So Shall Ye Reap

** Names and details have been changed to protect patient confidentiality, privacy, and dignity **

It is autumn in rural America. The green-hued sweet gums, oaks, and sycamore trees now boast their orange and yellow palates. The fields of corn which bore ears for the farmers markets and lifestock feed are actively plowed to the ground. Combines rest in the expanses after a hard day's work. Advertisements for fresh apples and pumpkins litter the roadway. It was harvest time. I drove to the hospital, surrounded by the changing fall landscape. Like the combine, I too was headed for a harvest.

To say that I met Kevin would be a misstatement. I became aquainted with Kevin in his ICU bed. He was a young white male, half a century younger than his hospital neigbors. He was intubated and unresponsive, with a central line sprouting from his neck, and an IV in his forearm. I examined him daily, noting his absent reflexes and fixed pupils. The ICU team evaluated him on daily rounds, noting any minute changes in his care. Kevin was not getting any better. He had multiple organ failure, and received multiple rounds of CPR over the past week. The treatment options for acute medicine had been exhausted. We placed a consult to the neurologist to test his brain function.

Kevin didn't blink when a cotton swab was placed on his eyes. He didn't turn when ice water was dropped into his ear. Hedidn't flinch when a reflex hammer was tapped on his tendons. Kevin was brain dead. His family was notified, and plans to withdraw care were determined. But there was a caveat; Kevin was an organ donor. His heart and kidneys had been damaged, but his eyes, liver, and lungs could be of use. We began giving IV fluids and monitoring his blood pressure more stringently, as to preserve the organs for donation. Surgical transplant teams were notified, and made plans to fly in for retrieval.

Since organ donation "harvests" take place at night, I was asked to attend. I had cared for Kevin for several days, and knew his histoy well.I arrived at Kevins hospital bed as the helicopter was landing 6 floors above. His family surrounded the bed. I noticed that he had been clean-shaven with the slight aroma of cologne on his bedsheets. He remained unresponsive as the family said their goodbyes, and whispered to him. The team slowly trailed into the room. Nurses, respiratory therapists, OR technicians, and myself were present as "farmhands", preparing and assisting in the process.I heard the screams and wails of his family behind us as we wheeled his bed towards the elevators.

The "harvest" went quickly. Teams from large institutions came in to retrieve the organs needed for their patients. Kevin remained sedated as the surgical specialists worked on various parts of his body, lowering his body temperature with ice to ensure that the organ was preserved for transport. They made the process as quick and as dignified as possible. The organs were packaged and placed in coolers, and rushed to the awaiting helicopter. I held his discordant, weak heart while his lungs were removed, and watched the contractions slow to a halt. Kevin's incisions were then sown together, and he was placed on a gurney.

Like Kevin, I too have elected to be an organ donor.This experience did not alter my decision-- I was comforted by the professionalism and dignity-preserving methods utilized by the transplant team.I was thankful for Kevin's decision to give life to strangers, to prolong the life of others, even in death.

At some point, I may find myself in an ICU hospital bed, awaiting "harvest".

As ye reap, so shall ye sow.

Pained: Folie a Deux

** Names and details have been changed to protect patient confidentiality, privacy, and dignity **  

Marla was in pain. 

Pain is subjective. Heart rate and blood pressure tend to elevate with pain, but this is not definite. We attempt to quantify pain by using a scale of 1 to 10, with a "10" equivalent to childbirth or the passage of kidney stones. Again, this is subjective. It can be a challenge to evaluate and manage pain, especially with the growing issue of narcotic abuse.

Marla rated her pain as "100 out of 10", and writhed in pain as I obtained her medical history. Her pain was generalized -- she couldn't verbalize a specific part or region that aggravated her. Her husband held her hand, and interjected responses designed to guide my decision making. She needed pain medication, he said. Surely I understood. Marla looked at her husband before answering my questions.

I observed their interaction as I listened to her tachycardic heartbeat. Her husband was agitated, and rambled about getting rich from filing million-dollar lawsuits against the hospital. They had visited numerous emergency departments in the area, and one one understood their predicament. She was hesitant. Was she afraid of him?

