The Things That Medical School Won't Teach You (11): "Communicating properly"

I'm recalling that in the course of this series, I've intimated that one of my justifications for getting into the business was my interaction with medical personnel during periods when I was sickly. Now, some of those interactions were uplifting, encouraging, even edifying; on other occasions, the interactions were simply dastardly. Medicine is indeed one of those fields where the old saying holds true: "They may forget what you said, but they will never forget how you made them feel". Every little thing you're doing, whether verbal or non-verbal, communicates something important to the patient.

My mind drifts off to the memory of "Communication 104" during Fall Semester 2002 (Messiah College). My biggest take home from that whole class was something that was taught very early on: while communicating, our responses can be broken down into 3 broad categories - Agreeing, Disagreeing, and Disconfirming. The first two are very obvious and I'm pretty sure everyone has a semblance of what they entail; whether we relate to what's being said, there is the underlying impression that we've at least recognized what the other person has put forward. Discomfirming is in a class of its own: not only are you obviously opposed to what's been put forward by your colleague, but you make it clear that you've disregarded it entirely. In other words, it is basically a "coup de grâce", a death blow.

From that little definition, let's dive into another little memory from my time at Messiah College.

I believe it was Thanksgiving 2004. My Zambian friend had been kind enough to invite a few of us from Rafiki House to go over to his host family's place for Thanksgiving Dinner. I remember it was a great meal; I especially remember developing an appreciation for pumpkin spice pie after that day (despite having disliked the taste of pumpkin up until then).

Unfortunately, the whole dinner didn't go down without incident. I remember that they had also invited over a (seemingly) 70 year old lady who had been a missionary in Sudan for a very very long time. Sometime in the middle of the dinner, she had the bright idea to chime in that she felt that the traditional systems had faded away in Africa, and thus she felt that the younger ones were lost with no one to impart the important lessons to them.

I remember being the most vocal of my friends (many of whom were predominantly African) in trying to convince this lady courteously that the picture was not that bleak. I reminded her that though traditionally my people were renowned fishermen, there is no disconnect despite the fact that we do not follow in the path of my ancestors; because between my parents, siblings and wider family, I can still get a good education on what's important in life. HOWEVER, it didn't sway her in the least, and she doubled down on her morose ideas. It's always a difficult task relating to people who are set in their ways. Here was a lady who had lived in a land steeped in civil war for decades projecting her bleak outlook on a whole continent without having ventured elsewhere within the continent. Worse still is the fact that she was old; everyone deserves a modicum of respect, especially the older generation; that being said, no one gets a blank cheque for their thoughts and tangents.

I remember casting glances at my friends during the conversation and getting two distinct vibes from them: "Richard...calm down...just let it go."

Being disconfirmed hurts no matter how old you are. It is the grand old equivalent of being patronized. It doesn't matter whether it comes from a friend, parent, sibling or colleague...it will sting deeply. Don't get me wrong: it can sometimes serve as a useful teaching tool. I am not a parent yet, but every parent definitely has a story where they've had to put a disrespectful child in their place. Those are definitely the times that children need to be humbled. There is nothing to be gained from negotiating. It is at times useful for people to be reminded who pays the bills that keep the house running, and that afford them the luxury that they experience every day. However, disconfirming should not be your primary tool of instruction. It wouldn't make a very good "coup de grâce" if you employed it willy-nilly, would it now?

Now, when I first got to Kenya after finishing med school in China, I was as "green" as they come. I hadn't really had any real employment experience, and I knew that there was probably a lot I'd have to get used to about practising medicine in a different context. It was rather convenient for me that they made me go through a 3-month pre-internship at the Kenyatta National Hospital (KNH). Surgery was my first rotation, which seemed like a great starting point because Surgery has always been my passion. The experience, on the other hand, turned out to be a mixed bag. I think that it was great to be around doctors of varying levels (Professors, Consultants, Registrars, Interns and students) as well as other cadres like nurses, nutritionists, physiotherapists, etc; however, what whittled things down a tad was the interaction with the consultants. I could understand that they were intelligent within their respective fields of specialization, but that didn't mean that they had to be so antagonistic. I especially felt sorry for the registrars; despite being my seniors, it wasn't surprising for me to encounter one of them being chewed out for no reason whatsoever by the consultants; if they were particularly unlucky, they'd be blasted in front of all the cadres of workers present during a ward round.

I remember experiencing something similar during my internship. It was particularly surprising when I would encounter it from the medical officers who oversaw us as interns. It's easier for me to sympathize with consultants who've been far removed from the experiences of their underlings for such a long time; but I could not understand how a medical officer - who was probably just an intern a few months prior - could be so quick to dish out the type of demeaning treatment that they had previously suffered to a whole new generation of interns. It bugged me to my core that someone would choose to incorporate such poor teaching methods, but then "that's the breaks".

I'm not trying to say that ALL Kenyan doctors are deficient in the communication department, but a lot of the ones I've encountered sadly fall into that bracket. I have encountered very many great teachers in this field, but the bad ones leave a particularly bad aftertaste. This is very different from what I'd experienced in China where we were free to mingle with all levels of doctors from Professors down to our own colleagues. Not knowing medical facts was not seen as a time to disgrace a student in front of his peers, but rather as a teachable moment in which to impart knowledge to the student. Sometimes, as an added bonus, the professor might provide you with the "cheats" that make him remember specific pertinent facts in a few seconds. Compassion goes much further in teaching than browbeating someone to a pulp. By the time I'd finished my KNH pre-internship, I felt pretty sure that I was not going to be pursuing post-graduate studies within Kenya. After slogging through a tumultous internship, it is now my conviction! I mean, an internship may seem long and tedious, but they can only stretch one year so long...and eventually it ends. I cannot fathom what 3 - 5 years of a registrar postgraduate experience must feel like given the same circumstances, but it is definitely something I would not look forward to.

Like I've already mentioned earlier, all these forms of communication are important in conveying ideas and truths. In light of how I've focused so negatively on disconfirming, you might think that I am totally against it...and that would be totally far from the truth. I remember at one point having to disconfirm a vast swathe of the members of my class at medical school. And that memory goes a little like this:

A surgeon had walked into our class to teach us about "The Liver". I couldn't tell you how much of the class was acting up, however, they were creating such a sizeable ruckus such that it was impossible to ignore them. It really was an untenable situation because the surgeon was having a hard time teaching, and the students who were actually trying to listen we're having the hardest of times hearing what was being taught.

My mind flashed back to the previous weekend. I had attended an international surgical conference at a symposium hall within the Medical Healthcare Centre at the First Affiliated Hospital (of Wenzhou Medical University) in the city. I remember 2 highlights from that experience - watching a livestreamed session of bariatric surgery which was taking place within one of the First Affiliated Hospital theaters; the second was a lecture on Selective decongestive devascularization shunt of gastrosplenic region (SDDS-GSR ), which is an adjunct measure to relieving liver and spleen issues arising from chronic liver disease. You could tell that people's minds were blown by this novel approach and people were eager for highly decorated Prof. Qiyu Zhang to explain it in detail.

A few days later, standing in front of my class and attempting to deliver a lecture to a bunch of unruly international students is none other than Prof. Qiyu Zhang. I was livid! A few days earlier, medical professionals from a host of countries had patiently waited to listen to this man, but today so-called doctors-in-training couldn't even bother to give him the time of day.

I walked up to the front of the classroom and pleaded with Prof. Zhang for a chance to talk to my colleagues. Taking the mic from his hands, I proceeded to lay into them for all the embarrassment that they had caused us. I contrasted their behaviour with that of the specialist audience a few days prior, and reminded them that within their respective countries they would never tolerate such belligerence from their juniors; the message was clear - sit down, keep quiet and act right!

I am glad to say that the class quieted down, and we had a problem-free lecture (at least for that day!).

I feel sad that my school really didn't bother relaying information about certain things to the international students...things that were very obvious to the Chinese students. I for one think that it would have been important for us to have known that Prof. Zhang was formerly THE PRESIDENT of the First Affiliated Hospital. Years earlier, this man had joined me at my table as I ate a meal alone in the hospital cafeteria, and I never found out that he had been a pillar of the hospital until much later!

If I had been in his position, and I was in a vengeful mood, I would have made things seriously difficult for the international students in my year. Only one year later we were slated to get placements for internships within the Wenzhou Medical University's affiliated hospitals, and he had the power to make that very difficult for us. Just have to thank God that he let things slide.

I know I focus on the medical aspect of things a lot, but the message here serves everyone: it is important to invest yourself in learning to communicate properly. Since medicine is such a hallowed profession, people usually make excuses for specialists who are poor teachers because of their clinical acumen. (they do that for pretty much any specialist in any field). You shouldn't make the same mistake. Acknowledge that people are differently gifted and aid them in their pursuit of personal betterment. Use all tools available at your disposal (including disconfirming), but reach out for compassion faster than anything else. The world will thank you for it.

God Bless
 

The Things That Medical School Won't Teach You (10): [Good] Leadership

"Thrown under the Bus" by Jason Jones

My (Kenyan) medical internship was a treasure trove of experiences, and thus on this fine day we will be revisiting one of those many formative experiences.

