Not All Doctors Are Created Equal!

From "The Fourth Plane"

I remember that it was a day much like any other at my first job as a Medical Officer. Internal Medicine ward round, longer and more nerve-racking than it ought to have been. My Consultant was a Nephrologist of some renown, but she had a peculiar bedside manner for a practising physician: she could be dismissive, condescending, insensitive or downright incendiary as we went about the business of assessing the patients. As we got towards the last room in the female ward that day, we had a new unclerked patient (let's call her "*Eunice") before us who appeared otherwise normal. Lately, she had been experiencing a recurrent localized right lower abdominal pain; her past medical history was hitherto unremarkable. My Consultant had me assess Eunice briefly,  and the only symptom she had was marked tenderness in the lower right abdominal area of her abdomen. I remember suggesting that it seemed likely that this patient might have been suffering from appendicitis, and that she might actually be more of a surgical patient. The Consultant wasn't having any of it and proceeded to berate me in front of the team, which included medical and clinical officer interns, nurses, physiotherapists, nutritionists and a counselor (and let's not forget the patients that were within earshot):

1. Why would I think it was an appendicitis yet the patient did not have the typical "septic" look of an appendicitis patient?
2. Wasn't her abdominal pain localized, and without the typical progression seen in appendicitis? Where are the other signs suggestive of appendicitis? 

I halfheartedly remember suggesting that perhaps it was an atypical case, but she was having none of it; I was summarily told to stop jumping to conclusions (known more technically as "confabulating") and a plan was made to work up the patient in terms of lab work and some imaging studies.

Getting insulted was usually par for the course, so I just took it in stride. Apart from that slight, nothing else really stirs in my memory from that day. Anyway, the ward round - which spanned 2 wards, and sometimes involved consults in other areas of the hospital - took so long such that the rest of the day typically involved drawing samples and tending to other ward procedures. I was also charged with attending to the Outpatient dialysis patients. A lot of the time, you would end up getting the results the next day, so it wasn't something that you could respond to too quickly. Provided the patient wasn't knocking on death's door, a little waiting wasn't really going to hurt.

The next morning was joyously a Thursday. Thursday was the one day in the week that I got to lead the ward round because it was the day when my Consultant was otherwise occupied running the Medical Outpatient Clinic (MOPC). This meant that we usually finished the ward round a lot faster. As I was conducting a preliminary assessment of patients prior to the ward round, I remember asking one of the clinical officer interns for the list of our patients. When I received the list, I noted that Eunice was unceremoniously missing. When I inquired why, I was told that she had been handed over to the Surgical Team. My interest was piqued and I decided to glance in her file to find out what had happened. The sonographer who performed her abdominal ultrasound had detected a mass in the tender part of her abdomen - an appendiceal abscess. What appeared to be more likely is that Eunice had probably suffered from chronic appendicitis; this inflammation was eventually "walled off" by the body, protecting her from the more adverse effects associated with a leaking/burst appendix.

The irony of it all is that a crowd was present for my ridicule, but my moment of vindication was mostly a private affair. Dear God life can be so unfair!

I must admit that I have been reading and watching a lot of news concerning Covid-19 lately. Part of the reason for this is that so many medical updates keep on arising concerning testing, and many of my colleagues on the front-line worldwide are providing a lot of useful advice that might prove helpful in our local battle with the disease. Another reason is to see how countries are dealing with the economic push-back from the virus, and to get a sense of what stimulus measures might be needed to protect the citizenry from the economic ravages of the virus. However, the last bit consists of the debacle-prone US response (with all its bells and whistles) and, surprisingly, tales of conspiracy theories and what not. Just recently, I caught a segment on Fox News whereby Dr. Oz was talking about possibly getting children in the US back to school after a Lancet (Medical Journal) study had shown that such a move came with a 2-3% chance of increasing the total US mortality statistics. This is of course par for the course when it comes to Fox News recently, and though they keep on emphasizing how precious human life is, it a repetition of their stance that some amount of human life sacrificed for the sake of the economy might not be such a bad thing. However, policing a news media outlet is not my duty; as a trained medical practitioner, my job is to at least make sure that people are getting sound medical advice wherever they choose to consume it from, and especially that is being delivered by a sound medical professional.

Now, rightly so, Dr. Oz drew a lot of condemnation for his comments and ended up having to apologize. This is not the first time that he has been forced to walk back his comments as he was actually brought before a congressional hearing to account for claims he had made on his television show about certain weight-loss regimens. For those who may not know it, Dr. Mehmet Oz is a renowned Cardiovascular Surgeon who is a media sensation who got a big push by being endorsed by Oprah Winfrey. His skill is unquestioned in the field of cardiovascular surgery where he is known to be an innovator; however, it is his media sensationalism that typically gets him into a lot of trouble.

I remember chatting with a group of my high school alums on Whatsapp and I remember being peeved at a suggestion by one of my friends that they needed to be hearing more from doctors in the national discourse during this period of Covid-19. That remark set of a powder keg in the group that drew the ire of the health practitioners. This came against the background of disdain and distrust that Kenyans have continued to hold towards doctors and nurses since a massive 100+ day strike in 2017 which was meant to address issues of poor renumeration and working conditions, and inadequate functional capacity. The politicians of course turned things around and made it seem like it was purely a salary push by a money-hungry lot, and consequently medical professionals and institutions were lambasted by the citizenry. Long story short, hearing my friend calling on the medical professionals to start waxing lyrical was like opening up an old wound. In retrospect though, having had some time to calm down, I can admit that my friend was right. People do need to be hearing from sensible medical professionals at a time like this. The amount of sensationalism, hoaxes, "miracle-cures" and conspiracy theories is proof of that.

I think that people understand even less about the practice of medicine these days. In the old days, people were awed about the profession, but nowadays the prevailing sentiment might be that the internet has bridged the divide between clinicians and patients. It is therefore useful to understand the typical career path of your typical medical doctor. In Kenya, there'll be 5-6 years of medical school (post-secondary), followed by a 1 year internship rotating in 4 major departments; from there you can expect 3 - 5 years of specialty training, and after that you add on as many Fellowships as you want, and you can aim towards being a professor, etc.
Now, since I am going to discuss Dr. Oz, I'll give you a glimpse into the American path of ascension.

