Who Dies from Typhoid?

salm4Hardly anybody.  In America, anyway.

This is why it was so shocking to hear that one of our translators in Haiti – a healthy father with children – died of typhoid fever recently.

I didn’t work much with this particular translator, Daniel, mostly because he spent so much time interlocuting between our group and the local community leaders, especially in Noyo.

I spent my second week in the very rural village of Noyo, and my experience there was vastly different than the one I had during my first week in Thomaseau.  The physical village looks like a bunch of twig huts that all unrolled themselves from one giant ball as it bounced down a mountainside.  

Despite this scattered layout, the people there were a tight-knit bunch; working with them required constant communication.  Work of the kind we did in Haiti brings with it nearly endless opportunities for misunderstanding.  Daniel was a big part of that because he was well-connected with the local leaders.  

A few times, I wondered what besides common humanity kept the locals from simply overrunning our tiny isolated clinic, taking all the medicine and holding us hostage.  We’re not just talking about picking up some bling bling, either.  They could demand HUGE ransoms for each of us, and never be in poverty again.  

I thought about this frequently in Noyo because the village clings to lost and forgotten hillsides so far from roads that you can’t find it on most maps.  We hiked for over an hour to get there.  And the road that brought us to the beginning of our hike arguably ended miles back from where we actually stopped our battered 4-wheel drive monster trucks.

I think the moral fabric of Haitian culture gets most of the credit for keeping us protected during our time in the mountains.  But some also should be given to people like Daniel, who moved easily between native, locally-powerful villagers and obtuse, big-hearted, mildly-guilt motivated Americans.

 More than once I saw disappoinment in the faces of patients as I sent them out the door with not much more than a toothbrush and some TUMS.

I’m sure I projected a bit, but often I felt their dismay at my ineffectiveness in the midst of so many very real problems.  I could almost hear some of them say, “This is all you have for me?  Look at all that medicine in the back of the church!  Look at those nice tents you live in!  Look at that nice watch and thousand-dollar camera you have.  All you have for me is some antacids?  Do you know that I could feed this child for weeks with just the money I could get for your sparkly watch?  How is it worth that much to you?  How can you still cling to your expensive camera when it could feed a family for months?  Is that moral?

If you claim to be a Christian…how is this not a sin?” 

Often I reflect on how much I care about my children – the lengths I would go to protect and provide for them.  In that light, I do not think I would be nearly so gracious if it were my child wasting away in my arms and some rich foreign king gave me only calcium tablets and a toothbrush (until we ran out of them and just gave the calcium).

Although the Haitians displayed celestial graciousness because I believe they are by nature a gracious people, translators like Daniel helped undergird that goodwill.

Being Haitian, he could agree that yes, these people come from a rich country and enjoy many things that people can’t even dream of in Noyo.  

But he could also point but these particular people don’t have as much as it seems.  He could explain that these kings used a very large amount of their own money just to be there, in the suffering, trying to help however they could.  He could explain that even with the best medicine, their children might still be very sick.  He could point out that ALL the medicine we have left over will be given to the village, to the most in need.

 

It takes over 100,000 of these (Salmonella) to cause disease in an average human.  A closely-related organism, Shigella, only needs about 100.
It takes over 100,000 of these (Salmonella) to cause typhoid fever in an average human. A closely-related organism - Shigella - only needs about 100 to cause disease.

Typhoid fever shouldn’t kill anyone.  It causes some fevers, some abdominal pain, some gnarly diarrhea and maybe some delerium.  Throw any of a number of antibiotics at the problem, and the odds of dying from it drop to about 1%.  If I gave you a 99% chance of winning big in Vegas, I bet you would put a good part of your inheritance on those odds.

 

Even untreated, typhoid fever is fatal in only about 30% of cases.

So Daniel’s story is a tragedy simply because death is a tragedy.  His death is a tragedy because there is a wife somewhere who loves him and is now alone.  It is a tragedy because there are children huddling around their mother wondering in pain and incomplete understanding what happened to Daddy.  It is a tragedy because his role was so valuable to our work and efforts in Haiti.

But most agonizing…Daniel’s death is a tragedy because it didn’t need to happen.

Doctor Sells Insurance For His Own Procedures

**The following is another installment in an SW101 exclusive series entitled Medicine In America (MIA), covered by our crack journalist team scattered around the globe.**

TULSA, OK – “Just in case I screw something up,”  Dr. Jason Hines says, smiling, as he helps an elderly man sign a form and pay for his “procedure insurance.”

Dr. Hines, owner of New Day Family Medicine, a small group practice here, is one of a growing number of primary care doctors who are getting creative as they struggle to increase falling reimbursements.

“I got the idea from my very own Family Medicine Academy,”  Hines says excitedly, holding up a postcard with bold, red letters emblazoned across the top reading LAST CHANCE!  “They’ve been trying to get me to buy their life insurance policies for about 2 years.  This is the 14th ‘last chance’ notification I’ve gotten.

“Then it struck me!  Even the AAFP is getting in on insurance, why can’t I?  I mean, we can’t all be lawyers and dentists, right?  Gotta make the bucks somehow. ”

Dr. Hines’ fledgling business-within-a-business had a rough start.  “Nobody saw a need for it,”  he said.

Debbie Lawrence, one of the first patients to sign on, described her initial doubts.  “It seemed a little strange, you know?  I’ve already got insurance for my car, my house, for medical bills.  I even usually get that extra insurance for rented DVD’s.  But then, as the doctor described the procedure of removing a mole on my back, I saw this slight tremor…and then he read me the consent form!  Boy, it just seemed like the safest thing to do.”

“I had to figure out some way to promote things.”  Hines explained.  “The postcard idea was already taken by the AAFP, so I wanted to do something more creative.”

His solution was to enroll in an acting class at the local community college.

“Watch this!”  He said excitedly.  “I’ll just reach for this piece of paper, aaaaannd NOW, I’ll have this nearly-imperceptible tremor just before I pick it up.  See that?  We really worked on the subtle-but-obvious thing in class.”