So I'm in the Obs/Gyne department (little surprise), and it was one of our elective theater days (either Monday or Thursday if memory serves me right), and I was assisting a consultant as he performed a TAH (aka Total Abdominal Hysterectomy). We've gotten through the relevant set of procedures, cut what needs cutting, and tied off any bleeders that need to be tied off. All this was done with very little blood loss all around.

So, now comes the moment of truth. Patient has been adequately hydrated by the anaesthetists and it's time to make sure that the patient is able to produce urine. So the patient gets a dose of a diuretic (Lasix/Furosemide), and we keep our eyes on the catheter that's been shoved up their urethra waiting to see some magic happen. Unfortunately, after about 10 minutes of watching, nary a drop of urine has collected in the urine bag. Basically, my consultant ended up tying up the patient's ureters during the procedure - the most common complication your medical school teachers would warn you about concerning this procedure.

So, it's back to the drawing board, or the chopping block as luck would have it. We proceed to backtrack trying to figure out at which point the ureters have been tied, and undo the damage. What should have been a 1 - 2 hour procedure ended up being a 5 hour long procedure with not so much as a break taken in-between; however, we came out of it thinking that we had at least salvaged the situation.

We skip forward to her time in the ward, and it becomes painfully obvious that the patient still isn't out of the woods. Her urine still isn't making it through the catheter, but, it is now draining through the incision scar in her abdomen. On the one hand, we're glad that she won't be developing kidney failure; on the other hand, we still have a veritable mess and our patient's dressing and bedding keep being stained with urine.

Worst of all was my consultant's decision to go AWOL and leave me "holding the hot potato". Imagine having to explain that stuff to the patient and her exasperated relatives day in and day out. At this point, the consultant is only addressing the issue via phone conversations with me. Eventually, plans ended up being made to transfer her to a bigger hospital to address the issue, but then some haggling over the issue of footing the ambulance bill to get her there broke out and threatened to lengthen her stay at our hospital. I don't remember how things finally got sorted out, but eventually she left, and I had never been so glad to see a patient leave.

Medicine in its most classical form is learned through apprenticeship. Some teachers might go a bit overboard with the "See one, do one, teach one" approach to learning procedures, but at the end of the day you need to be learning the nitty-gritty from someone else. With that in mind, when you're starting out you benefit from having a good leader who can impart useful knowledge, teach you the complexities of patient care, and even act as a mentor. Some of these people will actually sway you towards choosing which field to specialize in if you come into the game unsure of which direction you feel called in.

However, as I was recently reminded by a friend of mine, a "God Complex" almost certainly seems to be associated with doctors. I did take some time to correct the misconception though; just like I had been reminded by my friend Javed (circa Wenzhou, 2007), people have multiple reasons for choosing to become doctors. The way he broke it down for me, there were basically about 10 reasons, but the more common ones (of the top of my head) are as follows:

1. Prestige
2. Feeling called to help in society
3. Prior interaction with medical professionals due to your own/relative's illness
4. Money
5. Following in a parent's footsteps.

If "Prestige" is someone's driving force, you shouldn't really be surprised if patients, colleagues and juniors end up being used like mere stepping stones. You've probably been in the presence of doctors who made you feel like they were only interacting with you for the purpose of making a pay cheque - unnecessary tests, needlessly excessive repeat appointments, excessive medication, aggressively scheduling you for surgical procedures, etc. If we are looking to put a dent in your wallet, or take advantage of your insurance, many are the ways that we could make that happen. Truthfully, any doctor worth their salt should be able to explain their reasoning and justification for everything they subject you to, and you can always seek a second opinion if you're not convinced.

Medical school does not endeavour to develop people's character. They might sneak in an Ethics class or two, but character formation is really up to the individual and those that you choose to mentor you. So when it comes to "God Complexes", that was probably the default baseline setting of the respective individual. They would have ended up being a difficult lout regardless of whether they had chosen Business, Engineering, Politics, Fashion or Teaching.   

I have interacted with many doctors in my time who were very humble and willing to show me the ropes. My most vivid memory was working with Dr. Onkunya who showed me how to perform an excision of a breast fibroadenoma when I told him I had never performed one before. It was my first day in the Casualty, and one of my initial interactions with Dr. Onkunya, and I really didn't know what to expect. Fortunately, he was so concise and precise about the whole thing, and encouraging as he tutored me such that I was able to flawlessly replicate his technique and perform the next one on my own, and eventually teach the technique to others.

Unfortunately, I have also interacted with a lot of doctors that are a disservice to the profession. Some doctors merely see the practice of medicine as a power play and a chance to browbeat you into submission. You'd think you were in a boot camp, and they were drill sergeants. These doctors are usually short-tempered, prone to chastising and insulting you at the drop of a hat. Learning from them is also a task as they can opt to show you up in public (among your colleagues during ward rounds), and without remedying your ignorance, simply tell you to go read a book. Seems like their amount of bravado is inversely proportional to their actual skill. These doctors encourage you to basically hide your imperfection and basically "fake it till you make it", which, in light of rampant medical errors and malpractice, is about the worst thing you could ever do. Even at a basic level, doctors are tasked with repairing/fixing the human body and its processes after things have obviously gone awry; and we are expected to do it to such an extent - whether by surgery or drugs, physical therapy, etc - that the verisimilitude would approach that of a normal functioning body. You can't really fathom how much things can go wrong until you have to "undo" the work of one of your colleagues. This could range from poorly placed implants, poorly sutured wounds, erroneous drug prescriptions, missed diagnoses and misdiagnoses, etc.

A good practitioner will teach you to own up to your mistakes early, and to fix them as soon as possible; if that entails getting help, then get the aforementioned help; in retrospect, my Obs-Gyn consultant did just that - I just wish he had had the guts to actually talk to the aggrieved family face-to-face. A poor practitioner, however, is likely to be averse to admitting fault and/or blame others or systems for their failings. When that happens, you best be prepared to have yourself thrown under the bus for someone else's follies. I remember so vividly being tossed under the bus by my Director of Medical Services last year for something that was obviously a systemic issue that stemmed from poor management practices at the hospital, one of which they immediately course-corrected after this particular misfortune. (I cannot divulge any further information because that specific case might be undergoing some active litigation). If you haven't been thrown under the bus a couple of times in your career, then you've probably had a hallowed existence...like a unicorn. Since it is such a common evil, you should make it a point to cover yourself accordingly:

1. Document, document, document!  (Rule of thumb: if it isn't written down, assume it wasn't done!)
2. Be careful about anything that you end up signing
3. Be careful about being sent to witness a post-mortem. If litigation ensues (and court cases can last a really long period - years), you will find yourself sitting in court because of just one case.
4. Don't assume that the hospital has your back during a court case. It would be great to assume that this great community of individuals that you spend so much time with is your family, but such sentiment can turn in a minute. Distinguish yourself as a consummate professional, but always remember, "it's everyone for him/herself and God for everybody!" 

On a more positive note, remember that the vast majority of doctors actually joined the service for more philanthropic reasons. In a world this crazy, there are still good people trying to make things work; and the best of them can teach all these skill and experiences, and can inspire a whole host of people in the process.

As a parting shot, I remember that during my pre-internship at Kenyatta National Hospital (KNH), an Obs-Gyn consultant was walking though the maternity ward, and he was giving this rousing speech in order to let people know what was up. Can't remember most of it, but this little snippet (paraphrased) stuck in my mind,

"We are here to do a job. If you do not know what needs to be done, kindly make yourself known to us so that you can be taught what that involves; but if you feel like you don't need to know, then keep yourself out of our way so that we can still do effective work"

Very blunt and straight to the point! This hallowed profession demands that we always propel it forward, and check ourselves if our egos or other shortcomings are an impediment to its practise. We should remember that we are called upon to lead, as much as to be led. Therefore, invest yourself in learning to lead as much as you hit the books to improve your skills; and always remain teachable - the effort will never be wasted.

God Bless.

 

The Things That Medical School Won''t Teach You (9): The Ick Factor

I was just thinking about one recent night while I was on duty at the Casualty Department. As (bad) luck would have it, I ended up with the kind of patient that the nurses swore that I attracted to the department: someone with Per Vaginal (PV) Bleeding. Unfortunately, we didn't have ultrasound services operating at night, so we either had to send such cases out to a place where they could get urgent ultrasonography done, or tough it out with the little that we had at hand (good ol' back-to-basics medicine).

On this one occasion, I remember the patient being really embarrassed; it wasn't because of the invasive procedure that I was performing (which is the usual suspect); rather, she was embarrassed because she felt she was tasking me with dealing with this particular unsavoury medical malady. I just calmed the patient down, and let her know that this was basically what I had trained for, and she had no reason to feel ashamed. (I didn't mention that I'm also paid to do this kind of stuff, but money isn't exactly the thing I'd highlight as a saving grace).

This whole incident made me think about exactly what I've been through to get to where I currently am. As if on cue, the first memory that popped in my head was an incident from my internship - the surgical rotation to be exact. 

