Tomorrow We Leave

We leave for the refugee clinic in Athens tomorrow.

I intended to blog the step-by-step story for how we arrived at this point. But THAT didn’t happen.

Here are some specifics:

wpid-wp-1443899443776.jpeg-We intend to see approximately 30 patients per day for a week, working half-days on Monday and Friday. I suspect we’ll end up seeing many more than this.
-We will be working in an abandoned church in downtown Athens. We’re staying in a Youth Hostel a short distance away.
-We have access to labs, Xray (maybe?) and some medications but I’m not sure which ones.
-I’ll be using an antique oto/opthalmoscope manufactured by the Riester Company, which was based in, you guessed it, Germany.
-We plan to see Afghan, Iranian, Iraqi and Syrian refugees. There could be many others.
-On the last day we will likely go into a refugee tent camp and set up our medical clinic there.
-Donations continue to roll in, to date over $6000.
-I’m not without a sense of concern. It isn’t lost on me that Americans aren’t the most popular people in the world today, especially in the lands where these people are coming from. On this, the night before our departure, I’m keenly aware of all that I leave behind, and all I hope to see again soon.

Your thoughts and prayers are most appreciated.

Donations

Sansum Medical Research Institute

I used to work at a non-profit medical research institute. There, we didn’t “earn” a single dollar. Everything was given to us through some version of a donation. So I suppose I shouldn’t be so amazed and slightly mystified to receive the thousands of dollars sent our way for the relief trip to Athens.

True, our costs are estimated to run in the $6-10,000 range, and we’re still around $3,000. So it would be nice to get closer to our goal. But even if all the money stopped tomorrow, this has been a humbling experience. Things went from what seemed like a good idea that aligned well with my interests and lifelong training, to something more important. Quickly.

I’ll explain:

I spent a loooottttaaa time in that building. Still miss those days!

The medical school I attended is located in Israel. Called the Medical School for International Health, the curriculum strongly emphasizes International and cross-cultural medicine. It’s a small school, but is comprised of people who love, love, global, cross-cultural experiences.  I’m one of them. These are “my” people. Aside from my wife and children, to this day, I love nothing more than being somewhere, far, far from my familiar world, surrounded by languages I don’t understand and histories and stories and traditions and beliefs I have yet to learn. Being at MSIH put me in the lives of people who love the same thing. I’m not sure I ever felt more at “home,” and I was approximately 6,940 miles from the suburbs of Colorado Springs, where I grew up.

A refugee relief clinic in Athens, thus, is a natural thing for me. I’m wired for this. It’s what I’d do full-time if I didn’t have obligations to children and student loans. But, as evidenced by my parents’ one single excursion out of the U.S. to visit me in all the years I’ve lived overseas, this international stuff isn’t for everyone. In fact, especially relief and refugee affairs isn’t really for most of ANYone. It’s a briar patch kind of thing: This is what I do. But I don’t expect it’s what you do.

So I am amazed to see that what started off as something I care about, has become something you care about too. To those of you who have sent money, and prayers, and follow this blog, thank you. It’s humbling, and a little disquieting, to know that the work we’re doing isn’t being met with ambivalence around the world.

Indeed, it has been quite the opposite.

Athens, October 2015

Athens has long been a crossroads for refugees trying to make their way from the Middle East into Europe. So when I traveled there with my church pastor, David, this past February to explore the possibility of starting up a medical clinic, we had no idea what kind of summer was approaching.

At the time, it was clear that activity in Syria/Iraq (ISIS territory spans both) was worsening, so we predicted an influx of migrants seeking refugee status in the EU. We knew the numbers this summer would jump. But we didn’t predict anything to the level of what we’re seeing today.

Be advised that anything you read below this blog is from the days when my blog was largely a chronicle of my time in family medicine residency in Olympia, WA. Some of the posts are fun, some whimsical, some serious, some maybe a little helpful.

After residency I moved to Germany and live here still. I’m a practicing family medicine doctor and have long planned on working in international and relief settings. This is the primary reason for moving away from friends and family, and my decision has positioned me well to help with the current crises in Europe.

Can I, and this little clinic we’re building, do much to address these massive problems? Hardly. I understand that. But if lots of people do lots of little things, it can equal one big thing over time. So I’m starting with this little thing.

As such, from this blog forward, I’ll mostly be talking about the work we’re doing in Athens and the topics that relate to that work. Namely, cross-cultural medicine and global public health. If you care about these things, you may enjoy following along as I navigate through this project.

The media element of this project is just getting started, and it’s been awhile since I flexed my creaky “blingers” (that’d be blog-fingers). So bear with me.

However, already I’ve been met with scenarios for our clinic that I hope to present to you, SW101 nation, for input and ideas. This isn’t an easy challenge, with lots of questions that have no easy answers. So approaching this as a community is, I think, a much better way forward than going it totally alone.

So, if you’re willing to jump in with me, thank you, and welcome!

Lenk

switzerland

I recently returned from a church Men’s Retreat in the resort town of Lenk, Switzerland. This was MY kind of ‘retreat.’ The majority of our two days was spent on the ski slopes, not talking about God and theology and right and wrong.