Then he modified his legally-mandated consent form process.  “So, they make you blah, blah, blah about the risks and benefits of every procedure, right?  Well, I just figured I should capitalize on that.”

His consent form reads:

My signature is proof that I consent to the forthcoming procedure.  Procedures are dangerous.  Most are not proven to actually improve anyone’s health.  I understand that I risk serious pain, including but not limited to severe disfigurement such that my children and spouse might recognize me only by mannerisms.

Often, procedures of this kind result in lasting nerve damage, potentially to the genital area.  I understand and fully consent to an ambivalent and uninspired sex life from this point forward.

Bleeding is usually something that can be stopped.  If not, I am willing and happy to slowly dwindle into a shivering unconscious blackness from which I may never emerge.

I also agree to not underestimate the risk of infection.  I realize that flesh-eating bacteria exist everywhere, at all times, and are constantly attempting to gain access to my body.  I understand that should infection occur, I may wake up with parts of my body unexpectedly reduced to nothing more than exposed skeleton held together by rotting fascia.

“That’s the mellow one,”  Hines’ states matter-of-factly.  “I use it for wart removal and immunizations.”

After the slow start, business now is booming.  Dr. Hines calculated his acting class cost – “110 bucks a unit for a 3 unit class” – at $330, which he claimed on his income taxes as a business expense.  He sells insurance for any procedure in his office, usually at a cost of $25 to $350 per procedure.  “I’m thinking of adding waiting room insurance – you know, in case the roof collapses – but we haven’t worked that angle yet.”

What has been developed is the “Cabo” insurance package, which includes a special waiting room with palm fronds, seltzer water, a chaise lounge and soft music.  Aside from guaranteeing the procedure to be safe and “up to standards”, the patient also receives a massage at the conclusion.  “Sometimes, we’ll give their dog a massage also.” He said charitably.  “After signing my consent form, people are pretty keyed up.  I usually just throw the dog in for a reduced fee.”

The AAFP did not return calls for comment, but did release this statement,

The AAFP does not condone the practice of selling non-medical products within the environment of medicine.  We believe in assisting our doctors as they provide the best care possible for the entire family.  Just look at the success of primary care medicine in America over the past 30 years for evidence of our presence in Washington.

Although the insurance business does offer unbelievable profit margins and investment returns of nearly 50%, we strongly believe that individual doctors do not have the expertise to get into the business.  Individual family doctors should leave the big business and real financial gains to organizations that are qualified to actually make money.

Finally, although we typically keep information about doctors confidential, it should be mentioned that Dr. Hines appears appears to have let his board certification lapse.  He is soon to be rejected from our community as a “fellow” if he doesn’t pay his dues by cash, check or debit/credit.

“They can say whatever they want.”  Replies Hines.  “I got the idea from them.  The AAFP opened my eyes to the fact that there’s lots of ways to make money on the medical field, as long as you don’t waste much time actually practicing medicine.  I can’t believe it took me so long to figure it out.  I’m just glad I got in on the gig now, when the para-medical business is still in it’s Golden Age.”

More Doctors?

Without really meaning to, I pounded out a totally serious blog about our health care system.  We all do it.  We all think we have the answers.  I know..this is no more than a hit off the crack-bong of American medical politics, but it shuuurrre feels good, man.  

There’s something so empowering about imagining my little ideas solving the ills of the world….

An interesting commentary about the perceived need for more doctors was posted recently at CNN.com

In the article, 3 businessmen who run group called “Innosight” – an organization that attempts to help businesses be more efficient through innovative thinking – suggest that we have as many doctors as we need in the United States. 

Entitled “We Don’t Need More Doctors” – you can read the full article yourself – the authors present a sorta-new perspective on health care delivery in America.  Here’s a summary:

  • Current health reform plans are unlikely to break with the ways of the past.
  • Some advocate need for more doctors, but that’s actually not necessary
  • Nurses can provide quality care at low cost in clinics
  • This would free up doctors to do more complex work
  • Let’s look at some of their other points:

    All parents know the experience of worrying whether their child has an ear infection — treatment involves considerable pleading for a standby appointment at the doctor’s office, followed by a long wait, a 30-second visit with the doctor, and then a trip to the pharmacy for another long wait.

    Throw in the half-day of missed work and the stiff bill, and it becomes clear why many advocate the need for more doctors.

    Ouch.  Can’t really argue with that.  Our clinic has been putting lots of effort into “same day” appointments, and I know this is a push nationwide.  But still, the process is onerous.  Furthermore, a good majority of these cases don’t require treatment (ear infection is a good example).  So, add into all that waiting and effort, a “reassurance” from the doctor that things are fine and there’s nothing to do.

    However, a growing number of visits, incorporating quick and easily interpreted diagnostic tests and algorithm-driven care for conditions such as ear infections, sore throats and minor burns, can be handled better in nurse-run clinics.

    Algorithmic thinking.  I’ve lamented it many times before.  The less a person is trained, the more they rely on algorithms.  What is an algorithm?  It’s a recipie for care: “Does the patient have X?  If yes, do 123.  If no, do 123.”  Algorithms are the “Choose Your Own Adventure” of the medical world.  They provide efficient decision-making, but at the expense of good analysis. 

    Human beings, unlike the computers that generate algorithms, don’t fit well into specific enough categories for most “if/then” treatment plans.  Get yourself involved in any cardiac arrest code – where everyone is trained in ACLS, a completely algorithmic process – and you will see how poorly a care recipie works in the real world.  Furthermore, true thought and real experience provides better, safer and more efficient care over time.

    Nurse training is, by historical design, a non-analytical type of training.  Nurses are trained to react to data, not analyze it (exactly what algorithmic thinking is).  This feathers with analytical physician training perfectly, which is why the system has worked so well for generations.  Both types of thinking are equally important, equally intelligent, and both are required to provide the best care to a patient.

    To cheapen the process, we are now asking nurses to use reactive thinking to provide medical care.  Good care really should be provided through an analytical thought process, supported by reactive thinking (e.g. doc decides the patient needs a shot, nurse makes sure it gets done exactly right).  Remove either one, and inevitably the care suffers.  Even in primary care, medicine is no cookbook. 

