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!

Facilitating a Correction

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

Working in a women's correctional facility over the past week has been a very insightful learning experience. In many ways, there are no differences between care on either side of the barbed wire. Patients present for treatment of hypertension, diabetes, GERD, thyroid dysfunction, asthma, irregular menses, UTIs, and general health maintenance. Labs can be ordered on-site, and a relatively large formulary is utilized. Patients attend all appointments and are 100% compliant with medications. As in an "outside" clinic, patients with surgical needs are referred to the hospital. If not for the homogenous uniforms and locking steel doors, one would never know the clinic was in a prison.

I was allowed to examine Monica, a very friendly middle-aged woman following up with several chronic illnesses. Aside from her shackles, she could have been any patient seen in outpatient clinic. As we lightly conversed about the weather and the prison food, I realized that I had been previously acquainted with Monica. Several years earlier, I met her under a front page headline of the daily paper, her smiling mugshot juxtaposed by the grisly details of a cold-blooded murder. Her arrest and subsequent trial had been sensationalized in the media, due to the sheer cruelty and brutality of the crime. Oh yes.  

That Monica.

During my first year of medical school, we completed an exercise to identify possible prejudices we may have toward different groups of patients. We discussed the reactions we may have to treating homeless patients, welfare recipients, drug and alcohol abusers, criminals, unmarried mothers, racial supremacists, undocumented immigrants, and other difficult social populations. Through that exercise, I learned that I was uncomfortable with murderers and sex offenders. It seemed rather contradictory to provide love and care for someone who deliberately preyed on vulnerable people, or who ended a life in a planned, methodical manner. Would treating these offenders facilitate them to commit more crimes? This dilemma was discussed, but not resolved. We were advised to be cognizant of our biases, and maintain professionalism. 

Personally, I believe the doctor-patient relationship to be the crux of primary healthcare. Forming a bond with a patient is the key to obtaining an exhaustive history, and unearthing previously overlooked details crucial to treatment. How could I connect with a person who committed such a heinous act?

How was I going to effectively serve this patient? Employment of a defense mechanism seemed most appropriate. While I listened to Monica's heart and lungs, I considered my options:

• Denial - believing I had the names confused, and Monica was not the killer I recalled
• Intellectualization - considering the pathophysiology of Monica's chronic diseases 
• Conversion - involuntary development of blindness in order to avoid completing the exam
• Reaction formation -becoming overly accommodating and friendly to compensate for my negative feelings
• Idealization - convincing myself of Monica's innocence
• Suppression - curbing my thoughts and focusing on completing the exam
• Rationalization - believing that Monica had a justifiable reason for her crime
• Humor - joking with the patient to circumvent the elephant in the room

While I contemplated this and moved to test Monica's reflexes, she intuitively asked me how I liked working in the prison. "Are you OK with treating all these crazy people in here? That's gotta be hard." Without hesitation, I replied. "It's not so bad. Really, patients need care no matter where they are — hospital, clinic, prison, nursing home, on the street. I love helping folks, and making life a little easier for them". Wow. Where did that answer come from? I have no doubt that divine intervention was in play. How humbled and blessed I felt to realize that the Most High had used Monica to teach me such an important lesson. Monica was no more or no less deserving than any other patient. My calling is to heal and serve, not to judge. As a physician, my role is to provided objective, empathetic care to help my patients live with good quality of life and optimal health. After accepting this call, my objections to treat patients are moot points. It only took a day in prison to facilitate this realization, and correct my attitudes. 

Thank you, Monica. 

The will of God will never take you, 

where the Spirit of God cannot work through you, 

where the wisdom of God cannot teach you, 

where the army of God cannot protect you, 

where the hands of God cannot mold you

~ Author Unknown

Choices: The Question

  ** Names and details have been changed to protect patient confidentiality, privacy, and dignity **
Jenna presented to the prenatal clinic last week, looking younger than her stated age of 15. She was accompanied by her mother, who had a toddler in tow. The tension between mother and daughter was palpable. Through extracting the history, I learned that Jenna was 4-6 weeks pregnant, identified during a routine school physical, and she was unsure of her last menstrual period, as well as the sexual encounter which led to the pregnancy. We struggled through a family history based on Jenna's recollection, since her mother was not willing to contribute any information, and avoided Jenna's pleading stares by adjusting the younger brothers' jacket.