• 4 years of a pre-medical degree
• 4 years of a medical degree
• *Residency Program
• Fellowships

*The 1st year of the residency is pretty much just an "internship" (semantics). Unlike the Kenyan experience, American doctors do their internships specifically in their field of interest. Surgeons have a surgical internship, physicians do an Internal Medicine internship, etc.   
    

The aim of medical training is to start you off with as wide a base of medical knowledge as possible, and then whittle that down to the things required only for your area of specialty. Back in the day there were people who dabbled across the field of medical specialties, but nowadays - short of someone being a genius - such broad focus is discouraged. True Story - I remember being blasted for showing lack of focus during a surgical specialty interview at a local medical university. Why? you might ask. Because I had listed that I had performed independent research on Phytoremediation on my curriculum vitae (CV); the same CV further states that

"I aim to become an experienced doctor specializing in surgery, with a view towards
practicing and teaching medicine while infusing my practice with environmental
consciousness to enhance the focus on preventive medicine."

The Plastic Surgeon on the panel had a look of disbelief on his face; it was like this was blasphemy!

Therefore, applying this logic to Dr. Oz, who got his joint MD and MBA degree in 1986, the man has been a PURE SURGEON since 1986! This is not the kind of individual you want to be getting your principal Covid-19 findings from (media sensation or not).

The above 2 images have been part of a meme sent out by many of my medical colleagues, but I think that only the medical field is in on the joke. This is the grim reality: most of the specialist medical professionals do not have the skills to deal with this Covid-19 pandemic; but if we cannot keep the numbers of severely sick down to a level where the healthcare system can adequately handle the numbers, then every medical practitioner will eventually need to be drafted to help with the situation. They'll just have to be retrofitted and adapted to the situation.

If this post wasn't already too long I would've delved into the reasons why medicine is not the homogeneous field most people tend to think it is. There is a lot of direct antagonism going on that is the subject of much comedic gold.

• Surgeons vs. Anaesthetists, where surgeons believe it is the joy of an anaesthetist's day to cancel a scheduled surgery for the flimsiest of excuses. Anaesthetists in turn believe that surgeons will steam-roll through any procedure without considering the risks. (It's the relationship portrayed in the title cartoon!)
• Orthopedic surgeons being of questionable IQs (despite the research)
• Those who are not good enough to be surgeons become... (I once remember a surgeon toss this gem in jest at his accompanying scrub nurse)
• Doctors vs. nurses
• A surgeon only sees a surgical solution to a problem. A physician only sees a medical solution to a problem (typified by my experience with my Consultant)

All this aside, the best results in our profession (and its allied fields) are usually achieved when we have a healthy dose of respect for everyone and their training. The best approaches are always multi-disciplinary. Therefore, next time your relative with Diabetes/Heart Disease/Lung Disease etc. shows up for an elective surgical procedure and another doctor gets called in for a specialized consult, please understand that the hospital is not simply trying to pad your hospital bill; what they are trying to ensure is that the elective surgical procedure doesn't end up degenerating into a complicated affair with death as an outcome.

This pandemic is stressful for everyone, more so the medical fraternity which finds itself faced with a new enemy for whom our typical treatment regimens don't seem to be working. Despite that, we are soldiering on, and we are looking for our fellow (not-so-flamboyant) colleagues to provide answers. We are listening to the Researchers (Virologists, Pathologists, Epidemiologists, Biotechnologists), Infectious Disease Specialists, Intensivists, Critical Care nurses, Respiratory Therapists, Psychiatrists/Counselors etc. to help us chart the way forward. Their work will eventually filter down to the other medical professionals and inform our practice, and finally down to the general population.   

Now, more than ever, it is important for people to interrogate their sources of information. It has taken the medical field forever to get down to the level of Evidence Based Medicine wherein we have to let the efficacy of the science guide our practice. We are not witch-doctors after all! This level of supervision has not made its way to streaming and social media, and thus all manner of dubious claims are being made about this disease and its treatment. We have no way of policing all these dubious claims, but I would ask people to exercise restraint in dispersing all this pseudo-science. Sars-Cov-2 is out in the open and it will be studied intensively for many years to come, then we will finally have the truth; until then, for all these medical pundits making all these claims, remember to assess their backgrounds with the following lens

1. Researchers trump Classical Doctors
2. Internal Medicine specialists trump Surgical Specialists
3. Alternative Medicine specialists are pretty much at the same level as the typical civilian
4. Not every PhD has the acumen to discuss medical issues
5. Always look for conflicts of interest. The person is certain to be selling their dubious miracle cure as they tear into the conventional medicine, i.e. Miracle Mineral Solution (MMS) which is just INDUSTRIAL BLEACH; otherwise, look for them to be espousing a particular agenda
6. Check for reports about them being called out by their professional peers or censured by medical regulatory boards. This kind of behaviour is always a continuum       

This current sensationalism of medicine reminds me of that time when "The DaVinci Code" movie graced the movie screens. I remember that it was touted to have made a lot of people lose their Christian faith, and I wondered if watching it would have been detrimental to my own; then I watched it and I felt bamboozled. I remember at one point the author (Dan Brown) randomly included "The Peace of Westphalia" and used it to make a nuanced argument. I wouldn't have known anything about that incident if it hadn't been for the boring "Church History" lessons (my apologies Mr. Borruso) that I'd had to take while I was in High School, and thus I could see that the author was merely sensationalizing historical incidents that most people are not aware of.

The same exact thing is playing out with medicine right now. To tell you the truth, medicine - just like History - is very boring! Let me clarify, studying/reading medicine is extremely boring! You better thank a scientist who is able to take the time to truthfully summarize a lengthy research paper into snippets that you can digest because reading them is hard work! Being boring notwithstanding, it does not give us practitioners of science the right to mislead people. Always remember that

"The most dangerous untruths are truth slightly distorted." 

Therefore, as a medical practitioner, I will do right by my patients or anyone who needs some clarification. Honesty, Discipline, Empathy and fortitude will get us through the rigours of this pandemic. However, despite the readily available stream of information from social media and video streaming services, we all still have a responsibility to practise patience and critical thinking. There is no need for panic.

God Bless

 

 

Empathy

As far removed as I am from my internship days, every once in a while a specific memory pops into my mind from way back then. This one specific memory has been popping up from time to time; perhaps it's relevant for the times we're in. So here goes.