    By moving more complex care from specialists to primary care providers, the payments will follow. These changes would make primary care more fulfilling and financially rewarding, while freeing up specialists to do even more complicated work that merits their additional training.

    The problem with specialists in the American healthcare system isn’t that they need to be “freed up”.  Most specialists are perfectly happy with their workloads.  The problem is that they are paid disproportionately, which then drives more med school graduates into those fields when we need more generalists anchoring the medical system.  I agree that additional training merits additional pay.  But not 10 TIMES what a generalist is paid. 

    Another big problem here is that procedures are paid at MUCH higher rates than office visits.  This biases the entire system toward interventions and procedures that cost a ton, are often not proven or helpful, and influence sound medical judgement.

    We don’t need to take patients away from specialists, we just need to pay them more reasonably and make payments for visits and counseling equivalent to procedures.

    We should embrace eHealth initiatives that enable virtual clinic visits and online house calls.

    I absolutely agree.  SO much good medicine can occur online.  To really work, however, solutions to HIPAA hyper-draconian privacy ensurances need to be relaxed.  Additionally, litigation risk needs to diminish so that doctors can make judgement calls without fear of major legal backlash.

    Furthermore, I’ll highly agree with the authors about e-medicine:  We need to move away from the “guild” mentality that has kept boundaries narrow and created regulatory, licensing and reimbursement obstacles to new models of health care delivery.

    Finally, they get it totally right when they sum their opinion with: Patients want correct diagnoses and effective therapies, but they also value accessibility, convenience, transparency, communication and their time and money — none of which have been priorities of the traditional health care model.

    In general I dislike health care reform discussions by non-healthcare providers. I’m a purist that way. I think the discussion should be between doctors and patients and nobody else. You can’t really know how to direct the work, unless you’ve been there doing it. But these guys get it pretty close to right on. Although I disagree with their central idea – that we need more nurses and not more doctors – in general their thinking is innovative and realistic. Maybe someone will listen.

    Brief History of Mother’s Day

    This thing flashes and blinks on the original website.
    Ooooo, sparkles...

    I’m not a big fan of Mother’s Day…at least not the way America celebrates it.

    Same for Father’s Day and Valentine’s Day…and I’m even looking more dubiously on the big guns, like Christmas and Easter.

    The way we did it in Israel (where I lived for 3 years during med school), was way better.  A few of us expatriots got together in simple quiet gatherings while the decidedly non-Christian world churned onward all around us.

    Little fanfare.  Good friends and family.  Love, not stuff.

    I rebel against the materialistic consumerism of the American take on these occasions.  Innately, I resist the implied obligation and communal guilt-pressure that these days somehow manage to impart upon an entire national populace.

    American holidays today are so warped and insulated from their original meanings that trying to teach your children something valuable and – dare I even suggest it – remotely spiritual is virtually hopeless.  “Cool, Dad.  A cross.  Blood.  Sounds gross.  But if we act interested, can we do the egg-hunt?”

    Occasionally, I brag to people that my wife and I don’t celebrate Mother’s / Father’s / Valentine’s Days.  Members of the American Holiday Axis of Evil, you’re either with them or against them.  We’ve George Bushed 3/10ths of the American Holiday calendar…and we’re proud of it!

    It’s a good feeling – like we’re sidestepping this darker side of American culture in our own small way;  our own micro-insurrection against unchecked capitalism.  Abstinence from Valentine’s day is our own personal Toyota Prius of the immutable American celebration gauntlet.

    Reflexively it seems, more than one person has lambasted me for being an out-of-touch chauvinistic male whenever I mention – nay whisper – any sort of criticism of Mother’s Day.  I’m clearly nothing more than Al Bundy with a stethoscope.  I denigrate the holiday because I can’t recognize the profoundly harrowing and endlessly sacrificial life led by all mothers.

    I do admit that any of the holidays can be meaningful, even in America.  But I’ve found that in a family that tries to celebrate 6 birthdays, an anniversary, numerous other family birthdays, every single major holiday replete with lights, medically-catastrophic foods, lots and lots of material things and a whole bunch of forced smiles for the digital cameras…skipping a contrived holiday or two just should be ok.

    Furthermore, I do recognize that motherhood, like fatherhood, like singlehood, like childhood, like professionalhood and laborerhood and mechanichood and office-workerhood and plumberhood…is a tough road.  Life is tough.  For everyone.

    But I don’t really want to perpetuate American Materialism in regular recognition of these facts. It just so easily turns into some form of mild victim mentality…and that’s after the M.B.A.’s of society have grudgingly returned my wallet so I can fill it up again in time for the next Great American Event.

    Turns out that the founder of modern Mother’s Day, Anna Jarvis, abhorred the materialism that suffused her holiday as well.  I don’t know much about her, but I think I mighta liked her…and once upon a time, probably her holiday too.

    Here’s a quick history about Mother’s Day I took directly from The Writer’s Almanac, one of my daily reads:

    Today is Mother’s Day. Mother’s Day as we know it — where we celebrate our own mothers, with flowers, gifts, and cards — is relatively new, but annual celebrations to celebrate motherhood are an ancient practice.

    The motherhood festivities have historically been in spring, the season of fertility. In ancient Egypt, there were celebrations to honor Isis, the loving mother-goddess, who is often shown in Egyptian art with the baby Horus at her breast, much like Mary and Jesus in later Christian iconography. The cult of the great mother-goddess Cybele began in Turkey and soon moved to Greece and Rome, and she was worshipped in some form for more than a thousand years. Her priestesses led wild celebrations, full of drinking, dancing, music, and all kinds of debauchery.

    As the Roman Empire and Europe transitioned to Christianity, the Church set aside the fourth Sunday of Lent as a day to honor motherhood. It was a day to celebrate the Virgin Mary, and for people to honor their “mother church.”

    In the 1600s, England declared an official Mothering Day for that fourth Sunday of Lent. It was a time when families were encouraged to get together, and servants or workers were allowed one day off work to go see their mothers, since many working-class families in England worked as servants on separate estates and rarely got to see each other. Mothering Day was also declared an exception to the fasting and penance of Lent, so that families could have a feast together.