My rotation consisted of 4 sections (Male Ward, Female Ward, Theater, Casualty) which the 4 interns of the surgical department rotated among weekly. This just happened to be my first week on the Casualty rotation; so, it's Sunday morning - 8 AM-ish - and the Casualty Department is pretty nice and quiet...until it isn't anymore! They rush a patient in who's had a traumatic amputation of his right forearm. There's a tourniquet in place, but still, it's one of the more macabre things that you could witness in a day. Story goes that the gentleman set about using his chaff cutter early in the morning (before even 6 am), and while he was at it his right long sleeve got pulled into the machine, and his forearm followed thereafter. Thus, here he is before us, missing more than half of his forearm.

Dastardly as things might seem, you only get a few seconds of pause before instinct kicks in: get IV access, get vitals, draw blood for tests including blood grouping and cross-matching, shred clothing, run fluids to get his pressure up, get the patient warm and covered, call up theater to have it prepped for an emergency and then call up the Consultant Surgeon so that he can get down to the hospital pronto. Some of the steps actually overlap and are not so easily delineated in practice. So we finally get the man into theater to basically finish off what the chaff cutter started. (Unfortunately, the limb was too mangled and we were missing the other half which the chaff cutter must've  made literal mince meat of).  We deal with the veins and arteries, then we take care of any visible nerve endings, cut them as far back as we can; next we prune the bone fragments, remove the traumatized flesh and shape things up so that we can have a nice stump. All this is important because we want to improve his chances of being able to be fitted for a prosthesis later on, if the opportunity avails itself.

When surgery's over, he gets wheeled out into recovery, and we can all take a collective breath; and then, in one of those very weird medical occasions, we end up with a light moment. The anaesthetist had used Ketamine to anaesthetize the patient, (clinicians recognize Ketamine as "truth serum") so when he wakes up he's basically bawling about not being able to pay for the weddings of his unmarried son and daughter; he goes into detail about the whole thing (most of which goes over my head because he's speaking in Kisii), but the theater staff translate some of it for me in the midst of their chuckling. As always, my Consultant could be trusted to deliver a scathing remark, and even this time he didn't disappoint, "Why didn't he just leave that task for his workers to perform? This was just pure greed!"

By the time I met him in the ward, the Ketamine-induced reverie had ended, and he was stable. It might have seemed very heartless of us, but after the shock of the experience, I'd rather settle for a wailing patient than a dead one. On the plus side, we'd guaranteed that he'd live another day, such that he'd be able to thank his lucky stars, or alternatively be able to mourn for a lost limb.

I remember running into him at the hospital a couple of months later when he was coming to the hospital for physiotherapy, and he was in a jovial mood. I also ended up treating him for some nerve issues later on. It's always a strange experience when a patient who's had a limb amputated tells you they can feel their digits - in this case "Fingers" - itching or even hurting (the marvels of the human body). All in all, it was good to be able to glean a positive outcome out of such a bad situation.

Against the backdrop of such an experience, it should be clear that any medical professional before you (of sound training) is an amalgamation of many unique formative experiences, some of them quite terrible indeed. However, it is this very training which helps mould "book smarts" into actual experience, instinct and second nature. Many a time, I'm quick to remind interns that they haven't really had a true internship experience until they have intimately interacted with all manner of substances that a patient's body can produce. If your personal effects have not come into contact with Saliva, Blood, Faeces, Mucus, Urine, Pus, Meconium, Sweat, Vomit in any of their variations, then you've had a pretty sheltered internship. 

The more I think about it, medical practice sounds a lot like Motherhood. I doubt any mother would deny that they've had to weather all the aforementioned substances in taking care of their families; in our case, the only difference is that many a time we are doing this stuff while taking care of complete strangers, which might make it harder.  

The medical practice involves getting accustomed to a cornucopia of sights and sounds (even smells!). I'm reminded of my stint at Messiah College when I took an elective Anatomy class, which had somewhat of a tricky time slot; my only choice at getting a meal was either to eat right before the class, or grab a meal after it ended at about 5pm; the first time I had that class, I might have skipped the instructor's reminder to change gloves often because the smell of cadaver-infused formaldehyde seemed to leach into the gloves and become one with my skin. I vividly remember that I grabbed a burger as my late lunch that day, and it took sheer willpower to finish it as I battled my sense of smell to get through with the deed. Wouldn't have taken much imagination to have me reckon that I was sinking my teeth into some good ol' cadaver-du-jour. Fast forward a week or so later, and we'd all gotten so used to dissecting the cadaver, I'm pretty sure we could've had a meal in the classroom (if the situation had called for it).

My instructor - Sheri Boyce - told us that it wasn't unusual for some people to end up forgoing some specific meals after spending some time in the class. There was just something about the consistency of  roast beef or spaghetti that strikingly resembled some of what they were dissecting in the cadaver, so they could never bring themselves to sample those foods again. (Glad to say, I had no such problems, even in light of the "hamburger experience").

However, nothing reminds you about how much you've changed, until you interact with "normal" people. I don't quite remember how it happened, but one day a group of art students popped in to sketch the cadavers. Apparently they had the sentiment that sketching the human body in its most raw form was the pinnacle of an artist's experience. I guess they weren't prepared for what that raw form would look like once you'd peeled off some of the layers. All I can remember is that they came in with their sketch pads raised and started to watch us work, but for such an animated crew (some of whom I had interacted with) they were unusually quiet. Next time I peeked over, their sketch pads were down by their sides, and they were just staring, their faces a few shades paler. Suffice it to say, my attention was more fixed on the cadaver, with all the sharp instruments and sharp shards of bone posing quite the imminent risk, so I never really quite noticed when the artists disappeared, but when my attention shifted to them later, they were all gone. Takes a really strong constitution and some getting used to to handle some of this stuff!

I don't think it's a mere coincidence that one of the words I've used most often today is experience; that really is what makes all the difference. First time experiences need not be so pleasant with regards to half of this stuff because it really is a steep learning curve. I'm reminded of

1. a few medical school colleagues who would go faint at the thought of having their blood drawn or at the sight of blood; (always astounded me how afraid some medical staff are of needles!)
2. that one time I had a nursing student hold a child as I was attempting to perform a lumbar puncture (spinal tap). Must've been something about the novelty of the experience and him bending down to hold the child (maybe dehydration), because a minute or so afterwards, he felt light headed and I had him go sit down on a nearby bench where he promptly passed out.
3. drawing blood from a patient in the casualty department, and having his relative (who was standing by for moral support) suddenly collapse in a heap onto the casualty floor. Oh the joy of having one emergency suddenly turn into two!
4. the smell of singed flesh when first encountering the diathermy. Nothing quite prepares you for the sensation of burnt/roasted human flesh when someone uses the diathermy to cauterize tissues or to cause clotting.
5. dealing with any sort of perforated gut contents. You'd think the patient was sick enough when you reviewed them in the wards, but when you get them on the operating table and open them up, the most nefarious of smells will assault your senses. It's like literally being immersed in a septic tank. We always joked that the operating room was done for the day after such a procedure. Would need thorough cleaning and the grace of God before another procedure could happen in there again.
6. standing in during a delivery, and guiding the mother on when to push during her contractions; this one time though, the mother, being uncooperative, grabs my arm instead of her knee, promptly painting my coat sleeve with meconium. (Sadly, civilians seldom believe me when I tell them that child delivery is not the "sanitized process" they believe it to be, especially with regards to the mother's psyche)  

Fortunately, medical training is a marathon, and not a sprint. Ideally, a good superior will not hold initial uncertainty and inexperience against you, but will use it as a teaching point to enable you to gain the confidence you need to become a skilled clinician. (Perhaps it might even allow them to reminisce on how they were when they started out); and it is always an opportunity to derive a much needed laugh at the comedy that arises.

"We learn to do something by doing it. There is no other way." – John Holt

As usual, people should revel in the fact that "their medical friends" are all a little insane; but then again, someone would have to be slightly unhinged to do what we do on a daily basis. May your little bit of insanity bring stability and healing to this precious world.

God Bless

The Things That Medical School Won't Teach You (8): "Dealing with Drunk Patients"

After a short stint of dealing with inebriated patients within the casualty department lately, I guess this is as good a time as ever to highlight one of the mainstays (and frustrations) of the healthcare experience; and there can be no better way of showing this than to indulge you in a very sordid experience from my internship.

So there I was working in Casualty, and having an average kind of day. Then there's a bit of a ruckus as a group from a county referral hospital that will remain unnamed (including Medical Officer interns) brings a patient into the Casualty area. The patient's dramatic story goes a little something like this:

He had been drinking at a local tavern, and once he had consumed his fill, he decided that he was not going to pay the bill. He was most clear in communicating this to the bar owner, who happened to be a woman, and on this day she was not going to settle for this level of belligerence. She therefore proceeded to take a Fanta bottle and smash it against the left side of the bloke's neck.

So he's literally been hand delivered to us - a referral - because it has been determined that he's ended up with a laceration to his jugular vein. Without even staying to answer any more questions, the whole group disappears, leaving us to mull over the fate of this unfortunate soul. This was certainly a task that might have been better handled by a Vascular Surgeon (heck, even a General Surgeon), so I relayed the message to my Medical Officer (MO) and he told me to take a "peek under the hood", and make my assessment.