During the latter part of the Internal Medicine rotation, I remember early one evening, as I was almost leaving, I ended up being called to attend to a patient. This patient was neither in the ward nor in the casualty area; rather, he was at the TB clinic area, which was an Outpatient clinic where TB patients usually showed up for follow-up as they went about taking their medication. This was something that the clinic was able to handle so well without involving the other doctors, so it was something of a novelty for me to be called in to the clinic. I got there to find a young man - probably in his early 30s - flanked by another gentleman who looked to be in his 60s.  The elderly gentleman then proceeded to tell me a story. The young man was his son (I'll refer to him henceforth as *ALEX), and was a prospective patient; having been diagnosed with Pulmonary Tuberculosis (PTB) a while back, Alex had been started on treatment for the condition. Unfortunately, he was also an incorrigible drunkard, and his usual modus operandi had consisted of initially taking the TB medication (which doctors refer to as RHZE) then somewhere along the way - probably once his symptoms would subside - he would go back to his drunken ways and stop taking the medication.

Let's get a little technical here: the treatment for TB consists of 4 medications: Rifampicin (R), Isoniazid (H), Pyrazinamide (Z) and Ethambutol (E). You start off taking all 4 for 2 months (RHZE), then switch to 2 drugs - Rifampicin and Isoniazid (RH) for the remaining 4 months. There are variations to this dosing, but this is the simplest one for run-of-the-mill PTB. People should be aware that these drugs do have a whole bunch of side effects, most common of which is liver toxicity and injury.

So, by the time I encountered the young man, he had basically defaulted on taking his medication on 4 separate occasions. During that time, he had gone on to infect 3 other people in his village area; thus, he had been served with an eviction notice by his chief (and the villagers) that if he was found within the village, he would basically be beaten and burned to death! Father and son had thus ended up moving to the township area to stay with a relative as a stop-gap measure, and they had come to the TB Clinic in order to get him started on treatment. Because Alex was a serial defaulter, an option that has usually existed is for such patients to be institutionalised in a prison facility where it can be ensured that they take the full course of their medication. I remember making a call to the nearest prison facility, but they insisted that they were in no position to accept such a risky individual; the prison was already overcrowded, and imprisoning someone suffering from TB was a recipe for disaster.

With that option off the table, I called the Internal Medicine Consultant. He was very categorical that the patient was high risk, possibly suffering from MDR (Multi-Drug Resistant) TB, and thus there was no way he could be placed in our regular ward. I broached the idea that perhaps the patient could be placed into our TB isolation ward (our old Amenity Ward) while we tested him to confirm that he was in fact suffering from MDR-TB, but my consultant categorically refused. "Send him to Homa Bay" was the only solution I was given.
Now Homa Bay does in fact have a facility that can serve MDR-TB patients, but you needed to first have a confirmatory test (Gene Xpert) which confirms infection with a drug resistant strain of TB. Without that confirmatory testing, I worried that I would be sending the patient on a long journey only for him to be turned away once he arrived at the Homa Bay facility. In addition, if he was in fact infectious, he risked infecting an even larger number of people if he used public means to travel to that same facility.

My hands were tied in the matter, and I remember relaying this to Alex's father. This had been a surreal experience, sometimes so comical that a chuckle almost escaped my lips (damn that morbid medic sense of humour!). I was not expecting to see his elderly father almost break down into tears at the hopelessness of the situation! Contrasting that with Alex's laissez-faire attitude, this felt like a case where a careless man deserved to get his comeuppance. Sadly though, there was a family that was being inconvenienced by this man's carelessness, and that had to factor in there somewhere. Eventually, in contravention of my consultant's advice and against my better judgment, I ended up having Alex housed at the amenity ward so that he could have Gene Xpert testing early the next morning. I think my stomach was in knots that night as I thought about the prospect of having admitted a high-risk patient; worse still, if my consultant had found out, my goose would have been cooked. 

My elation was palpable on the next day when I eventually found out that he was suffering from "garden variety" TB. This meant that he could be treated at our facility. I hoped that the idiot would finally stick to his treatment for the prerequisite 6 months this time around, but, alas, I don't know how the story ended.

Seems like ever since this COVID-19 popped up, it really is the only infectious disease that's being talked about. In a most ironic twist, it has thankfully reminded people that hand hygiene and cough etiquette are matters of utmost important. You'd have thought that a high prevalence of TB and Cholera (among other things) would already have clarified that fact! After this is all said and done, we'll probably have the most hygiene-conscious generation of individuals ever.

The sad thing about being smack in the middle of this pandemic is that we can't even be 100% sure of the transmissibility of this virus. The asymptomatic carrier may have an extremely large role to play in spreading Covid-19. An oft-quoted line of wisdom with regards to Influenza used to suggest that you are most infectious before you start to show flu symptoms (might be more true for Influenza B than A). This same line of reasoning seem to hold true for Covid-19, and a pre-symptomatic or asymptomatic carrier might just go about shedding a lot of viral particles without being any the wiser.

I keep thinking back to how my response to this virus changed as the situation has evolved. Even while at the clinic, initially I wasn't afraid to shake hands. At that point, before seeing a patient, I would casually glance at their notes and only don a surgical mask if the patient exhibited respiratory symptoms. From there, it evolved to no handshaking, having the surgical mask on at all times, and eventually progressed to preferentially donning the N95 mask. I went from looking at my scrubs as benign items that I was confident to walk into the house while wearing (at the end of a shift), to germ-infested items that are tracking this nasty virus to my humble abode each day.
In case you might not have guessed it, a lot of your doctors and nurses are the biggest hypochondriacs out there. It started out during medical training when we were exposed to a whole bunch of medical conditions in the literature. Sometimes we could feel the lecturer diagnosing us with the rarest conditions on the spot; but because we stoically kept quiet, I think we eventually just overcame our worries and fears to continue with our chosen careers. It does of course help that once we begin actually practising medicine, we discover that "Common things occur more commonly"; and in case something uncommon jumps out at us, between our hands-on practice and help from peers and superiors, we can usually fashion a suitable response to the task at hand. Truthfully speaking, Covid-19 has a lot of us worried. There are no standard treatment regimens as of today for the disease, and there is no vaccine in sight until next year (at the most optimistic estimate). The disease remains a really theoretical concept for the ordinary mwananchi, but we in the medical field can physically visualize the downward spiral for an affected patient. We've encountered these effects with other diseases, but never on scale that's potentially this massive!