When the resident arrived, we took her to the examination room for a pelvic exam. Jenna had never heard of a Pap smear, let alone had one. She tolerated our poking, prodding, and manipulations well, though visibly disturbed to learn that she would have to endure more of these exams as her pregnancy progressed. We attempted to engage her with small talk around her aspirations, her social life, and her plans to watch the new "Twilight" movie, but she was quite withdrawn. It was understandable, given the circumstances. 

After the exam, we rejoined her mother. The disappointment in her daughter, guilt of the situation, and stress of keeping a toddler occupied in the office had taken their toll on her. Mother and daughter quickly engaged in a verbal altercation involving a newly received text message. My resident escorted sobbing mother and wailing toddler out of the room to calm them, while I remained with Jenna. 

So there we were. 

I asked Jenna if she had any questions. She shook her head "no". I briefly explained the purpose of pelvic exams, prenatal vitamins, and blood testing while she fiddled with the zipper of her hoodie. One remaining question ate at me, needing to be asked.

"Has anyone talked to you about whether or not you wanted to keep the baby?" 

Jenna's head flew up. "No, they haven't." She relayed that her boyfriend did not believe in abortion, but she wasn't sure what to do. She was scared to ask about her options for abortions, not knowing her mother's stance on the matter. Her pediatrician provided the prenatal vitamins and referred her to the office, without discussing the option of termination. Jenna lacked even the basic knowledge of medical or surgical abortions.

Should women receive information regarding the termination of pregnancy on their prenatal visits? Does the moral position of the physician matter? In my previous post Choices, I described the graphic nature of surgical abortions and my reconsideration of my strict Pro-Choice beliefs. I didn't want to encourage Jenna to have an abortion, but felt that she needed the information to make an informed decision. In the age of patient autonomy, all options for treatment should be discussed. Was Jenna too young to understand these serious issues? Possibly. Should I have waited until her mother was calm and ready for discussion? Perhaps. Would it be appropriate to refer Jenna to a clinic for more information? I'm not ethically certain. I felt it was my duty to at least ask the question.

After the storm had settled, Jenna's mother, brother, and the resident rejoined us. We scheduled an appointment for next month, which would still give Jenna time to decide if she wanted to continue the pregnancy. Mother was still a bit hostile, and Jenna still subdued, but seemed to be relieved that there were other options available to her.

Autopilot

After a night of turbulent air travel home from the American Academy of Family Physicians Conference this weekend, I relaxed by watching a NOVA documentary on— what else —air travel. This particular program investigated Air France flight 447, a flight from Brazil to Paris which crashed into the Atlantic Ocean on June 1, 2009, killing 218.

A team of independent investigators compiled evidence from the plane wreckage, weather conditions, transcripts from radio communication, and reports from past malfunctions of similar aircraft. It was determined that the plane had encountered a severe thunderstorm, which coated exterior speed sensors with ice. This caused the automatic flight systems to shut off, leading rapid deceleration and an eventual stall of the plane. A flight simulator was set up with similar conditions to that faced by the pilots of Flight 447. During the simulation, experienced training pilots relied on their manual skills to fly the plane, and immediately took control to right the plane. It was postulated that the pilots of Flight 447 may not have had the training to manually maneuver a plane out of complex situations, due to the over-reliance on automated technology. Once the automatic system failed, they may have hesitated to take manual control, advancing into an irreversibly, and ultimately fatal situation.

How does this apply to medicine? In this day and age, the growth of technology has been exponential in the healthcare setting. Digital imaging, electronic medical records, nuclear scans, Doppler ultrasounds, tablets and laptop computers have all become commonplace in America's hospitals and clinics over the past decade. Vital information regarding patient treatment and history is stored digitally. Simultaneously, blogs and editorials have been published describing the "death" of the physical exam, criticizing the ineptitude of recent medical graduates performing basic exams and missing obvious signs. 