So I take him into the minor theater with two assistants in tow to help me cope with any eventualities...and that's when things get interesting: the patient who appeared almost lifeless up until this point suddenly starts drunkenkly flailing his limbs all over the place, you'd think he was reliving some vividly joyous moment in the pub. Not only do I face the risk of perhaps dealing with a gusher of a leaking blood vessel, I have the added pressure of dealing with an uncooperative idiot. So I do the only thing I can do: ask for more people to hold this person down, which ended up being 3 more people (his relatives).

So, with the idiot well secured, I have one of my assistants peel off the heavy layer of compression dressing from his neck, with me standing with the needle holder and suture ready to start suturing. Luckily, there was a laceration, but the bleeding was minimal and definitely not from the jugular vein. After placing enough sutures and getting an adequate level of hemostasis, I sent him to the ward for observation and to sober up. Lord knows I wanted to rap his head with my knuckles, but I just held back the urge and walked away.       

No matter your attitude towards alcohol usage, I guarantee that you will without a doubt be irritated about dealing with an inebriated patient. Now, technically, people can drink alcohol at any time of day on any day of the week, you are more likely to be overwhelmed by such patients at night time and the weekend; but as in the experience I quoted above, that patient showed up around 3 pm, so if you're from a drinking nation you'll have to be prepared whenever.

There really is no way of telling what kind of inebriated patient you'll get; alcohol elicits many different responses from its consumers. Some people might just be happy and might even get more courageous (even awkwardly flirtatious), while others become a chaotic storm of anger and rudeness; then you also have the person who'll drink themself into such a stupor that they become like the living dead, practically comatose. I have also encountered the emotional wreck (more often a woman than a man) who becomes so overcome by emotion and just breaks down crying.

Come what may, it usually comes in handy to have a calm demeanour. Bear in my mind that there are a myriad of ways to effectively deal with the situation:

1. If the patient gets belligerent and violent, security has your back. If they refuse to get something like a wound looked at, allow them to go home and calm down. Soon as the numbing effects of alcohol wear off, they will make a beeline for the hospital to apologetically get their wounds treated.
2. The emotional lot can usually just be allowed to cry away their sorrows. They'll come to their senses once the alcohol has worn off, and there will usually be a relative on hand to console them.
3. If the flirtatious weirdos can't take a hint, use security to put them in their place.
4. The living dead will pose something of a difficulty: make your assessments and decide whether it's the alcohol that has put him under or possibly the effect of an as yet undetected head injury. If you have a CT scanner on hand, take a look at his brain and clear yourself of any doubt. If aforementioned patient lacks the capacity to pay for such imaging, weigh out the pros-and-cons of keeping that patient around for observation versus sending them out to a place with an ICU. It's remarkable how someone with a GCS of 3, can suddenly return to the land of the living once the alcohol has had some time to work its way through their system.

The experience might be rather annoying at the time you undergo it, but truth be said, these experiences are comedic gold that infinitely sharable among your colleagues; if you're going to deal with these folks, you might as well come away with a good story to tell.

God Bless

The Things That Medical School Won't Teach You (7): A mother is not supposed to die in childbirth

I always knew I'd wind up coming back to the Obs/Gynae Department, a treasure trove of crazy medical experiences. Suffice it to say, my drama in the department began as early as the very first day that I set foot in it. I didn't have the joy of being eased into the department in the manner I would've appreciated. Right after I finished my Surgical rotation, I moved into the Paediatrics Department along with 3 of my other colleagues; my time in Paediatrics was short-lived because an inadvertent gap had arisen in the Obs/Gynae Dept, occasioned by the early departure (read completion) of some of the interns who were in the department at that juncture. So I ended up being cherry-picked to be moved into Obs/Gynae after only 3 weeks in Paediatrics.

So the memory I'm choosing to highlight is Day One of Obs/Gynae, with all the machinations having already taken place.

We began the day with a mortality meeting to discuss the demise of a mother (the dreaded "maternal mortality"). So I sat back listening to one of my fellow interns highlight the patient's history: the patient had progressed to full-blown Eclampsia and had to be placed in the ICU; in addition, the patient's blood pressure had been very difficult to control and the patient's urine bag from her catheter was filled with frank blood where ideally there should have been urine. 

Now in my mind, I'm logically reasoning out that the eclampsia has caused major organ damage and that in addition to ICU care she would also need Dialysis if she was to have any chance of survival; surely there wasn't much that could've been done for this patient. 

This is where the story took a bit of a twist; after the intern had finished her deliberation, the Medical Officers went into attack mode and basically acted like they were pinning the patient's demise on the interns' follies. I even remember that one of the medical officers had rather scathing remarks for the intern who had used intravenous Hydralazine to try to control the patient's blood pressure. 

Interesting side note: (Intravenous) Hydralazine is one of those drugs that medical personnel are very very afraid of using. Quite a potent vasodilator - especially in its intravenous (IV) form - many a medical professional has had the misfortune of having a patient rapidly progress from high blood pressure to low blood pressure/shock or even death after administration of this drug. Some nurses are so afraid of the IV formulation of the drug that they will reconstitute it, and then give it to the doctors to personally administer it. 

Truth be told, the intern was merely following orders of that very same Medical Officer who had recommended the infusion when consulted for help via phone, but it would have been considered sacrilegious to bring it up at that Mortality meeting, especially against a superior. The blame game only ever seemed to have a downward trajectory at those meetings.

In case you aren't aware of it, working in the Obs/Gynae Dept is one of the hardest tasks ever. In most places, particularly public hospitals, the workload is immense; however, it has the added dimension of having the most medico-legal ramifications tied to it. The death of a child is definitely a bad outcome, especially if it ends up being a "fresh still birth", which can pretty much be construed as the medical professional having failed to act in time. On an ever worse scale than that is THE MATERNAL MORTALITY, which, at any time that it happens, generates a storm of controversy that will require explanations to higher-ups in governmental oversight organizations.

I remember one time during a ward round, one of the Obs/Gynae consultants made the following observation:

Childbirth is a natural process. Mothers who come to a hospital to deliver should have a better outcome, otherwise they might as well just deliver at home.

Superficially, this would appear to be an ever-abiding truth, but anyone who has ever worked in an Obs/Gynae ward should know better; after all, "the greatest untruths are truths slightly distorted."  Childbirth is not merely the number of hours that a mother spends in labour and delivery; rather, it is the culmination of roughly 9 months of nutrition, care/neglect, wisdom/folly, health/disease and development that has already occurred prior to actual labour and delivery.

The more distant someone is from the reality that goes into a successful pregnancy and delivery, the more they embrace that aforementioned untruth; in my experience, top brass (especially those in government) are the most likely to be ensnared by this untruth. I remember that when my country (Kenya) initiated a Free Maternal, Child Health Program, they simply declared Maternal Child Health services free at government hospitals, and made sure the public knew as much. So you had mothers rushing in en masse to have their deliveries at hospital, which should have been ideal, right? Actually, because the referral system isn't at its best, mothers overloaded certain hospitals of their choosing (Kenyatta National Hospital - bearer of most suffering - being one of them). Imagine the pandemonium when the medical professionals encountered massive patient loads against no capacity building efforts whatsoever, and handcuffed to the mantra that "a mother is not supposed to die in childbirth".

In my opinion, that mantra needs a little bit of tweaking; a better way of stating it would be that "it is undesirable for a mother to die in childbirth". This reflects the truly complicated dynamic that exists between pregnancy & delivery, and antenatal & post-natal care. When you deal with the common mwananchi, and even people who seem to be of an upper echelon, you get the vivid impression that people "freestyle" this whole pregnancy business. Many were the times that we were discovering a mother's medical problems as we had her up on the table prepping to perform a Caesarean Section (C/S); or better yet, we learnt it as the mother was wheeled screaming into the maternity ward. Here's a taste of that litany:

1. The patient who has managed to go all 9 months without any sort of medical checkup whatsoever. 
2. The mother who has been pushing with each and every one of her contractions, before she was even adequately dilated; her whole vulva and cervix are so oedematous that any chance of normal delivery is gone.
3. The dear soul who chose to augment her contractions (using herbs et al) so that she could speed up the whole process of delivery...which actually only ended up causing foetal distress.
4. The lady with multiple previous C/S scars who chose to stay at home till labour was dangerously upon her, convinced that she could perhaps deliver naturally this time around; unwittingly, she instead puts herself at risk of suffering uterine rupture.
5. Slicing through a placenta during surgery because the mother had an anterior placenta; something that we might've been prepared for if she'd had a recent ultrasound done.
6. The mother who has been suffering from Gestational (aka Pregnancy-induced) Diabetes and hence she's carrying around a massive (macrosomic) baby.
7. The woman who has been blissfully walking around with blood pressure readings that are so off the charts (for example 200/130) that you wouldn't be surprised if she had a stroke right there on the table as you're trying to operate on her.
8. That perfectly healthy young lass so overwhelmed by the whole mystique surrounding childbirth that she insists from the very beginning that she wants a C/S. Worse still if she's gotten reinforcement from friends or unwitting clinicians. Without the proper psyche, good luck getting her to cooperate with the midwives. As an added bonus, this is also the type of patient who the anaesthetist will have an especially hard time administering spinal anaesthesia to. 
9. The mother who has been manhandled or neglected at a peripheral facility, and usually ends up spirited to your facility a bit late in the game. Congratulations, all her problems now become your problems
10. The patient who, despite being an adult of sound mind, is unable to commit to being taken to theater for a C/S without her husband first showing up in person to give consent; this despite the medical professionals being pretty sure that they have a Non-reassuring foetal status (NRFS) on their hands, and that urgent surgery is the best course of action.
11. And with any pregnancy, you face the twin threat of massive bleeding events before or after delivery (aka Antepartum and Postpartum Haemorrhage).
    The causes are many, but by the time they are upon you you'd better act quick or risk losing your patient.