    When the pilgrims came to America, they stopped celebrating Mothering Day, just as they stopped celebrating most holidays that they thought had become too secular.

    Mother’s Day was reintroduced to America in 1870 by Julia Ward Howe, who wanted to set aside a day of protest after the Civil War, in which mothers could come together and protest their sons killing other mothers’ sons.

    But the woman who really created Mother’s Day as we know it was Anna Jarvis. Her mother had held Mother’s Friendship Days to reunite families and neighbors separated during the war, and when she died, her daughter, Anna Jarvis, worked to proclaim an official Mother’s Day to honor her mother and celebrate peace. And so on May 10, 1908, the first official Mother’s Day celebrations took place in Grafton, West Virginia, and at a church in Philadelphia. In 1914, Woodrow Wilson designated the second Sunday of May as Mother’s Day.

    But Mother’s Day became commercialized very quickly, especially in the floral industry, and Anna Jarvis was furious. She said, “What will you do to route charlatans, bandits, pirates, racketeers, kidnappers, and other termites that would undermine with their greed one of the finest, noblest, and truest movements and celebrations?” But flower sales and card sales continued to grow, and Anna Jarvis died in poverty and without any children of her own.

    In the last U.S. Census, there were an estimated 82.8 million mothers in this country, and about 96 percent of American consumers spend money for Mother’s Day.

    CDC Officials Upset About Champagne Return Policy

    logoATLANTA – Officials at the Center for Disease Control are contesting the return policy of the Korbel Champagne Company in what many here are calling “a classic swindle.”

    Effervescently giddy a week ago at the start of the Swine Flu outbreak, senior officials at the organization approved a “full-out partaaay”, says CDC spokesman Greg Thereou.  “But things didn’t work out like we had hoped.”

    “Look, the swine flu thing….we were gonna be important again!”  Says Geoff Davis, senior epidemiologist of the Floating Particles and Peanut Dust Unit and lead researcher of viral gene sequence XD449Cd.

    building“I was gonna get to make all the bus and cab announcements.”  Interjected another scientist – Dr. Franklin Sumpsen – as he passed by.  He then added wistfully, “Sure beats tracking the sperm count of banana slugs in the Mississippi Delta.”

    Amy Forsythe, lead statistician on the Women with Bizarre Sexual Histories Who Also Smoke Crack project, agrees.  “We had a lot going for us this time.  I mean, the SARS scare didn’t pan out at all like we’d hoped.  I think we only got 3 or 4 press conferences out of that before it was all over.

    “This time – ”  Amy interrupts herself to hold up a newspaper on her desk, “Look at the London Metro Newspaper..’Swine flu could kill up to 120 MILLION’.  I think they did that all by themselves!  It’s like they were working for us or something.”

    Dr. Davis did admit to some involvement the story, “Yeah, well, I photoshopped some surgical masks on a picture of a group of SWAT team guys enacting a raid for a public promo in Tulsa.  Then I put little Mexican flags on their uniforms and sent it to the Metro.  But what’s the big deal?  It could have happened like that.”

    bubbly1“We bought 128 cases of Korbel Champagne.”  Said Jody Flannagan, auditer of the Nosocomial Urethral Cath Infections Tracking bureau, and under-secretary of the party planning committee.  She quietly pulled down a giant banner that read:  We’re relevant Again!  Have a drink on us…hell, have two!

    “We mostly went with the Brut, but also threw in a smattering of Extra Dry and some Rose too.”  She continued glumly, popping a balloon under her sensible office shoes.  “Now the upper brass have called off the party and Korbel won’t even talk to us.  It’s like we’re dead to them.”

    All employees agree that coming back to reality after these heady past few days has been quite a blow.  “It was shaping up to be the most powerful moment of our lives.”  Said Dr. Forsythe, “If we could have nudged our pandemic indicator to ‘Crimson-blast deathblood of innocent millions’ level, we would have enjoyed utter domination of planet United States.”

    space-suitA warehouse on the CDC lot is now filled with unused supplies including 48 million square feet of rolled plastic, sterile body suits, goggles, bright blue gloves (“they show up better in the pictures” said Dr. Forsythe) and miles of biohazard taping.  Teams were already prepared to take over airports, schools, bus lines and other places of public congregation.

    “True, they only gave us daycares.” Said James Dickson, a tech in the Toe Fungus lab.  “It’s no JFK International..but still.  We would have gotten to do a press-conference or two.  I could have printed up lots of directions and mandates and plans and I’m sure we could have overseen the arrest of some itinerant parents who wouldn’t submit to our authority.”

    Sighing sadly, Dickson threw a box of round stickers in the trash that read, “It’s for your own good.  One day you’ll understand.”

    “We’re sending an official letter of complaint to the champagne company,” says Dr. Forsythe.  “They should understand that we have no use for the stuff now.  It would be like popping corks at a funeral.”

    Then she laughed conspiratorially as a man in a white coat whispered something in her ear.  “Oh, that’s right…on the back of the letter, we’re attaching a sticky note that says we’ll release Vibo0t778-XM2 into their heating vents if they don’t give us our money back!

    “That’ll teach ’em to ignore the CDC!”

    Swine Flu UPDATE!!!

    Deaths from swine flu world-wide:  Approx 147

    Death from normal flu every year in the U.S. alone: nearly 36,000

    It would be nice if the media kept it in perspective. 

    The concern at the WHO and CDC is that the virus is a novel strain combining elements of human, swine and bird influenzas that humans MAY not have any natural immunity to.  But so far there’s no evidence that the virus is particularly virulent or more deadly than boring, non-newsy, every day  influenza.

    So, it’s too soon to worry much. 

    Wear your seatbelt.  Eat your vegetables.  Do the usual, proven, stuff  if you really want to protect yourself from bad things. 

    Oh, and go ahead and ignore Joe Biden’s advice to avoid airplanes and subways.  What a tool.  If you really want to protect yourself…I’d avoid him.