Like the crew members of Air France Flight 447,  we are highly trained professionals, tested and trained for the worst-case scenarios. We are very comfortable with technology, and do our jobs using electronic tools as aids. This is sufficient greater than 90% of the time, but what happens when we encounter situations which void our tools? Can we effectively rely on "manual" medicine (inspection, auscultation, palpation, percussion) to diagnose and treat? Can we function without "autopilot" applications and calculators? Are we less adequate physicians because of our reliance on technology? And, in the worst case scenario, will our inadequacy cost lives?

Morte

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

 

Simone, a 15 year old patient with sickle-cell anemia walked into the specialty clinic today. She was not yet due for a follow-up, but her condition had changed. She was now 2 months pregnant.

As I performed the history and physical, critical thoughts ran through my mind. "What was she thinking? Teenage mothers are already at increased risk for premature birth, hypertension, and low birth weight. The additional burden of sickle-cell anemia may prove fatal for mother or baby. How did this happen?" I worked hard to remain non-judgmental, and tried to focus my interview to pertinent health issues.

After discussing the situation with a colleague, I came away with a different point of view. I expressed my worries of the teen mother and child. He coyly asked me to remind him of the life expectancy of patients with SCA. Based on current statistics, most never reach the age of 50. I immediately realized my error.

Considering this young woman's life, she has most likely had several bitter tastes of mortality. Living with sickle-cell anemia has probably brought her to many emergency departments due to "pain crises"-- severe pain in her extremities, abdomen, and chest caused by the stiff, sharp edges of her red blood cells occluding her delicate capillaries. She may have developed gallstones in her short lifetime, and may already experience declining kidney function. The threats of blindness, heart attacks, and strokes remain with her. Young Simone will probably endure numerous surgeries to save her organs, with lengthened post-op recovery time.

As I began to delve more deeply into Simone's situation, the picture broadened. As a young black female in an urban southern city, chances are that she has known victims of violent crime. She may have buried classmates, neighbors, and relatives by this point. She is also most likely bombarded with images of mortality on a daily basis; bleak news reports of war casualties, drowning victims, suicide bombers, celebrity overdoses, murder-suicides, bizarre accidents can all take their toll. In fact, it is quite challenging to open a news web page without viewing an article involving death. Simone may feel the underlying need to experience as much life as possible before she passes on. 

Perhaps this issue is not limited to young sickle-cell anemia patients. Perhaps the idea of impending mortality is pervasive among all young adults. Graphic media coverage of the Columbine shootings, the 9/11/01 attacks, Hurricane Katrina, the Haiti earthquake, Osama bin Laden's death emphasize the fragility of human life, and drive the urgency to live life to the fullest. Like Simone, young people may subconsciously strive to become adults prematurely and experience as much as possible, pressured by impending doom. 

How can I best inspire these patients? Is there any way to infuse hope? 

Death twitches my ear. 
''Live,'' he says, ''for I am coming."

- Virgil

Choices

Today, I visited a nationally-known family planning clinic, as part of a class assignment. I have always been pro-choice, but my perspective stemmed from abstract political and idealistic positions. The topic had never been real to me. I had never known anyone who was faced with the decision of whether to proceed or terminate a pregnancy. I had never seen an abortion procedure before. Today, my abstract sketch became a gritty, beautiful, full-color picture.

I was fortunate enough to have time to speak with the physician who performs abortion procedures, and who gave me a history of women's reproductive rights, as well as the current ethical, legal, and moral issues of today. He described that in the past, pre-Roe v. Wade, abortions were completed all the time, at the physician's discretion. Teenagers who were not ready to be mothers and older women with unplanned pregnancies were those most commonly provided for. At that time, abortions of fetuses under 20 weeks and/or under 500 grams were considered miscarriages. Those over 20 weeks required death certificate registration.

We also discussed today's legal dilemmas. First, when is an embryo/fetus considered a person? If "personhood" is considered at time of conception, are the 400,000 frozen embryos at fertility clinics considered people? If "personhood" is determined at viability (at present, 24 weeks), will that change as our technology becomes more and more advanced? Some may consider abortion permissible under the cases of rape or incest. However, who is to judge if a woman is raped or not? What constitutes rape? Some may support abortion, but object to women who continue to have abortion after abortion, as a form of birth control. The doctor believes that this is someone's personal choice, and ethically, we are obligated to provide care. Who are we to deny a woman a service, simply because they have had it before and we believe they are acting irresponsibly? Are we also to deny a patient with chest pain emergency care, because he continues to eat fast food and doesn't exercise? Who are we to judge who is "deserving" of medical care? Ethically, what applies to one should apply to all.