I'm pretty sure that there's more that could be added to the list, but it should at least be an eye-opener. My point in all this is that if you want to have the kind of health outcomes for Maternal Health that are the pride of developed countries, then you have to realize that your outcomes can only be good as the quality of your patients; you also have to be prepared to put in a lot of work.

1. Education of the common people about the importance of Antenatal and even Postnatal care; 
2. Massive investments have to be made into capacity building, because hospitals, and all classes of medical professionals (especially nurses and doctors) won't just appear out of thin air. 
3. Outreach must be emphasized; it''s time to embrace preventive medical aspects wholeheartedly.
   
   I have a personal gripe with how this was done in Kenya because part of it ended up as the "Beyond Zero Campaign" under the First Lady, which in my opinion is misplaced despite the well-meaning sentiment behind it. This decision would be on par with the president deciding to outsource the leadership of the Ministry of Energy's fledgling Nuclear Energy Department to someone without any experience in the field. This is not a pet project, and needs to be recognized as a pillar of healthcare in this country.              
4. Funding needs to be increased, and has to be targeted especially at mothers with High Risk Pregnancies.
   In line with this, ultrasonography has to be considered an essential service for mothers to have access to, and should be covered under Free Maternal Health.

There really are no quick fixes to any of these issues, but I think there is hope for useful course correction if we can all have a clearer appreciation of the bigger picture. I have hope that this would benefit everyone, especially the mothers (actual, potential and otherwise) who are such an important part of our lives. I also hope that I won't be scaring any students away from this Department; even if you won't be specializing in Obs/Gynae, it is still a delightful rite of passage that you shouldn't do without.

God Bless.

The Things That Medical School Won't Teach You (6) - Don't be afraid to diagnose death

It has been one of those trying weeks at the office. Lately it just feels like I'm stuck in a rut and the job isn't fulfilling. Even worse is the loss of patients; seems likes it's more traumatizing in these past few days. Despite working at a hospital, it's still easy to take it for granted that these vulnerable souls could just up and expire on you at a moment's notice. Makes you think twice about that expression "Sleep is the cousin of Death!"

With all the death we encounter, you'd think that there would be some special training to help us steel our nerves and encourage us despite the amount of loss we witness; training that would keep our minds at peace, so that we could be able to impart some form of closure and finality to the grieving relatives that we interact with on a regular basis. The answer to this is, of course, a big resounding NO!

I honestly can't recall any of my med school classes that evenly remotely mentioned the concept of death (beyond the usual sterile "cessation of all bodily functions" package). In fact, it's only been earlier this year in a Counselling CME (Continuous Medical Education) seminar when this issue was really broached for the first time. However, as in all things medically-related, we just have to make do with on-the-job training, usually carried out on your own. So next time you get a doctor with a questionable bedside manner delivering bad news to you, it might not entirely be his/her fault. Blame the profession.

I'm reminded of one experience that occurred during my internship while I was in the middle of my surgical rotation. On that particular day, I was manning my casualty post when an ambulance pulled up to the adjacent parking area. Convinced that an ambulance pulling up most likely signified either an Obstetric/Gynecology (Obs/Gyne) or Surgical emergency, I silently prayed that this was one for the Obs/Gyne team. (...and of course when I was in my Obs/Gyne rotation, I prayed the opposite prayer).
In a departure from the norm, the ambulance just sat there parked without anything apparently meaningful happening. I took a walk down to the Nurse-in-Charge's office so I could get some idea of what was going down. Turns out that the EMTs/Paramedics had ferried a victim (elderly adult male) of a road traffic accident that occurred in an adjacent county to our facility. This irked us to no end for a couple of reasons:

1. There is a protocol in place to follow when referring/bringing patients to our facility, which usually involves communicating with the Nurse-in-charge so that proper preparations can be made. Many people tended to ignore this common courtesy.
2. More often than not, some counties are particularly notorious for off-loading their workload by referring patients that they could satisfactorily deal with within their own county facilities.
3. With the advent of devolution, multiple county heads had acquired ambulances at a rate incongruent to the money they had invested in medical facilities. What this meant was that (as mentioned above), it was easier to handle an emergency situation by just dumping a patient at another hospital's doorstep.

So what we had was an actual stalemate. The ambulance had ferried an accident victim who was in urgent need of an ICU, but all our ICU beds were occupied (which they would have found out if they had bothered to inquire first); they were, of course, unwilling to transport the patient to another hospital or return him back from whence he came; our Nurse-in-Charge was sticking to her guns, and as per protocol, was not going to take responsibility for the patient.

I figure the ambulance had been parked for 30 minutes while this whole scenario played out. Finally, I made the decision to examine the patient within the ambulance to find out exactly what we were dealing with. So I step into the ambulance and the patient is eerily quiet; all I get from him is seriously laboured breathing. He's neither responsive to my voice or painful stimuli of any sort, and his eyes are closed shut; once pried open, his pupils are slightly dilated and not responding to a light stimulus. On the plus side, he did have a steady pulse. Thus, on the Glasgow Coma Scale (GCS), this patient registers an all-time low of "3".

Now any medic knows that this patient's breathing is going to be the next thing to go; devoid of an ICU with ventilatory support when that happens, death will most definitely ensue.
I relayed my findings to the Nurse-in-Charge, and we shared an ominous silence between us. The patient had no relatives/guardians that could organize for him to be taken to another facility, so he was stuck either way. Seeing as we really had no good choices, we opted to keep him in our casualty area, providing supplemental oxygen and as much supportive management as we could muster under the circumstances.

He lasted a good 2 days in that state (longer than I had actually anticipated), but in the end he passed away.

Despite all my experiences with death, even I fail to see how I would prepare a lesson to adequately prepare fledgling colleagues for what awaits them in the field. Every death encountered is as diverse as every life lived. You will watch some lives snuffed out within the few minutes you encounter them, and yet with others it will be a "slow burn" where you will get to experience the patient's life and those of their relatives for a prolonged period. And in itself, this notion of time is certainly a fluid concept: you could live a lifetime in the few minutes that you spend trying to resuscitate a newborn child, or, as in my experience with Edna, the 5 hours you spend with a practical stranger.

In my experience, I have found that you shouldn't be afraid to diagnose death! I'm not talking about that morbid movie-type experience where a doctor says something along the lines of you having 6 months to live (nothing is ever really that clear-cut); rather, you need to develop an acumen for seeing it coming. After being around death for such a long time, you and your colleagues develop a knack for predicting it (especially the nurses); in my Paediatrics rotation, I discovered that mothers are very good at sensing minute changes in their children's state, so when a mother asks you to check up on her child, kindly do it.

Any well trained health worker knows that recognizing the GCS will steer you right (except maybe in the tricky case of career alcoholics!). Thus, as a matter of fact, impending death is easy to predict in most cases, but occasionally it just sneaks up on you; I've had cases where we've fought out the worst of the patients' battles, and just as it appeared they were on the road to recovery, the war ended. So, in essence, the work of medical staff truly is that arm-wrestling match immortalized in my intro illustration. And in the end, we always lose!(...it is appointed for all men to die once, and after that comes judgment...).

Morbid as that may sound, death is not always the grim experience we all imagine; if handled correctly, it can provide closure to those left behind, a culmination of a life well lived. Pair that with the belief that people have of the afterlife, and you end up understanding that death is not the "be all and end all" of everything; it's just a phase.

I remember that during my first few months in China, I struck up a friendship with a young practising doctor from Mauritius named Javed. In the course of mentoring me, he gave me one quote that's stuck with me till today:

We treat, but God provides the healing!

There's only so much that you can be expected to achieve by the instruments and measures of your time/era, and death is always an inevitability, so be humble in your practice. A 'God Complex' is a liability to any true health worker worth their salt; do not give people false hope, but neither should you aim to dash their hopes underfoot; always do your best for your patients, and rely on all members of your team to get you through all eventualities. None of us is perfect, but as I've mentioned before, working with this segment of society is a privilege (despite its taxing nature); therein lies a blessing and a daily perfecting grace.

God Bless

      

The Things That Medical School Won't Teach You (5) - Being there for your patient

Yeah, that's right! I've got an Amazing Spider-man comic cover up for a medical blog post. It's not going to be something along the lines of a treatise about "with great power comes great responsibility" (that would be too easy!) However, comics, especially the well written ones probably have useful lessons to teach us; maybe even enough to have them regarded as seriously as "literature".

