Saturday, July 9, 2011

Happy Birthday South Sudan



If you can find a medical school that will accept you, my wife and I will support you financially.

That's what I told Mabior when I left Sudan. He was the best student I'd ever seen - he'd unknowingly earned a scholarship invented for him, on the spot.

The Nile

Mabior’s whole education had taken place in refugee camps in Somalia and Kenya. Instead of a formal degree, he held a certificate of training as a medical assistant (from UNHCR, I believe). He was a Lost Boy of Sudan. Mabior had lost his family and his home in the Sudanese civil war of the nineties. MSF (Doctors Without Borders) had taken over an abandoned building, inflated a tent as an operating theater, and become the only functioning hospital in an area the size of England. Mabior had returned to serve his childhood home community in South Sudan.

Bor was a Nile-side shanty town doubling in population every couple of weeks with returning refugees. I operated with MSF there, mostly on victims of inter-tribal gun violence and on infants who’d crawled into cooking fires.

Bor

At six-foot-nine, Mabior wasn’t the tallest of his trainee colleagues (many Dinka among them), but he distinguished himself as their natural leader. Easy charm, photographic memory, and tenacity served him well. After his daily twelve-hour shift, he’d come to the operating room to pass his free time learning anesthesia and surgery. In a couple of weeks he was doing inductions, unpaid in his spare time.

Mabior arranged for me and our Hong Kong anesthesiologist to lecture his young colleagues, who functioned as interns after a high-school education and a course in medicine. He took roll and helped his mates to understand our English.

Shortly after I flew out of Bor in a four-seater, Mabior left for Kenya with a bag holding his world.  He was bound to plead his case at Nairobi med schools. Election-time mass violence held him up, so he took a right turn for Uganda instead.  He was having trouble crossing the border – little surprise, given the lack of formal government, much less travel documents in his departing land. Absence of a bank in a two-hundred-mile radius also held up our plan.

I was in Phoenix drinking a Margarita under umbrella and cooling mister when Mabior called to update me from malarial African hinterlands. Our communication was poor, but I made out that he lacked money, a travel pass, and food. He had no school interviews pre-arranged and was bound for a city unfamiliar to us both. He'd never seen a city before. And now he was rafting the Nile or something - I couldn't really tell. Our scheme was a long shot, but I hadn’t intended to send Mabior to his death by crocodile. Best I could understand he was stranded halfway on a marshy 300-mile cow-trail between Bor and Kampala. (His phone service was a mystery, but noise from the Chandler Chihuahau races and my sizzling fajitas made hearing impossible.)

Mabior was a survivor, accustomed to long foot-journeys, hunger, and making his own way in a violent world without roads, leaders, or services. He walked back to his shanty town with its one bank, picked up my deposit, stocked his bag with bread and started again.

Weeks later, he called again. He’d been accepted conditionally at the third school he tried. I was ecstatic!

Just one problem Dr Chris.

Yes?

I was robbed while speaking to the admissions officers. I left my bag outside the office and all my things are gone. I’m very sorry.

Mabior. I said, Find a Western Union and buy yourself a stethoscope.


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July 9, 2011, South Sudan became our planet's newest nation, after decades of civil war killing millions. I'm hopeful Mabior will become the first native doctor in a new nation of peace.

Happy Birthday, Sudan - Mabior's education is a gift from my family.

Mabior, holding roll-book on right. Porter, white guy, second from right.

Thursday, July 7, 2011

e-Patient Dave on TED

I had some issues with this TED talk -  Dave deBronkart: Meet e-Patient Dave

Information is power. I'm all for patient networks - support groups are crucial for helping patients help themselves. I agree patients are an underutilized resource in health care.

The speech strikes me as adversarial, however (give me my damn data..,) when we should be striving for doctor-patient collaboration.

I'm also troubled with parts of the speech suggesting ignorance and conspiracy on the part of the medical profession. Such as,

Most hospitals don't offer it so they won't even tell you it exists...don't let them give you anything else first...Four years later, you can't find a website that gives you that information...this amazing substance...

Many of the comments on the TED page suggest the same. This jaded view (plus one terrible doctor) were behind the empowered-patient-led anti-vaccine movement which set back public health a great deal.

I'm doubtful that any oncologist in the US was unaware of Interleukin for RCC in 2006. Also doubtful that oncologists would keep it secret from a patient. I just googled and found it everywhere.

I would love to know how common or rare Mr deBronkart's result is - is the Interleukin amazing for many or for few? Useless or even tragic for the rest? Miracle cures are usually a miracle for very few, while anecdotes carry great persuasive power.

As many faults as our health care system has, I believe that promoting distrust (You people can't be trusted to keep [my data] clean) on TED of all places, is a disservice to provider-patient relationships and to public health.

Let's cooperate, please, for the greater common good.

Added 2 AM July 8: 
To be clear, I believe his frustrations with our system are common and well-founded. My concern is the speech demonizes not a system but 'they' and 'you'. 'They' and 'you' are people trying to help him.

I nevertheless praise the lecture as inspiration for patient self-advocacy. Clearly most listeners took it as such.

Saturday, July 2, 2011

Hospitals in July


Me, as an intern:

Hello? This is Porter, general surgery intern.
Yeah, this is Engel. What’s going on? The nurse said you’re treating a tachycardia.
Hi, Dr Engel. Yeah. There’s a post-op heart patient here…um…64-year-old man who is status post…
Did you call the cardiologist?
No.
How did you know what to give?
From the ACLS algorithm. I just took the class.
You just medicated a post-op CABG patient with an ACLS card?
Um. Yeah, was I sup…
You didn’t call the cardiologist, the surgeon, or your senior resident? Man, you got some balls. The nurse called me cuz some cowboy intern was pushing drugs…
Sorry. I didn’t know I was supposed…

Besides clinical medicine, new computer software, cutting, sewing, and where to find a Kerlix, a fresh surgery intern has to learn his/her expected scope of practice, communication protocols, chain of command, and social norms in hospital culture. It takes time.

My instinct was to do whatever anyone asked me to do. As I result I packed bleeding noses I had no business packing, admitted patients without calling anybody, ordered x-rays without checking results.

Chief would tell me to order a CT on our inpatient and I would, without bothering to tell the patient or the nurse. I’d hear later the patient was refusing his CT scan.

I wrote transfer orders to the ICU without checking if a bed was available.

On speed rounds, an attending handed me a chart and said, put her back on Coumadin, whatever dose she was on, and discharge her. See you in the OR in five minutes.

I looked at her last Coumadin order – 10mg – wrote it in her discharge orders and ran to the operating room.

Asleep on the couch after a thirty-six-hour day, I was paged by a very excited internist and schooled on Coumadin dosing. (The woman’s usual home dose was 2 mg.)

It’s July. Remember who’s watching the flock.