And then it was time for the procedure. The entire procedure took about 15 minutes, but seemed as if it lasted an hour. First, an ultrasound was done to confirm and date the pregnancy. I had seen and performed ultrasounds before, but this time was different. The mother was not excited to see the fetal heartbeat. She didn't wish to know the gender of the baby. She didn't discuss future names, or where she plans on delivering. She didn't want a copy of the sonogram. It occurred to me-- this was the last time that fetus would be shown alive and well.

After confirmation, the doctor began the procedure. A nurse stayed at the head of the exam table to hold the patient's hand. I stayed at the "business end", with the physician. First, the patient's cervix was sterilized and numbed. Then, dilation began, using metal rods of increasing width. Judging from the patient's tears and cries, this is a painful process. After the cervix was dilated to an appropriate size, a suction was inserted, and bloody tissue filled the tube. After 5 minutes, it was over.

While the patient rested, the physician and I went to the sink to filter the tissue to ensure that the pregnancy had been terminated. It was just expelled tissue, until we saw the tiny fetus. I saw its spine, its legs, its toes. Abortion had never hit me as being that real. Pro-choice activists claim that the fetus is just "a clump of cells". That was what I had expected, but not what I saw. And what I saw will stay with me, burned into my memory.

My experience was emotionally trying, yet enlightening. As a future family physician, I may be asked to complete or assist abortions in the future. Given my personal standpoint on children, I had flippantly decided that I would "just get an abortion" if I happened to become pregnant. After witnessing the procedures, I'm not sure if I could. While I remain firm in my belief that women have the right to choose whether they carry a pregnancy to term, I'm now unsure of what choice I would make in that same position.

For Here or To Go?

I was watching a rerun of Gordon Ramsay's Kitchen Nightmares, in which Chef Ramsay attempted to aid a failing French restaurateur who believed that his business suffered because American diners didn't "appreciate the quality of life" as they do in France, and didn't want to enjoy rich foods over a 3 hour service. Throughout the program, Ramsay convinced the chef to begin cooking simpler dishes that were more attractive to American clientele, which would allow for shorter service time and higher turnover of tables, and thus, more profit. In order to achieve success, the French chef had to adapt.

Is this the case for all service in American culture? Although it is known that slower meal consumption aids digestion and prevents overeating, Americans typically eat quickly and move on with their day's responsibilities. The most successful businesses in America offer fast services (fast food restaurants, one-stop shopping, online ordering, quick lube stations), multi-tasking (smartphones, multi-function gaming consoles) and low prices. Medically, the "minute clinics" flourish -- a mechanism to see a health professional to manage minor problems, complete physicals, and get out quickly. American society revolves around convenience, impulse, and speed. A doctor's office appointment is often too long to accommodate. In this society, who has the time to wait? Once seen, patients expect a pill or a shot for immediate relief. The culture no longer allows for extended respite, or long recoveries in countryside sanitariums.

In the clinics and wards, this is referred to as "Fast Food Medicine" or "Drive-Thru Healthcare". Patients demand the organized service of a Subway, with the speed of the fastest sandwich artist, and the efficiency of McDonalds, with relief as immediate as heartburn after downing a QPC or a 10 pc nugget meal.

In my health promotion undergraduate education, we discussed the principles of cultural acceptance and tailoring health treatments to fit the cultural norms. If American culture is that of speed and pressure, is it reasonable to expect American patients to adapt to long-term lifestyle changes? Are we, as health professionals, akin to the arrogant French chef, insisting that our way is superior, and the customers are the ones with the problems? Do we need a different approach to address chronic health problems in Americans?

Perhaps the following would enhance care of Americans:

• focusing on short term goals (i.e. losing 2 lbs this week)
• accentuating immediate relief  (i.e. feeling stronger the night after working out)
• less wait time in the office (allowing kiosk check-in, not over- or double-booking appointments)
• more availability (more offices in strip malls,close to schools and centers of commerce)
• price lists, depending on patient payment plans

We tailor treatment to patients of different cultures on a daily basis. Let's not forget our own.