I also keep thinking back to a few of the patients that I'd been encountering in the previous months. I was - initially - particularly annoyed at the patients who'd travelled from hotspots; instead of quarantining themselves off for the agreed 2 week period, they were breaking quarantine to come into the clinic to seek reassurance. Practically all of them were asymptomatic, but they still worried that they had possibly put their families/loved ones in danger and worried about the fallout. They wanted to have themselves tested, but the truth of the matter was that only government labs were conducting the testing, and due to scarcity they were only really testing patients with marked respiratory symptoms coupled with a positive travel history or contact with a Covid-positive individual.

I can understand their fears. For the longest time I have had 2 fears concerning this condition:

1. Suffering the most severe symptoms
2. Unwittingly spreading it to others

I daresay that if all I was going to encounter was the typical flu symptoms - with the assurance that I'd be immune thereafter - I'd rather get it over with (same way parents used to opt for their kids to get exposed to Chicken pox). All I could do was reassure them that they had an 80% chance of being on the good end of this condition. Until such time as they would develop severe symptoms, I advised them to simply continue with their quarantine schedule whilst monitoring themselves.

Lately, however, I've developed a 3rd fear that stems from our government's response. As a matter of policy,

"Until the Ministry of Health establishes the existence of sustained community transmission, all confirmed positive Covid-19 cases identified should be monitored closely at a HEALTH FACILITY ISOLATION ROOM...Once sustained community transmission has been established, home management of mild cases should be encouraged."

 *Interim Guidelines on Management of Covid-19 in Kenya (PDF Page 13) - Available for Download here

I'm of the opinion that because we have under-tested thus far, we have already reached the level of sustained community spread. This is the reason that I'm all for random mass testing of the general population because it will push the number of confirmed cases up exponentially, which will in turn escalate the government's response; ideally, this should mean home care for Covid-19 positive individuals with mild symptoms.

The government's understanding of the situation and its "playbook" keeps changing as time goes on. After a recent webinar by medical professionals, I feel like the government might choose to accommodate a Chinese solution, meaning isolation of POSITIVE people, whether they might be asymptomatic or mildly symptomatic. If that's the course they follow, picture a whole bunch of people who might at most only require Paracetamol, cough syrup and bed rest being isolated away from the general population in designated facilities like hospitals, stadiums and high schools.

I also appreciate that the government also needs to do contact-tracing of those individuals that have possibly been exposed to a confirmed Covid-19 patient. Defining the extent of the disease's spread is important, but I believe that we also need to safeguard the dignity of our citizen's who've been inadvertently exposed to this disease. These contact-tracing officials riding gung-ho into a neighbourhood in the name of carrying out their duties risk panicking residents, or even worse turning the infected/affected into pariahs within the community (like Alex in my initial story). Ironically, to quote Donald Trump,

We cannot have the cure be worse than the problem

    
Life will go on for most of us beyond this virus. We cannot afford to "burn" people in the community in the name of protecting everyone else. Despite how crazy things might be around us, we must retain our humanity through the whole experience.

I really sympathize with the government as well. It can't be easy charting a course in the chaos with all the differing opinions about their approach (though I suspect they're having a much easier time than the United States). I can respect that they've chosen to have people wear masks like the CDC recommended (but not the WHO), but hate that they've left us at the mercy of hoarders and quacks supplying the goods. Have they even stockpiled enough masks for healthcare (and affiliated) workers in this same period? Then there's the problem of indiscipline among Kenyans. In much the same way that overseas travelers failed to self-quarantine, it can be postulated that Covid-19 positive patients are unlikely to self-isolate of their own volition (as recent reports of mischief would suggest).

We have a powder-keg of a mess on our hands, but there is always hope if we empathize with those that we mean to protect. Worldwide, Covid-19 is showing us that traditional inflexible systems cannot work. Just like the fictional human society in Star-Trek, we might be forced to abandon concepts like "profit" and "individualism", and just work together to confront a common unseen enemy, if at least only for the moment at hand. At a countrywide level, our politicians need to make sensible policies for the citizens they govern. Despite all the buzz about Kenya being a middle-income country, they know that we are still a fledgling developing country with a vast vulnerable population. Their policy needs to acknowledge that and put in place measures to safeguard the most vulnerable; ignoring this will only lead to revolt.

At the local level, there needs to be public health education on a massive scale. People need to feel entrusted with the knowledge and acumen to fight this disease. They also need to be reminded that with all the RIGHTS that they exercise there are also congruent RESPONSIBILITIES. The only way we come out of this any better is by abandoning the inefficiency and bad habit that have failed us in the past; we need to empathize and we have to be better. Our very survival depends on it.

God Bless  

2020

I was hoping to have started 2020 better than this. For starters, I have totally procrastinated and abandoned this blog for quite some time. I've missed writing up a couple of movie reviews, and then the knockout punch came with the demise of one of my favourite artists - Lyle Mays. Being the glue that held the Pat Metheny Group together, I'd hoped that they would eventually bless us with another album that could stand the chance of eclipsing their 2005 Magnus opus "The Way Up". Sadly, we won't get that opportunity. However, Pat Metheny released a new album "From This Place"in February, which, it turns out, is the first album I've ever pre-ordered. I'll be sure to talk about that in another post.

However, another matter has us occupied altogether. Seems like Mother Nature turned on us in the  starkest of ways, unleashing on us the ongoing COVID-19 pandemic. Now, as a clinician, my mind is always prepared for this kind of an incident (at least in theory); when we had a teen die of Acute Respiratory Distress Syndrome (ARDS) secondary to the flu at a local hospital last year, we braced ourselves for what we thought might be the next big thing. It really took till the end of 2019 for us to develop the challenge that we've always felt lurked out there.

It would behoove me to blame Mother Nature for this specific occurrence; also, unlike conspiracy theorists, I DO NOT believe that this new virus (SARS-CoV-2) is a bioweapon. It's very insidious, and once you pair that with it's ability to "return-back-to-sender" you understand that it makes for a very dreadfully poor bioweapon. The problem here is that wildlife trade that going on in parts of China. Let me clarify that this is not me launching an attack on people's food choices, vast as they may be. While we're on the subject, I remember that (while I was in med school) one of my Mandarin Language teachers used to recite a long held gem of wisdom about food choices in Guangdong (Southern China)

"If it moves on the ground, apart from bicycles and cars, and if it flies with the exception of airplanes, then it is considered edible".

I have paraphrased it slightly, but that was the general gist. Though it was uttered in jest, living in China basically exposed us to a fair share of "exotic" delicacies. Digging into the history of the country reveals that some of these cuisine options came about in times of hardship, and we can't begrudge them that part of their past.