Gut feelings are hardly admissible as objective medical findings or evidence in a courtroom, but I was suspicious of Marla's husband. I examined her carefully, searching not only for the source of her pain, but for signs of domestic violence. Her abdomen could be concealing a pregnancy or inflamed appendix, but could also hold welts. Her eyes may have the recession of dehydration or the pallor of anemia, but may also reveal the jaundice of healing bruises. Her bare arms were tattooed, but may have also been burned by cigarettes. I found nothing. 

Marla's husband grew impatient. He yelled in my face, demanding a prescription for Dilaudid to relieve his wife's pain. She flinched as he raised his voice. Was he using her to obtain narcotics? Did he force her to come to the ED?


I escorted her to the restroom with a specimen cup. Before she shut the door, I whispered the SAFE screen. Did she feel Safe in her relationship? Had her husband ever threatened or Abused her? Would her Friends or Family know if she were hurt by him? Did she have an Emergency plan? Her responses centered around the supportive nature of her relationship. She told me she would have never survived without his support. Her eyes were dull, but she begged me to believe her witness.

Still, I wasn't convinced. Were my suspicions valid? Perhaps my reaction was transference from my prior violent relationship, and I identified with Marla. Perhaps I was searching for the real reason for her vague symptoms and intense pain. Should I refer her to the police? A social worker? What would I say to them? I had no evidence to support my suspicions. I also had no evidence to support a prescription for narcotics.

I watched as they left the hospital, arm in arm, commiserating about the unfeeling doc who wouldn't give her Dilaudid. 

TIH: Bonjou (Hello)

Early on the first day of Kwanzaa, the 40 members of the International Medical Relief - Haiti team arrived at the Miami Airport. Given the large amount of people and luggage, we were extremely well organized. We moved through security with ease, and bought our last lattes, biscuits, and cinnamon buns of 2011.

I was thrust into a test of my limited French during the AirFrance flight. All announcements were spoken in French, followed by curtailed English summaries. I had expected to hear Haitian Creole, but learned that most affluent people from Haiti (those who could afford plane tickets and passports) were well-educated, and received academic lectures in French only.

From my prior trip to Africa, I knew a notable perquisite of international travel was the airplane food. During the 90 minute flight, I pretended to read the SkyMagazine (printed en Français), sipped hot tea and nibbled on a blueberry muffin, while poorly phonating "s'il vous plait" and "merci beaucoup" to the multilingual, impeccably dressed flight attendants. They collected our food trays as the aircraft descended over Cite Soleil, one the most dangerous and impoverished areas of Port au Prince.

Upon arrival, we were greeted by a small band playing guitars and steel drums; a warm welcome to an even warmer climate. We retrieved our baggage from claim, though it was difficult to maintain control of the luggage. The airport employees were desperate for American tips and insisted on our acceptance of their help. Some heated conflict developed outside the bus over the dispersal and amount of money given. Our security officers cleared up the confusion, and we headed to the base camp.

The base camp, run by a forward-thinking, community- rooted, eco-friendly organization, was prepared and ready for 40 volunteers to unpack and settle into the living quarters. We received a tour of the grounds, including showers and bathrooms. Already uncomfortable using public facilities, I was a bit squeamish with the system of placing sawdust in the outdoor latrine, rather than a flush. But this was Haiti, not America. I came to Haiti to provide care, not to ensure my own comfort. If this was how one uses a facility in Haiti, so be it. 


While some made beds and organized, a few volunteers walked 40 minutes to an orphanage to distribute chewable vitamins, toothbrushes, and toothpaste. I was fatigued, and opted to stay at the camp. When the group came back, they shared what they experienced. They passed a corpse in the road, apparently who had expired earlier that day. In the US, one last a lifetime without viewing a deceased body, but this was Haiti. Between the rogue violence, prevalence of disease, lack of access to healthcare, and the mass casualties from the 2010 earthquake, an average citizen may encounter a deceased body every day. Once at the orphanage, my teammates enjoyed playing and visiting with the children. They were excited to receive the items, and proceeded to eat the toothpaste and vitamins like candy.