    I Want It Thaaat Way

    “Just…look under your seat.  I’m sure it’s there.”  Said Bobby, my driver.  We were rushing my ailing patient from Thomaseau to the general hospital in Port Au Prince when Bobby suddenly stopped our car to find a CD.

    He made me get completely out of the car so he could check all around my seat, under it, inside the faux fur cover.  Nothing.

    bobby“Daang, MAN!  I borrowed that from a friend.  Now I lost it.”  He sighed, “Ok, get in.  We’re in a hurry here.”

    Thus began my first experience with the most famous man in Thomaseau.  Bobby grew up here.  His parents owned a general store that apparently did extremely well.  But with the rise of an anti-aristocracy movement when he was young, Bobby’s family found themselves in the grim cross hairs of a violent revolution.  So, his father pulled some strings (one very convenient perk of wealth in Haiti) and immigrated to the United States.

    “I’ve never been to a public school,”  Bobby said as we bounced over a stretch of land that might be described as smooth for a Siberian rock quarry.  With Jedi-like reflexes, he swerved around some of the the bigger pot-holes and cranium-sized stones.  “Always private.  Even college.”

    Bobby has a smile like a sun-flare and fashion sense straight from New York.  He knows English well enough to drop innuendo and colloquialism into his jokes.

    “S-s-s-s-oh you went to c-c-c-c-c-ollege-ege?”  I chattered out as we pounded the Haitian “road” into submission.

    “Yep.  Boston University.  Was getting a degree in…beer.”  He laughed.  “It was such a waste.  I dropped out and started my own contracting business.  Made a fortune.  I had money everywhere.”

    But now he runs an orphanage in one of the poorest villages in Haiti.

    Bobby's Mom
    Bobby's Mom

    When his parents decided to return to Haiti, Bobby followed.  Soon after returning, his Dad died and Bobby stayed to take care of his mom. Just like that.  Shut down his business, sold off the valuable parts and stayed.  It’s a family thing, I guess.

    Bobby and his wife have been unsuccessful at having children, so they closed the family store and opened an orphanage in that building.  Mom lives in what was their house.  Lemons from lemonade.

    “So, can you even make a living as an orphanage director?”

    “A living?  HA!  Tell me another joke.  I don’t even know where I’m gonna get the money to pay my friend back for his CD.”

    “Then,” I pressed, baffled, “clear this up for me: you left a few hundred-thousand dollar a year job to come back to Haiti and live on donations?”

    Something like that, he responded.  “You do what you gotta do.”

    I once heard a missionary talk about why they lived on pork and beans in a hut in Gambia.  “Love constrains us,”  he asserted.  Sometimes the call to service overwhelms the call for comfort and the pursuit of happiness.  Bobby seems to think the same way.

    slum1That said, I myself do not believe in true altruism, with perhaps the exception of one perfectly selfless act somewhere around A.D. none.  Even the great works of Mother Teresa and Father Damien, most probably, have some selfish motive tied up in them.  The great Christian missionaries like Hudson Taylor and Jim Eliot were as much promoting their own worldview as providing service.  They probably would agree with me in this assessment on some level, too.  Great Christians are constantly in touch with their need for salvation.

    And I wasn’t about to let some Haitian guy restore my belief in completely sacrificial love, but he certainly got me thinking about it, especially as we entered the inner city of Port Au Prince…

    I wasn’t prepared for the hopeless destitution I saw there.  The place is a singular universe, filled with the dank and putrid entrails of human suffering.  The streets teem with staring hungry, lifeless eyes.  Hollow, gaunt faces watch expressionlessly as our car blisters by.  Breathe too deeply and you will retch, but you won’t know if it’s because of the stench or the scene.  Maybe both.  These slums fester like an abscess, limitless human pestilence stewing within the wound.  And instead of drinking with his buddies at Boston U, Bobby drives through this nearly every day.

    orphankids
    Some of the orhpans

    As we bounced along, Bobby described some of the problems that led to such squalor.  I noticed his voice drop a pitch in the effort, and I could feel the sorrow in his countenance.  He described the floods, the fires, the rebellions and litany of misguided UN and WHO initiatives.  He outlined some of the self-serving and catastrophic policy choices by the French, and lately by – you guessed it – the United States.

    We stopped at a stoplight and a child came to the window, asking for money, food, anything.

    “Say something in English.”  Bobby told the child in Creole.  “If you want something from me you have to earn it.”

    “Gim me dullah.”  Said the boy.

    “Allright!”  Bobby exclaimed, “You’re on your way!”  He flashed his fantastic smile, the display of mirth some sort of anachronistic throwback to better times, handing the boy a US dollar bill.

    Then my escort looked at me, reading my thoughts.  “I know about the handout thing,” he said.  “It just perpetuates poverty and dependency.  I know.  But you gotta remember…this is Haiti.  That kid isn’t going to go buy drugs or something stupid with that money.  He and a good portion of his family will eat with it.”

    He paused as we asserted ourselves – alpha-wolf style – through a melee obliquely described as a roundabout.  “And anyway,”  He said swerving around a donkey and accelerating into oncoming traffic, “It’ll get that kid off the street for at least one night.”

    Just as he said this, the expansive grill of an impressively huge white truck bore down upon us; clearly with no intention of stopping.  Deftly, Bobby yanked the steering wheel to the right at (what felt like) the very last moment, the blare of the truck’s horn bending into lower tones as we passed by.

    But in avoiding certain death with the truck, even the Bruce Lee reflexes of Bobby couldn’t avoid two giant potholes now in our path.  I gasped slightly and dug my fingers into the IV bag I was holding for our patient.

    Blam!  Followed quickly by BAMBAM!!

    “No problem,”  he started to say, “we-…”  Bobby stopped, looking at me as he drove.  “Do you hear a crowd cheering?”

    bbbExtracting my fingers from the ceiling, I listened.  “Actually, yes!  I hear it too.  Like, a real crowd.”

    Just then the band kicked in, “Tell me WHYii!”  And then the crowd REALLY roared (screams, actually…it was mostly girls).  “III want it, thaat way!”