This particular Spider-man adventure is from the Spider Totem story arc. Here we're dealing with a slightly more mature Peter Parker (unlike the one people seem to be pining for so much in Spider-man: Homecoming). Science teacher by day, and superhero extraordinaire when the occasion calls for it. As events begin to unfold, we're given the foreboding news that a big baddie has his sights set on Spidey; but Spidey being Spidey foregoes the advice to lay low and ends up being accosted by this mighty predator, Morlun. 

Soon as he steps on the scene, Morlun knocks the wind (and literal jokes) out of Spidey. He's pretty much Spider-man's worst nightmare: a seemingly unassailable foe that can track him no matter where he goes. A couple of battles are fought, with Spidey having to retreat each time to get a breather; in the end, however, he's worn out, quite practically defeated. So he ends up saying a few goodbyes and prepares himself to "not go so gently into the good night".

This, of course, is where the magic happens: someone miraculously comes to Spidey's aid!
This is the part that has always remained crystal clear in my mind since the first time I read the story. It's heartbreaking to see Spider-man humbled to the levels achieved in this episode, but it's elating to see him get the help he needs. His reflection at this juncture is priceless:

"And in that moment, oddly enough, I finally understand what it feels like for someone else to look up and see me...and it's great..."   

Anyone who's had someone bail them out from dire straits would probably have their own unique way of articulating this very same sentiment; and let's be real - everyone has a little something to offer whenever we find ourselves in need. As someone involved in healthcare, my greatest contribution to this world is definitely medically related.

My mind harkens back to my orientation week in 2001 at Daystar University; Pastor Mwalwa's orientation speech in particular. These were his exact opening words:

Every system in this world will fail you! 

No set of words ever did ring truer; and each time it comes true, it is an utter betrayal of the human condition because it underscores how small we are in this life; so finite, so fallible, for the most part really powerless to change a lot of the circumstances in our lives. All things considered, though, could there possibly be a greater betrayal than that of our own health failing us? Every other systemic failure is external, yet we choose to internalize it; our health, on the other hand, is automatically internal, immediately personal.

This is the backdrop against which we encounter patients every single day, and an issue to take to heart. A lot of medical school work preps you for dealing with a patient's illness, but not the ramifications of that illness on the person's being or integrity. However, just like any task we may be poorly equipped to deal with, on-the-job-learning bridges the gap; even if we were never taught how to be counselors, it becomes an essential skill to pick up. It also helps to pick up some virtues along the way: patience, respect, honesty and humility. Every new patient poses a unique set of experiences, especially bitterness, anger or depression occasioned by their illness. Thus, always exercise patience even when they (and/or their relatives) drive you up the wall; respect the patient enough to be honest about their condition, and the treatment options available, and do all in your power to help them; and, lastly, be humble enough to accept the patient's wishes and your shortcomings.

Come what may, that patient can't help but come out of the experience a little more enlightened. All this is summed up in a great quote:

Pain is a gift. Humanity without pain, would know neither fear nor pity. Without fear, there could be no humility, and every man would be a monster. The recognition of pain and fear in others gives rise in us to pity, and in our pity is our humanity, our redemption (Dean Koontz, Velocity)

As one who gets to behold broken humanity every single day in your line of work, may that spur you to restore that humanity, and alleviate that same pain. Understand that people will look up to you, and you shouldn't be scared to have that responsibility heaped on your shoulders; it will mould you, everyday, into a better human being.

I feel I can safely end this with the last words from that orientation speech from Pastor Mwalwa. He didn't set out to scare us that day; just to steep us in a little bit of reality. Thus, like a good teacher, he left us with something positive and hopeful at the end by completing his opening remarks.

Every system in this world will fail you...but God will never fail you!

God Bless

The Things That Medical School Won't Teach You (4) - Sometimes, you'll end up hating your patients!

Everyone gets a little tired of their job sometimes, it's about as natural a process as it comes. If someone is enjoying their job 100% of the time, they are probably as rare a commodity as a unicorn. I believe job satisfaction probably lies somewhere between maximizing the "ups" and minimizing the "downs" of your typical work routine.

As a medical practitioner, I can attest that medical school, TV shows and even forerunners and mentors at least gave me the impression that the medical field would be hard. The hours are tedious, the life is downright difficult, and your colleagues and their respective idiosyncrasies will prove to be a challenge. But then, no one ever prepares you for how challenging your patients will actually be; I'm not talking about your patients' illnesses because between your training and your superiors you'll have that covered. I'm talking about those little unexpected moments when your patients (and their relatives) set you up for failure.

Scenario 1: No situation rings truer than the one I so optimally used to introduce this post. If you've managed to go through your internship without your patient turning on you during the ward round, you are one lucky person. Tragically, even very recently as a medical officer, I had taken an extensive patient history that lasted about half an hour in preparation for the major ward round. As soon as the consultant shows up to listen to the history, the patient starts to poke so many holes in my retelling of the history such that even I am left in doubt as to whether I clerked that very patient. However, the embarrassment doesn't stop there; if you have a consultant like mine, you will be berated in front of your colleagues, accused of 'confabulating' (aka LYING) and dismissively asked to return to take a proper history. Lord knows I am not a spiteful human being, but whenever I have been privy to such treatment, I usually give such a patient a wide berth.

Scenario 2: There are probably fewer less comfortable conditions than morbidity. Being stuck in a strange bed, having nurses (and nurses aides) interrupting your rest on a regular basis to take care of you, and last, but not least, having to endure the ward rounds. Granted though, patients will put up with this because they understand that we're trying to get them better. I remember once having a patient in the ward who looked so sickly, like he was on his way out of this world; on the cusp of kidney failure, yellowed eyes and just a generally poor disposition. First time I talked to his family, I basically HAD to reassure them that he would get better. Eventually, we basically discover that he's only suffering from an acute infection, and we're sure that he'll recover full kidney function.

Once the relatives discover he's out of the woods, their true colours come out: complaints and demands galore. Suddenly, it's as if my medical knowledge counted for nothing, and they're the ones who were in charge. Mind you, this happened during the healthcare workers' strike, and it was beyond irritating to have a basically stable patient demand more attention than the less stable sicker patients. Can't lie: I thanked God when we discharged that patient!

Scenario 3:

Speaking of demanding, few things will irk you more than the patient who shows up at the most inopportune moments. As a rule of thumb, kind of like Murphy's Law, a patient is likely to show up needing your help when it's time for you to clock out and head home. Even worse, though, is the scenario where someone shows up at the Casualty (A&E) Department at the oddest hour of the night with an easily treatable malady. If you've been unlucky enough to work the late night shift, you'd understand that you're usually working with a skeleton crew, basically the bare minimum. As if that wasn't enough, the late night clientele can sometimes resemble the idiosyncratic late night Walmart shopper: CRAZY!

I understand that you may have your issues, but it does help if you're considerate about the tasks that we juggle in those circumstances. We operate in triage mode in the Casualty Department, meaning that regardless of the time you set foot in the department, I am going to address the needs of the most severe patient first. I pre-assessed you really quickly and I'm 97% sure you have the flu, so I'm pretty sure that between your headache and chills you're not likely to expire within the next hour. Allow me to attend to this head injury patient who's so banged up that he lacks the capacity to even complain about his situation.

Scenario 4: All hospitals are definitely not created equal! Every person working in a hospital is particularly aware of their hospital's degree of competence, and perhaps more critical of the hospital than an outsider might be. Be that as it may, we are sensitive to being criticized by an outsider. It's very much the same way you might feel comfortable calling your sibling an idiot, but God protect the individual who tries to heap such disrespect on the very same sibling.

As an intern, I once had the misfortune of having the uncle of an MCA (Member of County Assembly) admitted to our hospital to undergo prostate surgery. This was tragic on so many fronts:

1. An MCA is, for the most part, an overpaid but practically useless political post that we've somehow been saddled with since 2013
2. Many of the individuals chosen as MCAs take it upon themselves to lord the position over individuals in government institutions, like hospitals.
3. The limited staff we had in the surgical ward ended up being diverted to the VIP patient's beck and call...and he wasn't even thankful in the least.

In my opinion, if you really can pay for admission at a better hospital, why would you feel the need to game the system, and then mistreat the people who are trying to help you?

Scenario 5: The dysfunctional family. There are few experiences more trying than having to deal with a sick patriarch/matriarch who's admitted in your institution, but is pretty much in the middle of a "custody battle" that gets dragged into the hospital. Sometimes it feels like their relatives are already counting the spoils even prior to the patient's demise. Never have I run into a bunch of entitled individuals who will frustrate your management of the patient, and seem ever eager to drag the hospital into a lawsuit at the slightest perception of an insult.
For your sake (and that of the hospital), make sure to DOCUMENT EVERYTHING! Your notes had better be crisp and concise and up to date. Lord knows you don't want to be sucked into the black hole that this debacle will turn into. On many an occasion, don't forget to emphasize how inadequately your institution is equipped to handle any serious emergencies that may befall the patient, and be on hand to provide them a referral to a top-notch medical facility of their choosing.