What is problematic, however, is how those animals are handled prior to slaughter. We've known for a long time about zoonoses/zoonotic diseases that can spread between species because we sometimes end up as unwitting sufferers of such conditions. This continues to be a relevant matter as we encroach further into other environments like forests, caves, etc. that we've been relatively isolated from. The wildlife trade in China actually complicated things a bit because by all admissions all manner of animals were held in pretty close proximity to each other; this created the perfect petri dish for a zoonosis to spread between the species, and maybe along the way it run into a multiplier species that set off this whole issue. Due to the fact that we are in the middle of a pandemic all this is a matter of speculation. Consensus seems to suggest that the virus probably originated within Bats, but the missing link in the chain prior to it making its way to humans is still a matter of research (people have suggested a Pangolin).

Regardless of the way in which this thing came into existence, the rate at which it has been able to spread so prolifically has accentuated just how much of a "Global Village" the world has really become. We saw it take root in China, and watched as it spread first to adjacent Asian countries, then made its way across the world to everyone's doorsteps. It's not unrealistic to say that it surprised everyone, but what has come to the fore is that some people have been better at dealing with this situation. The fact that Italy, Spain and France have taken quite the walloping despite their remarkably high level of healthcare is a truly sobering fact. The United States' response has, however, proved to be quite the conudrum; coupled with its late response, its president's "unique" personality, bipartisan distrust and its administrative composition, we are being treated to widespread confusion on a massive scale. In hindsight, Trump and the Republicans might be forced to admit that their "hack-and-slash" treatment of measures already put in place by previous administrations might very well be the country's undoing. Also, maybe they also need to accept that this is not a problem that can be dealt with from a strictly "capitalistic" point-of-view; this virus will not bend to accommodate our inclinations, and therefore our systems must ideally be molded for the best outcomes. 

The US, however, is not an isolated incident; here in Kenya we are suffering something similar, but on a smaller scale. Granted, this COVID-19 situation is a one-of-a-kind occurrence, and better equipped countries have also found themselves overwhelmed, what is going on in Kenya is a mess of our own making. The government won't outright admit it, but there was a particularly slow response to closing of our borders when you consider that a China Southern plane was allowed to bring 239 passengers from mainland China in late February before China had gotten control of the pandemic on its end. When pressed for answers, government officials only seemed to focus on the fallout of failing to let the economy progress in business as usual fashion; it's also likely that they feared retaliation from China if we didn't allow their flights into Kenya (I fear that our overwhelming debt owed to the Chinese doesn't give us much room to negotiate). It must be poetic justice to note now that China has its COVID-19 situation under control, it has forthright banned foreigners in possession of valid visas from returning to the mainland; they are basically doing the right thing to safeguard their borders and prevent importation of the virus back into their country.

We are currently waiting for the COVID-19 pulse to hit the country. Thus far the government has locked down the borders, stopped all international flights as of midnight March 25th (with the exception of "evacuation flights"), put in place "social distancing" measures and has initiated a dusk-to-dawn curfew (7pm - 5am); recently, concerned that 81% of confirmed cases were within the vicinity of Nairobi, they've initiated a lockdown of the Nairobi Metropolitan area to prevent the virus from spreading to the rural areas where it is felt that it might be particularly passed on to grandparents and similarly aged individuals.

The government is perhaps scared to admit its folly in this matter. A lot of medical professionals (myself included) will openly admit that the virus has already achieved nationwide sustained community spread. The numbers of confirmed cases remain low because of one factor alone: testing. This is a scientific endeavour, and the only real way for us to quantify how well we are doing in this situation is by our ability to measure the situation. The truest measure is to pinpoint the infected and to keep the infection from spreading. If we wait too long, there are other quantities of measure that will start to surface - Deaths! Ideally, we cannot afford to wait that long. The government thus far, because of the shortage of testing kits, is stuck testing those people it had forcibly quarantined as well as the symptomatic cases that are coming in to hospitals; this comes to an average of ~300 tests in a day.

I applaud the government for what they have done thus far, and for where they are headed. However, they need to set their sights higher. They already lost the first battle to keep the virus out of our borders, and we have to move on. People were not busy sitting in Nairobi as we awaited the government's "Will-it/Won't it" decision to place the country under lockdown; people already panicked and traveled beforehand to the rural areas. As insidious as this virus is (in comparison to something like Ebola), we have no idea what a COVID-19 sufferer looks like. A majority of people will suffer anything from no symptoms to mild symptoms. That is a vast range including anything from a seemingly normal person to simple upper respiratory tract symptoms (coughing, sneezing, runny nose, itchy eyes/ears/nose, loss of taste and smell, sore throat and voice hoarseness) to flu symptoms (fever, headaches, malaise, chills and rigours, muscle and joint aches, nausea, diarrhoea and vomiting).

I can't help but smile everytime the WHO/CDC adds another symptom to the list. Those of us who treat Cold and Flus on a regular basis recognize that there's nothing unique that distinguishes COVID-19 from regular flus and colds. Between the dust and pollen in the air, we also have seasonal allergies (Allergic Rhinitis) and asthma to deal with. The few people who will develop the characteristic severe symptoms will find themselves in an extremely unlucky position characterized by medical personnel's worst bunch of condition:

1. Acute Respiratory Distress Syndrome (ARDS)
2. Kidney Failure
3. Sepsis
4. Multiple Organ Dysfunction Syndrome (MODS)
5.  Death

This is a unique time in medicine because a lot of us are basically flying blind. Thanks to a bottleneck in testing, we don't know how many infected we are actually dealing with. We have no vaccines and no particularly proven treatments for this specific disease, so we are relying on measures that have saved us in the past and hoping that the experience of countries that have been hard-hit by the pandemic will provide us the answers we need.

However, with hindsight from the past 2 or so months, some measures appear to be better than others.

• Social distancing is helping
• Hand hygiene is DEFINITELY helping
• Decongesting hospitals by keeping the mildly symptomatic people away is the wisest of all options.
• Isolating the infected at home, provided they are stable, goes hand-in-hand with the above mentioned measure.