At night, a group came to express the history of Haiti through spoken word and visual aids. They performed the history of Haiti, describing how the European lust for gold had triggered the slave trade, and graphically described the rapes, lynchings, and torture of Haitian native residents and African slaves brought to the Caribbean. I could tell that a few group members were uncomfortable with the implications of Christian missionaries and Europeans in these acts, but this was Haiti. How would we effectively understand the struggles of our patients, if we didn't acknowledge how history may contribute to their perceptions, expectations, and challenges.

We ate dinner, packed supplies, and slipped under mosquito nets for rest in preparation for our first clinic day. 
[to be continued]

TIH- This is Haiti

I had the opportunity to volunteer on a medical mission over the Winter holidays. While my 2009 trip to Ghana invigorated my passion for international medicine, I hadn't had the time to travel since then, due to clinical rotations and Step exam preparation. With the goal of completing a short-term mission prior to residency, I searched for organizations via Google. I stumbled upon International Medical Relief and applied.


International Medical Relief (http://www.internationalmedicalrelief.org/) conducts 1-2 week medical mission trips to India, Senegal, Haiti, Panama, Ethiopia, Kenya, Romania, Cambodia, Peru and others; utilizing physicians, nurses, therapists, dentists, healthcare professionals, as well as non-medical support staff to bring care to underserved rural and urban residents. IMR was present in Haiti only 4 days after the 2010 earthquake, and established partnerships since this point. I was impressed by the focus on teaching and training for disease prevention and management, rather than providing a month's worth of medication and retreating back to the US with no patient follow-up. The deep-rooted relationships IMR forms in countries also ensures that critically ill patients can be admitted, treated, and re-evaluated. The Haiti trip sounded like a perfect opportunity to impact lives and utilize my health education background while receiving mentorship from physicians committed to international medicine.


Several months of paperwork, conference calls, and vaccinations later, I was on my way to Haiti. The team met in Miami on Christmas Day to sort supplies become acquainted. It was exciting to meet my 40 teammates and begin organizing the thousands of donated medications and equipment. The altruistic synergy among us was incredible. We ate together and shared stories and experiences from varied careers. Most of us had never visited Haiti, while our team leaders had been very instrumental in medical relief immediately after the 2010 earthquake. Their passion and excitement for the trip was energizing. I was lost in admiration for their courage, compassion, and dedication during such a stressful, tragic emergency. They became instant role models. Early the next morning, we loaded up shuttle buses with passports in hand and arrived at the Miami International Airport. [to be continued] 


The following entries contain my notes and thoughts during my week-long medical mission. 
Please enjoy and comment freely!

Identity

My first hospital job was in an OR recovery room. I was more of a switchboard operator than anything else...communicating with the OR and hospital floors- finding beds for patients, coordinating with ambulatory care for discharges, and keeping staff abreast of OR scheduling status. The calls would come in from the OR in the morning: "there's a hip coming in at 800am, after that we've got a lap chole". I envisioned a disembodied knee crawling down the hallway, followed by a hopping gallbladder. How would patients feel, knowing their hospital existence was reduced to their conditions? Or...maybe it's self-inflicted....

There have been plenty of JAMA and NEJM articles regarding the depersonalization of patients, the reduction of humans into disease conditions, but I have yet to read an article detailing how self-labeling impacts health. It always amuses me when a man introduces himself to me, and right away discloses that he has "ADHD". I usually retort, "Does that mean you can't take me to dinner?"

I hold the firm belief that everyone has or will have some medical issue, be it mental, physical, social, or otherwise. Does a disease define the person? Does the person define the course of disease? Does identifying oneself as a sufferer of a disease hinder the recovery, because that becomes their sole identity? Would a cure or remission deprive one of their identity? Would you be the same person if you were in complete health and free of disease?

I am not the panic disorder. I do not hug the brain injured in the morning, go to school with the depressed,  meet for lunch with the diabetic, and work out with the bowel disease. I do not call the stenotic valve and the prostate cancer on holidays, and send a gift to the preemie. The disease shouldn't define us...it should simply be an aspect, a facet to the many sides of a complex personality and a lifetime of memories. It should add richness to life, a chance to learn, teach, and be a catalyst for others' learning. I was told that Navajo weavers are sure to include a tiny defect in their rugs, acknowledging the imperfections and mistakes in life, and recognizing the beauty despite it, and within it. The mistake is not the totality of the rug, nor is it diminished into obscurity. It is celebrated for what it is.