There are a myriad of other situations, but this is all I can summon up from memory at this juncture. The commonest string that binds them all seems to be "the demanding patient"; thus, it is in your best interest to always be able to pick out those patients that are likely to be the most demanding.

 Take home message: this life can be hard, but the more prepared you are to face the other awkward stresses that come your way, the more bearable your medical experience will be.

Take care and God Bless.
   

The Things That Medical School Won't Teach You (3) - The Giggles

I'd like to start this particular post with a very specific memory: it was circa 1997 and I was in my first year of high school. We were out on the sports field taking part in a class rugby game, and a member of the opposing team tackled me by grabbing me around the waist and swinging me backwards. It was by no means a bad or dangerous tackle (I've taken much worse hits), but unfortunately, I fell awkwardly on my right wrist and experienced excruciating pain.

I dragged myself onto the sidelines and sat out the rest of the game. Despite licking my wounds, the pain had not subsided by the game's end. From there it was off to the high school clinic, then back home, and finally off to the hospital (the former Masaba Hospital, if my memory serves me right). Just as I'd feared, I had fractured my wrist. Was probably a stress fracture because I can recall that, not too far back, one of the poles from a tent had struck that same wrist while we had dismantled a tent at school. At least it wasn't bad enough that it would require an implant; but it did require me to endure a POP cast for a period of 3 months. The worst part of this whole affair was the indignity that I was exposed to at the hospital. I remember the two female nurses taunting me for having the gall to play rugby, me being so spindly and all. Even worse, each of them kept squeezing the wrist to elicit the tenderness. Worst of all was when the doctor showed up and joined in the taunting. I remember that he was a massive fellow, but despite his stature, he claimed that he wouldn't be caught dead trying to play rugby. What on earth made me think I could indulge in the sport? Three taunting medical professionals, a fistful of pain and a dented ego made for one unbearably bad night.

Fast forward to my days as a medical professional, and the experience has been softened in hindsight. This is neither an admission that I have taken up a heavy-handed approach to patient care nor find it acceptable for other practitioners to disregard their patients; it is, rather, an admission that sometimes one person's malady can be another's (comedic) pot of gold.

I've said it once, and I'll say it again: a lot of your friends/family/colleagues who work in the medical field are damaged goods. You can attribute that to years and years of rigorous training, being part of a profession where your superiors have the bedside manner of an army drill sergeant, and impossible situations that everyday practice will throw your way. Like any good professional, we get used to the life....and then we begin to find humour in even the most macabre of situations.

Thus my disclaimer would be, "we're laughing with you, we're not laughing at you!"

Medical personnel's brains are wired a bit different from the rest of the population. In much the same way that firemen (and other first responders) are geared to run towards situations of danger, we actively seek out those situations that we've been trained to handle. A lot of times we're even fascinated by all that strangeness. A lawyer friend of mine was talking about his experiences with helping Key populations (aka people most at risk of contracting HIV - Gay men and IV Drug users). He commented that some gay people feel stigmatized when they show up with anal infections because the nurses start calling each other, "Kujeni muone maajabu!" (come see these wonders!)
Two things are at work here:

1. Bad PR because sometimes we focus more on the ailment than the person.
2. Utter fascination at getting to see things that previously we've only ever encountered in our books.

Size, complexity, consistency...really a treasure trove for the senses. If you happen to be at a teaching hospital, you and your "condition" will be celebs for the day.

Thanks to shows like House MD, which exaggerate bits of the medical experience, you can understand that our minds are trained to probe situations, sometimes to extreme lengths. So, for example, when a patient walks into the Emergency Room with a fractured penis, normal minds might stop at merely thinking "Ouch! That must really hurt!" But not your medical friend. His/her mind works a little like this

1.  "Ouch! That must really hurt!" Let me take care of the patient's discomfort first.
2. Let me document the patient's account of what happened (Will it be truthful, though? Patients lie, right?)
3. The likely cause of injury occurred when aforementioned part probably encountered such-and-such in a traumatic clash 
4. Chances are that the woman that caused this "accident" is not likely to be the man's wife, because statistics show that ...
5. My colleagues have heard about this case and have come trooping down to see for themselves what's up. Everybody's going to be giving their "2 cents" about this case.
6. How on earth am I gonna keep a straight face when I have to present this case to my consultant?

If it's a good day, I'd be putting on my stoic face and would succeed in keeping a straight face throughout the whole encounter. If it's a bad day, anything can set you off laughing. Sometimes the patient's voice or demeanor could be a trigger; sometimes the consultant will callously utter such a brash statement that leaves you beside yourself with laughter. At other times, it's just the nature of the situation. I remember getting the giggles when my colleague was presenting a patient history in the ward: this middle aged lady had been walking home in the dark and had, in a stroke of bad luck,  randomly fallen into a pit latrine that was being dug. Don't know what it was about the case, but it left me in stitches. However, God forbid that you should draw attention to yourself by randomly bursting into laughter while you're in a team of 15 conducting a ward round. You suppress that laughter like a boss and ride out the period of mirth.

Sometimes I feel guilty, like I'm headed to hell for finding some of these things funny; but, it is a coping mechanism. I think you'd rather prefer that I find your situation funny and can engage with it 100%, as opposed to fearing it and being overwhelmed by it as most normal folk would. As the disclaimer states, "I'm laughing with you, not at you!" Don't condemn us for our laughter/amusement, but appreciate that it is a joyous part of our day to find amusement in a day's work.

God Bless.    

The Things That Medical School Won't Teach You (2) - Don't mess with the nurses!

This has basically been one very crazy week; a crazy year for that matter: first we had Brexit, and now...well I don't even know what to call that little stunner that our American compadres just pulled on us (Amexit hardly seems adequate). Oh well, if frustration voting is the current wave, I'm hoping it persists until next year so we can get some real change down here in Kenya.

But I digress; as an addition to my medical school series, on this occasion I'm highlighting a topic that's on a different end of the spectrum than my usual fare. So without further ado, another rule of thumb for the wise clinician: Don't mess with the nurses!

Whenever I've highlighted my experiences, they typically focus on the doctors; that's mostly due to convenience because trying to encompass everyone and the skill sets involved would make for much longer posts. If you happen to spend anytime near any sort of health facility, however, you would quickly come to the realization that most of your time is spent in the company of nurses, the true unsung heroes of the medical world.

From a lot of my posts, and a myriad of others floating freely online, you can understand that the life of a medical doctor is no mere cake walk. However, nursing is on an even grander scale of difficult. I would estimate that as much as 70 - 75% of all the strict medical work taking place at a hospital is carried out by the nurses. Nurses are so essential that - as I've experienced in Kenya - to get any sort of decent medical strike going, you need the nurses' muscle to weigh in on the matter. You can keep a hospital running with a few Consultant doctors and a full team of nurses, but you can barely even hope to run a mere Outpatient department with all the doctors in the world devoid of a single nurse on board.

As I've mentioned before,

"Contrary to common thinking, it is a team effort that helps save lives."

Therefore, the message herein is twofold: 1. Respect the nurses; 2. Fear what comes with crossing a nurse.

During my stint at the Memorial Hospital (circa 2006), I remember one of my colleagues highlighting the importance of nurses; surgical nurses, to be precise. Surgery is hands-on, and the consultant will only 'hold your hand' for so long. You are expected to gain competency in surgical procedures through the long respected traditional method: "See one, do one, teach one."
However, even in cases where neither your Consultant nor medical officer are around, you are never really alone! The surgical nurses are veterans and have participated in so many surgeries as assistants in the Consultants' presence that they could actually perform some of the procedures themselves. However, since they are not legally licensed to carry out the procedures, they can at least guide you.

Now, initially, interns may be unaware of this vast resource at their disposal. Particularly egotistical interns might even rub the nurses the wrong way and choose to treat them like second class citizens. Now, nurses are a patient lot, and will usually let things slide; however, should the aforementioned intern find himself stuck during a surgical procedure in which he is the primary surgeon, then the nurses will just be content to let him sweat things out on his own. Worse still, at the end of it all, the intern would have to call his superior in to assist him, which many times could end up with the intern being berated. To me the point was clear: Respect the nurses!

I would daresay that the greater part of the refinement of my surgical technique occurred under a nurse's watchful eye. Mr. Nyabaro taught me subcuticular suturing, Mr. Mutaroki schooled me on the surgical tools; Sr. Asiago, Sr. Lydia, Sr. Dinah, Sr. Judy and Sr. Alice augmented my effort in any procedure that I performed. When the tides had turned and I had become adept at performing a myriad of the tasks, then they all helped me teach these skills to the next bunch of interns and students.