    Bobby laughs.  The sound reverberates through the car, energetic and infectious.  “THERE’S my CD!  I knew I didn’t lose it.”  Apparently the shock of foot-deep potholes jarred the CD player loose from some track fixation and it just spontaneously started playing again.

    I never, in the imagined space of 10,000 lifetimes, thought I would find such joy in a Backstreet Boys song.  But I did.  There we were, driving through a sorrow I will never forget, singing one of the cheesiest pop songs in American music history…together.

    This child would not survive the Spring.

    Later I would tour Bobby’s orphanage, a jewel of glimmering hope for forgotten children.  I would see the 40 foot well he dug through the hard dirt and rocks in his back yard.  I would listen to him describe his days that start at 5am so he and his wife can care for nearly a dozen kids with no home, no family and no safe keeping.  I would meet one of his orphan boys with cerebral palsy that would be dead within a month.

    Through it all – with so much emotion and despair pressing me into ineffective stillness – Bobby is belting out American pop tunes, driving like Andretti with a midichlorian infusion and trying to save lives.

    Sure, some part of what this guy does is self-serving.  He’d laugh if anyone called him a saint.  He’d probably ask that you dispense with the titles and donate t0 his orphanage instead.  But his life reflects a near-image of genuine altruism in ways that might inspire even the most jaded.

    And he’s a perfect fit here.  This place is destitute and tragic to me.  But this is Bobby’s home.  He can see the hope that I can’t.  He waves to friends he knows as he barrels down the street; he looks with affection on the same things I see as symbols of misery and suffering.  With just a little help from people like me – so ill-fitting here – guys like Bobby will change the world.  They will change Haiti.

    Even in a place like this, he still sings.

    Half A Delivery

    I wouldn’t say we’re competitive, me and ChinaDoc.  If you don’t recall, she was the other FP resident on our trip to Haiti.  Although I’ve mentioned her actual name before, in true blogging fashion I will heretofore call her by a nickname.  Being Chinese, and very small and elegant, I’ve settled on ChinaDoc.

    True, she plays Hearts to the death.  And we’re constantly harassing each other about who has more deliveries.  But that’s not real competition…is it?  Just friendly banter.  Or so I thought…

    Just as we’re closing up shop on the 4th night of our adventure in Haiti, a woman arrived in labor, but dilated to only 3cm.  Since she needed to get to 10 to be “complete”, we knew she had some work to do.  We thus set up a makeshift labor room out of the flight-line of the bats that inhabited our clinic at night.

    Our stellar OB nurse – with something like 30 years experience on a labor ward; one of the best I’ve ever worked with – stayed with the patient to watch her, while the rest of the team walked across the courtyard for dinner.  ChinaDoc and I each had one delivery since arriving in Haiti.  It was thus my turn for this one.

    Stretching nonchalantly as we headed up the stairs, I just mentioned to my illustrious colleague, “Hmmm.  Looks like this will be TWO for me.  How many do you have again?  Sorry, I forgot.  Something like…uhhh, ONE, isn’t it?  Don’t feel lame, dear ChinaDoc.  Some doctors are just, you know, more successful than others.”

    I can’t recall what mean, snide thing she said then – MUCH to my surprise since I was just trying to make personable conversation (and gently help her feel better for losing the delivery race).  It was something along the lines of, “At least I’ll sleep, loser.”

    She made a good point, actually.  I was probably in for a long night.

    Since I was “on”, I found a perch along the edge of the balcony where we ate our meals.  From that vantage point, I could see through the door of our OB room and observe things as they unfolded.

    About an hour later, my nurse stuck her head of the room and yelled up to me, “She’s 7.  Won’t be long!”

    Good, I thought.  7cm.  Our patient had delivered numerous other children, which we medical folk term “multiparous” (multip, for short).  Multips don’t usually hang around at 7cm for very long.

    To my surprise, a short time later I saw our patient wander away from her hastily constructed labor room.  Accompanying her were the two friendy/family types who arrived with her.  No nurse.

    Here’s the thing about walking while in labor:  It almost always helps things progress.  We encourage it most of the time.  How it works is something of a mystery, but it has to do with gravity, and mental distraction and pain control.  However, I can NOT envision a time when an experienced labor nurse would encourage – nay, allow – a multiparous mom at 7 cm to walk around.

    Welcome To Your Delivery Suite, Ma'am
    Welcome To Your Delivery Suite, Ma'am

    Babies have been known to drop right out of multiparous women.  Into toilets, showers, cab seats, soccer fields, gondolas, dog bowls, ferris wheel benches, classrooms, ski slopes, two-seater airplanes, office cubicles, hot air balloons, the space shuttle, those suction chutes at banks that kids love…

    …OK, so I made some of those up, but you get the point.

    But for some reason, this woman wandered away from our clinic room – ambling slowly with one hand in the small of her back – into the front courtyard of the building we use daily for the clinic.  From my roost on the ledge, I watched our patient virtually evaporate into the pitch-dense maw of the rural Haitian night.

    To describe just how dark it was in the front courtyard, I’ll refer you to the ’80’s classic movie “This Is Spinal Tap”, where at one point the question was, “How much more black could it be?”  And the self-evident answer: “None.  It’s none more black.” (stated by a band-member describing the cover of their new “black” album).

    Thomaseau has no street lights.  Or, maybe a few odd ones here and there, but realistically there aren’t any.  Furthermore, the power for this village comes from Port Au Prince, which shunts electrons out there based on some whimsical benevolent prescription that befuddles even the least logical among us.  On this night, there was no power.  So the courtyard was…black.

    None more black.

    Nervous by this point, I figured my OB nurse had been taken captive and thrown to the yapping Haitian dogs.  She would never walk a multip at 7cm.

    Just then, the two women who walked out with our patient came running back into the halo of generator-powered light from our clinic, frantically yelling in Creole.  I knew exactly what they were saying, “YOU LET OUR MULTIPAROUS SISTER WALK AT 7cm AND NOW WE’RE HAVING A BABY IN THE PITCH-DARK!  WHAT KIND OF TWISTED FREAK-SHOW OF AN EXCUSE FOR OB DO THEY TEACH YOU IDIOTS IN AMERICA?”

