins said basically, that it's not a conspiracy its a way of life. It is run by corporations who heavily influence government who want access to fuel and markets and resources etc. For example, whenever the government does something in a new country private companies get the money. Halliburton is a prime example in that it profits off of a politically established situation. When people say Iraq is about oil they are right but it is not just about oil its about money in general: see documentary Iraq for Sale. The worst part is that there are other situations that have happened and are happening just like this on a smaller scale where companies are capitalizing from development contracts, smaller wars and insurrections, privatization of things like water and other utilities, and in many cases the countries gain little in comparison to what the 'donating county' gains. So if corporations are behind it all, then we as consumers are behind it all. If governments are behind it all, then we as active or inactive members of our society are behind it. Every dollar we donate to organizations is almost like retribution, blood money to replace our unfair extractions.

But we are the non malicious piece. The system around us may also be non-malicious as everyone just tried to do their job. We want to be able to live our lives as we know it, but the problem is the life as we know it. If the recession and the issues with banks has taught us anything it's that we consume too much, we spend too much money we don't have. We are fueling the corporatocary paying those folks salaries all for lower prices for things that we mostly don't need! We fuel the malicious piece so if we know we should try to take a step back and be conscious shoppers. I don't think that people should completely ditch buying things, I think people should try to think about what they buy. Where does that outfit come from? What are the practices of that company? How much oil was used to bring that thing here. The point is understanding whats behind what we're doing so we can not blidly contribute to companies that are heavily polluting our enviroment , expoiting impoveristed nations, etc.

And if all of this is just too much to think about consider this (thanks Christine): If Chiquita Banana used poor children down the street from you to pick their banana's, would you support/patronize Chiquita? If oil was mined by your house that caused massive destruction of the surrounding environment such that you have changes in your farm lands because of it, AND you lived in poverty due to that destruction of the land you live off of, would you support that oil company? These scenarios play out everyday somewhere in the world. Please try to see the impact of some of these companies and realize that you will be fine without as much stuff and that you can afford to pay 5 dollars (instead of paying 2 dollars at ****mart) for fair trade or locally produced something if you don't buy as much stuff. People have a right to make a living, but I don't believe making a living is simply to be accepted no matter what the cost to people or environment.

I still do a lot of shopping and wasting, but I'm trying to do better. I know that all any person can do when bombarded by very convincing adverts and a culture of buying of disposables, is try his or her best to resist. And Lord willing one day I will be in a place where I feel good about all the money i earn and spend.