Some things are still in doubt

• Hydroxychloroquine and Azithromycin are not quite the cures people were looking for. Both drugs have their proponents and opponents in equal measure, but there is nothing conclusive in the water.
• Wearing masks is also just as contentious. The CDC is all for it, but the WHO is against it. And being a long time wearer of surgical masks, I am honestly worried about the quality of masks that are currently in the market. The masks are ill-fitting (*I favour the tie-ons to the elastic banded ones), people are not wearing them the right way, and at upto sh. 100 ($1) per disposable mask, people have been recycling them, thus rendering them useless. *In light of current shortages, hoarding and the exploitative prices, I would pray that the government rescinds this order and looks for a more workable solution

Other things don't even need to be mentioned.

• Walking around with disposable gloves all day is one of the most disgusting habits ever. Saw this introduced at Carrefour for shoppers, and the same shoppers proceeded to take those gloves everywhere. This is an infection control failure.
• Police bundling people into crowded vehicles or cells is a plus for COVID-19 all the way. (at the end of this debacle, we are going to need to have a serious conversation as a country about using police officers with zero PR training and comprehension skills, and equally poor demeanors to enforce important government directives)
• Any religious folk claiming they can heal COVID-19 sufferers should be locked up in their lavish abodes and be forbidden from contacting any of their religious faithful. THERE IS NO TIME FOR THIS KIND OF NONSENSE. Tithes can also be humbly directed to the medical efforts or to feed and take care of the less fortunate in society.

There is still a lingering question concerning the low fatality rates occurring in Africa thus far. People might say that we are probably at an early stage of the infection of the populace, and not quite at the "Critical mass" level. I am silently hoping for a genetic/environmental advantage. Realistically speaking though, we need more testing. Initially, we've been doing PCR testing, but eventually we will move on to rapid kit testing. Eventually, we should get to Serology testing where we detect antibodies. At that phase, we'd be able to know patients in the acute phase, and more importantly those who've already developed long term immunity to the virus. Such testing would obviously push our numbers through the roof, but then it would provide another bit of ammo for us in this fight. Let's not forget that plasma from immune individuals could technically be used to confer passive immunity on direly sick COVID-19 individuals as a stop-gap measure until we are able to produce a vaccine.

It has been quite the crazy start to the year, but I'm hopeful that things will get better. I would like to salute all essential staff at this time, particularly the healthcare and allied professionals: the doctors, nurses, physiotherapists, pharmacists, cashiers, cooks, cleaners, etc. This one pandemic will shine a spotlight on an oft-neglected sector, and will become a rallying call for us to fund it and fix it as much as we can. To ignore it any further is tantamount to disaster.

Be safe and God Bless.

Cholera: A Sign of Things to Come

I remember a time during one of my (Messiah) college Bio classes helmed by Dr. Jon Makowski. I believe we had gotten to learning about faecal coliforms - indicator organisms that basically indicate faecal contamination of water sources - and he posed a basic question at the end of one lesson which would be addressed at the start of the next lesson:

"What is the acceptable amount of coliform bacteria (Colony forming units, CFUs) in water meant for drinking?"

I remember having to scour my books looking for the answer. My internet searches were similarly difficult; this was in Pre-Google days, so I was mostly checking for my answers on Ask.com. I remember glimpsing an article that listed the answer summarily as "zero" without much explanation, but I also came across something that gave some leeway for CFUs in recreational water sources.

True to form, Dr. Makowski started the next lesson with the same question. Varied answers were given, but none of them was right. Without much trust in my answer, I told him "Zero."

"Correct," he answered. He then proceeded to give us a very simple analogy:

"If I took a speck of stool and mixed it into a glass of water, would you drink it?" 
"Of course not!" came the general class answer.
"What if I dilute one drop from that glass into another glass of clean water?"
"Still No!" the class answered.

Despite the promise of even more serial dilution, no one would accept the challenge of drinking the water. His point was clearly made. It didn't matter how much water was used to dilute that water containing the coliform bacteria; no one in their right mind would consciously consume such water. And thus go the standards for our drinkable water. None of the intestinal bacteria (indicative of the presence of possibly more dastardly organisms in our water) is meant to be detected in our drinking water.

My mind alluded back to this memory in light of the current cholera shenanigans we are facing in Kenya. A work colleague doesn't mince his words when talking about cholera when he's talking to patients about it:

"you've basically got to let them know that they've come into intimate contact with shit!" (pardon the expression)

I am a bit more diplomatic about it and I'll talk about (faecal) contamination of consumed food or water.


Cholera always used to be thought of as a disease for the poor and disadvantaged, living in their hovel abodes with poor sanitation. However, 2017 appears to be the year that things changed: first, came the cholera outbreak at a posh wedding ceremony in the upmarket Karen area; then there was the outbreak at Weston Hotel which ironically affected a medical practitioners' conference, and saw many a doctor (both domestic and international) hospitalized due to the disease; and last, but not least, there was the outbreak at a trade fair at the Kenyatta International Conference Centre (KICC), which saw two Cabinet Secretaries and one Permanent Secretary affected by the infection. A lot of people forget that our very own President opened the fair and was potentially meant to have dined on the food at the same area. The food vendor for the occasion is a prominently known hotel, but it is only discussed in hushed tones lest anyone experience any blowback.

I have dealt with my fair share of Gastroenteritis (GE) at the clinic lately; that's the technical term for conditions that affect the stomach and the intestines, which ultimately yield vomiting and diarrhoea. (technically clinicians may sometimes refer to conditions causing diarrhoea as GE). Gastritis (stomach inflammation) and Enteritis (intestinal inflammation) also exist as different entities, and yes, my colleagues and I have had to treat that too. The strange thing is that it is now very common for me to request an accompanying cholera antigen stool test. As is the norm now, a lot of my patients are middle to upper class individuals, and the reality is that their status will not confer upon them any sort of special favours when it comes to cholera.  

People seem to think that it is strange for me to test them for Cholera, especially if they were able to walk themselves into the clinic; the image of a person laid out by the disease and knocking at death's door is what they seem to cling to; however, as with many disease conditions, there are grades to this condition. I have had many a patient walk into the clinic with a mild case of food poisoning, sometimes so mild that they wouldn't even mind returning to their offices afterwards. When the Cholera antigen test comes back POSITIVE, they seem to think that I'm messing with them. That becomes a good teaching point for the fact that a cholera infection is actually dose-dependent: the more of the bacteria that you ingest, the worse your infection is likely to be. Also deserving of special mention is the people who are using antacids; lowering your stomach acidity, while making you feel comfortable will also reduce your stomach's ability to deactivate certain types of harmful bacteria. Thus you can have all levels of cholera sufferers ranging from the mildly inconvenienced to the dastardly ill requiring intensive care.
 