    Already I was bolting down the stairs and running for the courtyard.  I was armed with only 1 tool, perhaps the most valuable physical item a doctor can have in Haiti:  A headlamp.

    I rounded the corner, flipping on the light and arriving at a scene that would make the prop crew of CSI envious.  The mother was sitting on the top step of our clinic porch, with a wide pool of blood mixed with clear fluid and thick meconium shimmering from between her legs.  Lying right in the middle of this stark lake of glistening life was a motionless baby, still connected to the umbilical cord, which still curled it’s way into the mother’s body.  The picture of that initial visual moment still glistens realistically in my mind’s eye – the image etched and harsh under the chill glow of my headlamp.

    My first concern was the baby.  Motionless, caked in blood meconium and mud from the dirty courtyard, I worried about hypothermia (a real risk for a wet newborn even at Haitian temperatures), and I knew that tactile stimulation would be the best way to try to get “it” (I never even noticed the gender) breathing.

    Since I had nothing but the headlamp and clothes on my back, I pulled my shirt off and wrapped up the baby in it.  “It’s dark, I reasoned, nobody will see my rotund beer-gut anyway”.  In the process, I scooped a good amount of the birth-goo onto my bare hands.  I’ve done nearly 100 deliveries, and never touched a newborn with my bare hands.

    For the record: it feels exactly like it does in gloves, so there’s no sense in trying it at home, boys and girls.

    Dropped Out of my Mom Onto Concrete.  All Good.
    Dropped Out of my Mom Onto Concrete. All Good.

    Eventually, we got the baby and mom back into their rightful places.  Turns out our OB nurse had been unable to talk the patient out of a walk, and so asked her to wait while she ran up to her room to get her shoes.  The patient didn’t wait, and off she went before our nurse could return to walk with her.  So, no fault of ours, ma’am.

    The baby did great.  No head wound from a drop onto concrete.  Breathing fine.  The mom had no vaginal lacerations, and did great too.  We sent them home that night.

    ChinaDoc arrived as we were settling the mother back into her cot with the baby, now wrapped in a blanket.  She seemed completely uninterested in the fact that I was shirtless and covered in blood.

    “So, I heard the baby was on the ground when you got there.”

    “Uh, yeah.  Blood and stuff everywhere.  All I had was my headlamp.  I’m incredibly awesome.”

    “So, you didn’t actually deliver the baby, then.”

    My eyes grew wide.  “WHAT?”

    “Yeah.  It doesn’t count.  All you did was pick it up.  We’ve both delivered one baby in Haiti.  We’re still tied.”

    “Here I am, shirtless, covered in blood – look, LOOK AT THAT POOPY, MUDDY, SOAKING FORMER-SHIRT I JUST THREW AWAY – I don’t get credit for a delivery?  I could have AIDS!  I could have an alphabet of hepatitis!  I didn’t even use gloves for God sake, woman!”

    ChineDoc sniffed, unmoved.  “You wrapped up a wet baby.  Brilliant work.  But anyone could have done it.  Don’t need a doctor for that.”

    Quickly I determined the best way to bend my itinerant classmate to my will was to smear my contaminated hands all over her face.  She backed away quickly at my advance, “OK!” She relented, “Maybe you can have a half a delivery.  Nice job…I guess or whatever.”

    Partially gratified, I made my way to the showers to clean off the painting of real, human blood from my body.  Turns out Port Au Prince didn’t deign to allow running water that night, either, along with electricity.

    Faced with laying around for the next 8 hours in that blood, purified only with a Wet Ones shower, I realized the bald injustice of my colleague’s proclamation.  “Forget it, ChinaDoc!”  I yelled to the parched shower.  “That’s one WHOLE delivery!”

    Haiti – Part 1

    I’m leaving for a medical mission trip to Haiti for 2 weeks in a matter of days.  Naturally, my life – aside from residency – has been largely focused on this big deal.

    This is the season of Lent – a time of giving up and doing without, in Christian circles.  Well, let’s be specific: Lent is commonly practiced in more traditional branches of Christianity where guilt historically ran its totalitarian regime on the human soul.  Back then, the guilt-vibe generated extreme and wonderfully creative (in a Nazian sort of way) acts of suffering and penitence.  Think dull iron hooks and exposed collar bones.  Anyway, these days, many Lenten observers give up something rather level-headed, like T.V., to remind them of the suffering of Christ.

    My family – slouching ever closer toward the Episcopal church, thanks largely to this wishy, squishy, lukewarm, doubtful Christian in the loosest sense of the word (as charged by my hyper-conservative heritage) – is observing Lent this year.

    Wife is giving up chocolate.  Eldest daughter is giving up goldfish (the crackers, not the creatures).  Next daughter threw out the same.  Things get hazy in the lower echelons.  I’m trying to give up desert, but…lukewarm, you see.  We’re all giving up restaurants.

    map_of_haitiBut what we’re really giving up is 2 weeks when I’m in Haiti, doing work I had once hoped to do full-time.  Truth is, I sold my soul to medicine in a mist of Christian charity back when I was debt-free, young, rather dumb and convinced I could do anything.  Something about, “if God is for us, who can be against us?”

    Then I ended up $300,000 in debt and unlikely to be free of it until after retirement.  Couple that with the recent incident where guys uttering something similar to the above scripture – but in Arabic – blew up the World Trade Center and Pentagon in firey madness.  Suddenly, relativism and reality colluded to hamper as many elements of my personal life force as existentially possible.

    So, I’m soon off to do for 2 weeks – jaded, hopeless about the lofty ideals I once had for my career – what I once had hoped to do with my professional life.  Not the last 5 years of it, but the first 40.  And to do these 2 weeks, my kids will give up their Dad.  For some of the younger and more empirical kids, there will be a lingering question about whether or not Dad is gone forever.  The older ones will have to deal with a MUCH quieter and decidedly feminine-heavy abode, with all the accompanying sorrows drama and virtues.