Of note is one memory that is as clear in my mind as the first day it occurred. I remember on my very first night on call in Obstetrics/Gynaecology, there was a lady who had an obstructed labour so she required a caesarean section. However, I froze up on the table, and I couldn't extract the baby; the scrub nurse was the one who successfully pulled the baby out. In the same procedure, I had yet another stroke of bad luck: I was unable to find the edges of the uterus, so I was unable to suture it and progress any further. At that point, I had to call the Medical Officer to assist me.
He was livid! From the moment he made his way into the changing room I could hear him protesting and cursing me out! He made his way into the operating room and scrubbed in amidst all sorts of threats. At the end of it all, he told me to either shape up or he would have me dismissed from the Obs/Gyne rotation. It was at that point that I made up my mind to be as self-sufficient as possible; also, I decided that I'd rather rely on fellow experienced interns or nurses to get me through the rotation.

There is a silver lining to this particular story, though: the scrub nurse was so disgusted with the behaviour displayed by my medical officer, so she made a point of reporting him to my Consultant; personally, I'm more of a "let-things-slide" kind of person (Lord knows I didn't want any bad drama), but the nurse stood up for me, and in the end won me some respite; and for that, I am deeply indebted to her.

That's right...nurses protect the doctors too! I can give two example in this regard: when (as a fledgling doctor) you mess up and write up the wrong medication, dosage or route of administration, the wise nurses will bring it to your attention, correct you (in private without embarrassing you), and prevent you from causing major harm to the patients. Also, recalling the "perception of impending death" that experienced nurses develop, the nurses will be able to draw your attention to the most critical patients. Depending on the kind of hospital you work in, sometimes the workload is overwhelming; this means you have to be able to triage the patients so you can divert a limited resource (your time, energy) where it's needed most. To the inexperienced doctor, it might be easy to get overwhelmed by the work, and to come to grips with the challenge of managing patients in a resource poor setting; however, the nurses will keep you on track, thus protecting you, the patients and the hospital's reputation all at the same time.

Don't get me wrong, I have no delusions that all nurses are good people. Some particular painful experiences during my internship came courtesy of nursing staff. Like I've mentioned previously, (medical) school doesn't teach people how to be good doctors; the very same truth applies for nurses. What I am highlighting is the positive outcome that comes from working with good nurses, and in my experience most of them have been very good individuals. There is an unparalleled synergy that just makes the job a delight. I would compare it to a good marriage where you're so in-tune with your partner that eventually you become aware of their thought patterns and can complete their sentences. I remember trusting some midwife nurses so much that if they told me that they would be unable to deliver a child naturally, everything else became academic; I would schedule the mother for a caesarean section on the spot! (You know yourselves Sr. Zipporah, Sr. Lilian, Sr. Elizabeth, Sr. Rose, Felix and Nyambane). When people give you their best each and every day, then you in turn can give your best.

This post wouldn't be complete without me reminding you to steer clear of vexing the nurses. It is one thing for nurses to bear the heavy load associated with their work; it is yet another for them to feel underappreciated, especially given the nonchalant and boneheaded manner in which people of authority have usually dealt with them. Kindly, do not add to their stresses by treating them disrespectfully for they can act out with a vengeance; keep in mind that the camaraderie between nurses runs deep, and one slight against one of them could be technically be viewed as a slight against all of them. Imagine trying to get your work done without the aid of the nurses! Thus, act accordingly and pick your battles; you can't win if you pick a fight with the nurses.

Patients too should be mindful of the manner in which they treat the nurses. In the course of their practice, the nurses develop an acumen in simple things...like knowing the least painful way to administer a certain medication. Acting belligerent towards a person who might end up with the task of injecting you with a multiple cocktail of medications throughout the course of the day can end up causing quite painful ramifications. Therefore, please, be kind to your nurses (for your own sake).
Have a Blessed day.

The things that medical school won't teach you (1)

It's been a bit overdue, but I guess I might as well jump into that whole list of things I stated about the "fine print" with regards to things medicine; let's start things off with a biggie: You will sacrifice a great deal in caring for your patients that will never be compensated.

I actually mentioned this as number 6 on my list, but it is as fine a point to start with as any other. Poignantly so with the latest spate of medical strikes that have occurred in different counties all over the country.

I don't know if there's any analogous experience outside of the medical field that can really prepare you for what practising medicine really entails. I should know: I've taken quite the long route to get to where I currently find myself - 10 years of post-secondary education (4 years of Pre-Med Biology and close to 6 years of Medical school). Interspersed somewhere in there is some volunteering and doctor-shadowing.

The medical profession is still one of those very revered fields (seems like the reverence currently far outweighs its economic incentives). I'm making a calculated guess that any parent would feel proud if they were to hear that their child had chosen to pursue a medical career; sadness may creep in, though, when they realize how much money they would have to invest in that decision. So we make the decision to follow this path, put in all those hours of work and commitment, choose the right schools, get adequate extracurricular activities that reflect well on our character; also, lest anyone forget, medicine today, just as it was in the past, is learned through apprenticeship; therefore, having a good mentor in the field helps keep you motivated, and can show you up-close the sacrifice entailed in your career choice.

So, when you eventually make it past medical school, you eventually settle down to one year of basic serfdom aka "the internship". I'm thankful here in Kenya we only spend one year doing our internship, because my Ghanaian colleagues have to spend two (dreadful) years as interns. As I mentioned earlier, learning medicine is done through apprenticeship; the nature of that apprenticeship can very often mirror boot camp at the mercy of an unkind Drill Sergeant. I would be lying if I claimed that any two internship experiences are alike; some people have relatively calm internships, while some people (myself included) go on to have troublesome internships (the universe can be so unkind). You may find yourself dealing with many a cantankerous consultant; if you're unlucky, the medical officers might also decide to make your life a living hell. In my case, I run across the foul trifecta while I was rotating in the Obstetrics/Gynaecology Department - the Consultants, Medical Officers and even some of the Nursing staff took turns dishing out grief.

It really is quite the sad turn of events. Despite all the knowledge we rack up in medical school, nothing quite compares to full hands-on experience with a living breathing patient. What we do in medicine is definitely far from the norm. Normal people aren't supposed to do the things we do. Normal people aren't supposed to see the things we see; poking/prodding/probing and incising/ligating/exploring the human body all while assuring you that we mean you more good than harm is a hard deal to pull off. And in case you haven't noticed, a lot of your friends in the medical field are a tad unhinged - possessing a wry sense of humour and unmatched fortitude. It's just the nature of the business, and unfortunately, you pretty much have to learn it on your own.

That's right, there is plenty that is learned on the job. One of the more fascinating facts about medicine is that despite the fact that we deal with death on quite a regular basis, no one actually teaches you how to deal with it (breaking news to the patients' relative, how to inform someone that they have a poor prognosis); no one lets you know how to deal with the fact that your actions (in)directly may lead to a patient's death; also, no one teaches you to develop the sense of detachment from the patient that keeps you objective come what may. Something else they may not emphasize is that you also become really adept at knowing your limits with regards to saving lives. Sometimes you walk into the ward and you have a pretty good feel about the patients most likely to perish on that day. At first, it unnerved me a bit that nurses would just mutter that

"the patient in bed so-and-so is a goner!" (rephrased). 

Dastardly as that might sound, it actually is a "good" thing because it lets you know where to focus your intervention the most. Also, it lets you know who needs to be referred out for special care that you may be unable to provide. However, if you're in a resource poor setup dealing with poor patients who obviously can't afford to go anywhere else, then you prepare yourself for the worst. We don't get to wash our hands of the impending death, but we can at least assuage our consciences of the guilt.

Sometimes people assume that this stuff is easier to deal with because (apparently) doctors make a ton of money. Personally, on many occasions, I've had people step up to me and state that "medicine is a calling!" When you have people from all walks of life constantly reminding you that your chosen profession is a calling, you better believe that the money will definitely not be commensurate to the amount of work you'll put in. If the money's the reason that you're choosing medicine as a career, I'd prefer that you chose one of a host of other jobs that require less schooling, afford you more free time, better salaries, and a life free from frivolous litigation and egotistical individuals. Apart from medical professionals, the only other professionals that gets reminded so much of being "called" are probably teaching staff. (that's not exactly what I'd consider good company!)

Despite all the challenges and pitfalls, there are many good doctors who are in this profession and conscientiously make the effort to care for their patients no matter what the circumstance; who aim to do good by their patients with whatever they have at their disposal. They take care of your precious defenseless children, they support you in your times of weakness, will care for your aged relatives when their feeble bodies fail them, and will add life to any person's days that they encounter.

It is a hard life, but it's a life that I enjoy; I've witnessed some crazy stuff, but it's interesting to share treasured war stories with my colleagues from time to time. Though, I do wish the government would do its part in helping us take care of our patients. I would definitely prefer the job satisfaction that comes with being able to adequately address my patients' needs over a pay rise. The government has absconded its commitment to the health sector and the majority poor; without giving us the tools to care for this society, they turn us into mere palliative specialists. Like I've already mentioned, I have already learned to be pretty detached in my line of work - for my own sake, and my patients' too; but having my hands tied any further would only make me bitter, cynical and ambivalent...qualities you do not want in any of your doctors.

Take home message: if you choose this life, prepare for a gamut of challenges, and for the reward to mostly be in the work itself. That being said, you should also remember that it is a noble profession, it is God-ordained. Not many jobs have as immediate of an impact on the people served; so embrace it, and make your mark in this world as only you can.

God Bless.