But how could it be that we've fallen this far where a disease like cholera is fair game for every one in the land? It should be child's play dealing with cholera because we know how it's spread and thus how we can keep it at bay. I surmise that a couple of factors are key.

1. Sprawl - I pass through some areas in Nairobi, and I'm taken aback by just how much has sprung up in terms of new developments. Areas that used to consist of well built bungalows were replaced with high-rise buildings as the bungalows of yore were brought down en masse. People might see this as a mark of progress, but to me it merely spells disaster: sewer lines have not been upgraded to keep up with the pace of construction, and other people may opt to set up septic tanks that are ill-equipped to deal with the demands placed by their inhabitants. And in case anyone forgot, WATER is a finite resource that keeps getting more scarce by the day.
2. Clean Water Trucks - with the water shortages suffered on a regular basis (some of them actually orchestrated by unscrupulous individuals for material gain), these trucks have been making quite the profit. However, it is a slippery slope with this vastly unregulated sector: what is the source of their water, and what is the level of cleanliness in those tanks that are used for storing and transporting the water?
3. Poor surveillance and enforcement - seems to me that we have so many government bodies in charge of everything under the sun, but the typical Kenyan citizen gets burned by everything that those aforementioned bodies are meant to be protecting us from. NEMA (The National Environmental Management Authority) is probably one of the more useless ones. Despite the major cholera outbreak in 2017, they spent that time patting themselves on the back for chasing down the infinitely less important "plastics issue". They practically made Kenyans feel like criminals for walking around with plastic bags, but they dragged their feet about dealing with folks openly discharging untreated waste into water sources.

I feel that the last two might be particularly intertwined. Lately, while driving along Ngong Road - at the point after Westwood - I have been seeing  a water truck parked right next to the edge of the Mbagathi River. Granted, there used to be car washing services occurring in that general vicinity, but the vehicles were never parked at the river's edge. I think that those trucks are pumping in water directly from the Mbagathi River.
This shouldn't be such a bad thing until you consider the situation upstream of Mbagathi River. A stream which eventually drains into Mbagathi starts out around the Mathare slum area of Ngong Town; by the time the stream makes its way down to the Zambia Road vicinity, it literally consists of black water. The stench is unbearable, the water is murky and turbid. It is obvious that raw effluent is making its way into the water from houses adjacent to the river (and a clinic, if rumours turn out to be true). This water is what will eventually make its way into the Mbagathi River, and even the Nairobi River downstream.

There is room for dilution of the black water as it joins the Mbagathi River; but in much the same way that my Bio teacher couldn't get us to drink water that contained a serially diluted amount of fecal matter, I don't think anyone should conscientiously consider using that water for anything.

Now, I will note that I have seen a similar looking truck (with a white tanker) being used to spread water on the Lang'ata Road expansion occurring in the Karen area. But it isn't a stretch to consider that the same truck might dabble in being used to transport potable water to people.

NEMA should be at the forefront of sorting this issue out, but I have very little hope in the people of NEMA, from personal experience. My family used to live adjacent to a compound that consisted of many houses, but all their waste drained into one septic tank. Now, the landlord was not in the habit of emptying that septic tank, and, periodically, it would overflow into our compound. My mother brought this to the attention of the relevant NEMA individual in-charge, and he came to assess the situation on the ground. Threats were issued to the offending party, but it soon became pretty clear that bribes laid the issue to rest.

The sad thing is that I'm pretty sure ours was not a one-off experience. Perhaps that man would have acted differently if he'd had to deal with a cholera sufferer. We had a patient come into the clinic some time ago who was cold to touch, had low blood pressure and was incoherent. She was bone dry and her kidneys had started to shut down from severe dehydration. That patient practically brought our well-staffed clinic to a standstill as we struggled to resuscitate her and we eventually ended up sending her straight to the ICU. I think anything less in terms of management would have been a death sentence for her. It ended up being a rough week for her, but she survived.

We cannot sit down and pretend that this issue does not exist. The solutions are simple, but they will require dogged stubbornness and resolve to make sure that they are followed to the letter. We are all at risk, and we need to prepare for the worst. Our personal vigilance needs to be bolstered by proper surveillance and enforcement by all the relevant statutory bodies otherwise our own efforts would be for naught.

Be vigilant.

God Bless

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
 

Survivor's Guilt

I was at the clinic the other day, and I was finishing up the evening shift. A female patient showed up for a review with regards to lab test results. It isn't uncommon for us to end up reviewing a patient on behalf of one of our fellow doctors because their shift might have ended before investigations they'd ordered were complete. I honestly don't mind because it is usually a case that can be handled quickly.

In this case, it turns out that the lady was the one who had specifically asked for the tests. We get this from time to time too: some individual may have suffered from a specific malady in the past, thus they come in on a regular basis just to check on that specific parameter - Lipid profiles (cholesterol), Liver Function Tests, Blood pressure or sugars, Clotting profiles, etc. I pored through the lady's results and everything was essentially normal, which is the best kind of news - no management needed whatsoever.

At that point, the lady decided to let me know what had occasioned the testing. She had lost her last pregnancy in her 3rd trimester, and was considering getting pregnant again. I decided to question her further, and asked her if the baby had any identified malformations; she answered no. Next, I asked her if there were any problems with her blood pressure during the pregnancy; Yes, she answered.

So my mind pretty much knew what the diagnosis had been: Preeclampsia. So I continue to peel away the layers, finding out that she had very elevated blood pressures which had worsened towards the end; she had also developed generalized oedema. With blood pressures towering above the 170/100 mmHg mark at some point, she had generally crossed over into the realm of Severe Preeclampsia. She had been admitted for monitoring, but somewhere along the way foetal movements ceased and the baby passed away - an IUFD (IntraUterine Fetal Demise) at 32 weeks of gestation. To make matters worse, the lady ended up needing to undergo a Caesarean Section to deliver the recently deceased baby.

The hits had just kept on coming during that pregnancy, and almost 2 years down the line, this lady was still coming to me with questions. In some regards, as usual, she still felt that the doctors were at fault and didn't do enough to save her pregnancy; she was obviously hoping that the same thing wouldn't happen in this subsequent pregnancy attempt. In the course of the conversation, I also got the impression that she felt that things would have turned out better if it had been her life lost in the pregnancy and not that of the unborn child.