    My wife will give up my daily witty commentary on  politics and my clothes flung to every corner of the house (actually, her Lent may get under way not long after I return).  She will also take care of everyone by herself for 2 weeks.  I flatter myself to suggest that this is much different that usual…but I suppose I have put a diaper on someone in the past month or so.

    Me?  I can’t say I’m giving up much at all.  My passion for travel and curiosity about the rest of the world trumps the negatives of dusty, sweaty days in a medical clinic.

    Long ago, I figured I needed to just be honest and admit that the reason I wanted to be a missionary had much more to do with the love of knowledge and travel that it did the lost souls of Ximbiaha.  Sure, Jesus loved me enough to die for my purity and for our relationship – yeah, I really do actually believe that, lukewarmness notwithstanding – and if you push me you’ll find that I do have a reasonable amount of energy for passing some semblance of that kind of altruism on to someone else.  So, Haiti won’t be much of a sacrifice for me.  There are lots of upsides in my world.  It’s a brier patch sort of thing.

    Except that malaria is endemic there.  So’s dengue and typhus.  I gotta say, if I end up crapping my innards out for 3 weeks…consider my debt to Lent paid in FULL!

    What A Pen Can Do

    Doctors love pens.  You wouldn’t be too far afield to say we worship them.

    Every few weeks, 3rd year residents like me take over as “chief” of the medicine service in the hospital for a full 7 days.  The transition is dramatic.  Our former lives prior to chief look almost quaint and idyllic compared to the intensity and workload of those weeks.

    So, with a chief week approaching, you can imagine my heavy-heartedness this past weekend knowing that Monday morning at 6am would mark another 7 days of suffering probably on a level similar to licking the entire circumference of a New York city block.

    It isn’t that I don’t like chief, by the way.  In fact, I like inpatient medicine more than most rotations in residency.  It’s just so much harder that there’s an emotional hurdle to get over as the new week approaches.

    But what, you’re probably asking, does this have to do with pens? Simple. To combat the downer vibes, I did what any self-respecting doctor would do…I bought a pen.

    Keep in mind that doctors love pens, but not just any pen.  We have all these specific, detailed, exact standards for the perfect pen.  And most of us believe that although our current pen is the world’s greatest…there’s always the possibility that yet a more perfect union of writing instrument materials does exist.

    Given that pens are relatively cheap, I don’t even chastize myself for constantly striving for a better and more perfect tool of locution.  The grass is always greener, and when it comes to pens, that’s damn right.  I’m sure of it.

    Hmmm. You're real nice and all...
    Hmmm. You're real nice and all...

    Typically, I use Zebra pens.  It’s something of a dysfunctional but torrid love affair, really.  I wander away, pursuing the curviest, the silkiest.  You know the ones, the sultry models with squishy midsections that caress the writing surfaces of your hands.  Or the ones with multiple colors that reveal themselves on demand.  Hot, those pens.  HOT!

    But the passion fades.  *sigh*  Not unlike teenage angst, eventually I return – humbled, learned, schooled – to my old favorite.  The Zebra.  Specifically the model F-301.  Been using them for years.  Machined brushed aluminum barrels with textured plastic gripping surface and crafted with a satisfying *click* (that I fired repeatedly through one of my interviews to land this residency, for example), these pens rule the universe of analogue human communication.

    So, to psych myself up for another week of strife and toil, I went to my local office supply store to pick up a couple of old friends to add to my collection (I’m pretty much always running low on them, you see).

    But what to my sharp eyes did appear…but a NEW pen.  A NEW model, shiny and sleek, perched in it’s own display container next to the plebian F-301’s.

    Yes, I’ll admit that in reaching for Old Faithful, I did give certain liberties to my wandering eyes (we have an “open” relationship, ok?).  And YES!  Maybe I’d found the perfect machine to compliment, to fulfill the untapped potential of my opposable thumb!  Perhaps there, in that shiny bubble-plasto case, lay the final answer to all human evolution.

    Oooo!  White.  Like clouds.  Or Mist! Or Sunlight!
    Oooo! White. Like clouds. Or Mist! Or Sunlight!

    The good news is that the pen is also a Zebra, so I’m not really defecting.  Not cheating.  All in the family, right?  THIS is the F-701, and WOW what a testament to human ingenuity and engineering.  Walk into the middle of the Crimean Wars and raise this baby, flashing brilliantly in the sun, and every knee would bow amid the clatter of dropped weaponry!

    Important to keep in mind, however, is the subtle motivational trick I was actually playing on myself – a new pen requires WORK!  I need to have reason to write with my maybe-perfect baton of neurophysiological realization.  The Cartesian dilemma, few knew, was badly mis-translated.  In reality, it reads, “I think, I write with my Zebra, therefore, I am!”

    Given all the new power I’d just bought, settled in the crook of my thumb, “snug as a gun” as Seamus Heany says, I went from dreading my early Monday at work to barely able to sleep in anticipation of it.  I had a new pen.  Maybe the best pen ever created, maybe crafted by God himself…all I needed now was piles of patient charts, sheaves of unsigned orders and dozens of new prescriptions.

    C’mon Monday morning!  Let’s start at 5!

    I can report after one day that the pen is living up to it’s billing.  The barrel has scoring on it to create texture at the writing surface.  It comes equipped with a “soft” clicking mechanism – so very Hamptons, so Riveria!

    In the end, let me say simply that pens can change the life of a doctor.  THIS doctor, at any rate.  Incidentally, I’m such a fan of Zebra that I wrote them and tried get them to “sponsor” me.  I offered to put a patch on my white coat and to carry around sample pens.  Hey, I figured I’d be around pen-worshippers all day, I’m a GREAT agent of marketing.  I added that I could even be talked into sewing black zebra-stripes into my doctor’s coat.  EVERYTHING’S got a price, right?  Didn’t we all learn that from “Indecent Proposal”?

    They turned me down flat.  Actually, they didn’t turn me down at all.  They just never responded.  And what did I ask for?  What was my requested payment?  A lifetime supply of Zebra pens, of course.  What more could a doctor want?