Being blunt
I had tried to be compassionate and offer up as much empathy as I could while we talked, but at some point it became necessary to give her the cold hard facts.

1. She had experienced preeclampsia in her very first pregnancy; it had been a mild case that had developed in her 3rd trimester, but that was evidence enough that she'd be at risk of suffering preeclampsia in subsequent pregnancies. For this (fateful) pregnancy, the preeclampsia had started earlier (in the 2nd trimester) and progressed even faster. She definitely should have been booked into a High Risk Pregnancy Clinic for her 2nd pregnancy; but I let her know that it was imperative that she start any future new pregnancies with prior visits to her Ob-Gyn before conception.
   
2. Preeclampsia/Eclampsia is no joke. It's one of those conditions that gives doctors nightmares because we don't fully understand its cause, but we have dealt with its ramifications many times. Any organ damage that happens during the pregnancy stands the chance of being irreversible! Let me mention a few of my fine examples
   
   
   • Pre-internship (KNH) 
   • A mother shows up after a normal delivery in Kibera. She seems to be acting particularly aggressive and out of sorts, so we assume it is a case of puerperal (post-partum) psychosis. Only thing gleaned from her discharge notes was that she's had a BP of 160/100 mmHg at one point. 2 weeks into her stay we end up performing a Head CT scan which shows a massive bleed into her brain. A few days later, she's gone.
   • A mother is 20 weeks pregnant, but her whole body is swollen like a grapefruit. We have a special term for this kind of oedema: Anasarca. I have never seen a case of preeclampsia progress this fast! Coming this early in the pregnancy, my consultants have no choice but to terminate the pregnancy to save the mother's life.
     
   • Internship 
     
     • My introduction to the Obs/Gyne Department: a mortality debriefing. Mother had suffered kidney failure and basically had blood streaming into her urine bag instead of...well, urine. Patient succumbed soon after.
     • A mother had developed seizures in the course of her delivery, and thus ended up being taken to ICU for further treatment.
     • Typical night in the labour ward. Mother transferred in from Lord-knows-where in need of a Caesarean Section (CS). Mother hasn't really had any sort of antenatal clinic visits, so there isn't much for us to glean in terms of past medical history. Anaesthetist hopes to perform a rapid sequence induction using Ketamine, but, with the patient already on the operating table, finds out that the patient's blood pressure is at the 180/100 mmHg. Ends up having to switch to more traditional agents, which have a pressure lowering side effect, and as the surgeon I have to perform as quick a CS as I possibly can, and hope for no complications.
        
   • Post-Internship - a relative comes down with a case of AntePartum Hemorrhage (APH) just 4 weeks prior to her official due date. Investigations prove that she's developed HELLP syndrome, and ends up needing a CS one week later to avoid any further complications.
     
   • Most preeclampsia pregnancies -  with regular doctor's visits and appropriate medication, we are able to ensure a smooth pregnancy. Delivery of the placenta usually results in normalization of blood pressures for the mother; an unlucky few go on to develop chronic hypertension.
     
3. A doctor will NOT risk the life of the mother for the sake of the child. This is not some form of Roe v. Wade permissiveness - this is a real question of life and death where the pregnancy places the pregnant mother's life in immediate harm, possibly of imminent death. We don't particularly like sacrificing the life of an unborn child, but in terms of priorities, it is basically
   

   Save the Mother first; if possible, save the Mother AND Child.

   I do not hesitate in this matter in light of my experience losing Edna. I have been adequately prepared to answer this question by a Philosophy 101 class from my first semester of (Daystar) University. The justification for this is strangely Utilitarian: the mother is a microcosm - she has built up a wealth of relationships, and has very many people who actively depend on her; the foetus is wholly potential. Thus, as a doctor, in weighing the scales, it is more ideal for you to save the mother's life, preserving the already intricate web of relationships that she is a part of.
   
   But then again, life is not so clear-cut and absolute. I remember hearing about the case of a mother who delayed chemotherapy treatment so that she could have a normal pregnancy, and give her unborn baby a fighting chance at a normal birth and life. This was wholly a mother's choice and sacrifice, and a reminder that mothers (and fathers) will on many an occasion make the ultimate sacrifice for their children.
   
   
4. Hindsight is 20/20. Doctors usually get asked to review situations where things have gone wrong, and asked to chime in our thoughts. This is why we typically have Morbidity and Mortality (M&M) meetings, which give us a chance to backtrack and see how things could have been done better. However, we are not always so quick to assign blame because there is the realization that every health situation evolves along a vast array of lines. In this case in particular, someone may argue that the baby should have been delivered earlier. Theoretically, I can think of 2 reasons why the doctor might have chosen not to.
   
   
   • The mother's blood parameters might have been with normal ranges, and it was hoped that adjusting the set of medications that she was on should have allowed the doctors to prolong the pregnancy.
   • It might also have been possible that the baby was considered "small for gestational age". Preeclampsia is one of a host of conditions that can cause Intrauterine Growth Restriction (IUGR), so prolonging the pregnancy would offer a better post-delivery outcome for the foetus.
     
   It is no mere coincidence that I am emphasizing prolongation of pregnancy. Some people may remember a Christian song by the name "Better is One Day". One lyric in that song is particularly poignant

   Better is one day in your house...than thousands elsewhere

The songwriter was referring to being in God's presence...but he might as well have been talking about a foetus in the womb. Nothing we scientifically possess is capable of mimicking the fine-tuned conditions that exist in the womb; thus, as normal a progression of pregnancy is one of the main aims of any OB-Gyn. We usually find that it is ideal to let nature take its course as much as it possibly can.

Conclusion
I think it's worth noting that the patient described me as being "very blunt" at the end of our talk. I don't regard that as a worthy hallmark, nor is it representative of my typical bedside manner. However, she was thankful that I had taken the time to explain things to her in a manner she hadn't experienced before.

In hindsight, it is possible that we sometimes mentions these things to our patients, but they fly right over their heads if they're not yet ready to hear them. Sometimes, we really don't have that much time: I had the chance to go over the situation with her because it was a slow evening at the clinic; I can't guarantee I would've had the same outcome on a busy day. This is why it's probably a good reason to readily recommend some counseling for such patients. Allowing them to talk about the experience often provides more relief than merely doping them up for their depression.

I am thankful for opportunities to practice medicine, and chances like this to clarify things to my patients. I hope this patient gets the outcome that she desires, and can get the true healing that she needs from the events in her past.

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