 

I’ve been a Christian since I was 8, so the pastoral lectures and Bible verses never feel especially new to me.

I routinely enjoy the music, and in our case a great band led those times in the evenings, but I was happy to attend a retreat that was mostly just a cheap ski vacation. I met some cool guys, got a little better on a snowboard, and stood in absolute awe at some of the most beautiful scenery I have ever known.

 

I don’t worship God very well through study, or through listening to lectures from pastors. Lectures, ever, haven’t worked well with my brain. Ask any teacher of mine all the way back to 1st grade and you’ll probably get some version of the same mildly exasperated half-smile, and a reply along the lines of, “he really, really TRIED to give a crap.”

 

Adelboden-Lenk

But when I’m in the shadow of the Swiss Alps, with 1,000 year old glaciers clinging to jagged sawtooth ridges in a 300-degree ring all around me, I pay attention. Somehow, breathing in crystal-pure air, with rolling forests and organic dairy farms dotting the countryside in every direction far below me, I have no problem thinking about God and wondering how I couldn’t possibly be closer to His almighty Spirit for that moment.

So, it was a spiritual time for me, but with very little preaching or Bible-studying. Perfect.

 

I was also struck by the unity and beauty of the towns we passed through on our way to Lenk. Switzerland has been highly resistant to change over the years, from what little I’ve read of the country. It is fairly hard to immigrate there, and once you ARE there, good luck building consensus around any particular idea or religious creed that departs from the time-honored ways of the Swiss. Du willst ein Minaret? Das wird nie passieren!

Deutsch: Chalet in Pöschenried, Gemeinde Lenk,...
These, dotting the countryside as far as you can see. Plus snow when it’s winter.

 

 

In Switzerland, you know you are in Switzerland. Especially in the countryside. The buildings are stirringly beautiful, most made of a light-colored wood sometimes set on dazzling white painted rock or concrete bases. The barns looks related to the houses. Everything is clean, ordered, pristine.

This unity isn’t by accident. But it takes enormous force of will to maintain a cultural identity in an increasingly pluralistic and mobile society. To do so inevitably becomes political, with increasingly volatile arguments on either side.

My homeland, America, has never really had a unity of culture and history to this degree. We’re a nation of very few subjugated natives, and very very many immigrants. To walk through my country – or any large American city – is to walk around the world.

Both have their merits (except for our treatment of the natives). But there’s something so deeply peaceful about meandering through a place that knows itself so well. A place that is OLD, and has not forgotten the value of of old things. King Solomon was rewarded by God with power and money because when God offered to give Solomon anything he wanted, the young man asked for wisdom. Any place that honors age, honors wisdom, and God seems to have blessed the Swiss accordingly.

I’m not saying Switzerland is paradise or utopia. There are problems. But they’re getting lots of things right. Here, walking is revered over driving. Food is valued for quality and purity rather than quick access or cost.The country has some of the best health care access in the world, with 3.6 doctors and 10.7 nurses per 1000 people. Life expectancy is around 73 years old. Obesity is less than 8% (it’s almost 50% in the U.S.), and it is estimated that 100% of the population has access to clean drinking water and sanitation facilities.

As a Caucasian from the American suburbs, with no knowledge of my heritage further back than my grandparents, this place holds an impossible appeal for me. I don’t know my family history, whether a story of thieves or kings. My nation’s history doesn’t even span 300 years.

As our retreat drew to a close, I knew I could never truly be a part of a place like Lenk, Switzerland. I could only marvel and yearn, watching that priceless world slip past my car window, as we hurried home.

 

Bread Between The Legs

English: Candida albicans
We call these ‘branching hyphae’

Yeast infection: Yuck-central to the average vagina owner. Discharge like milk curds, funky smell something akin to old toes floating in rotten vinegar, and an intense itch that you can’t actually itch because if you try, it hurts. Cool, huh?

When you’re talking about this fun experience, what you’re largely talking about is overgrowth of a specific type of yeast called Candida albicans, which is actually a fungus. Pretty gross.

Truth is, there’s probably a few of these little guys hanging around the average human vagina all the time and it’s no big deal, but too many of ’em and you’ve got a problem.

Candida albicans
Same as the above pic, just the DANCE version.

Of interest, Candida is kept at bay by another creature that you want hanging around in your vagina called, as a group, the lactobacilli. These guys don’t fight candida, they’re much more suave. They simply produce an acid (“lactic” acid…get it?) as part of their normal life cycle that subsequently keeps the vagina acidic. This makes things real tough for most other creatures, except for the odd Bear Grylls of the Candida world who eat acid for breakfast.

Yeast infections result when the acidity levels in the vagina drop. It’s hard to predict when and how the pH will change in that region of the world, but often it does.

Historically, yeast infections were easily treated with anti-fungal creams or a single pill of the drug fluconazole. But the “easy” part is going away. Increasingly, I’m seeing patients who have recurrent yeast infections despite the usual treatment.

Often, these patients have a history of heading to the doc for “that pill.” And often, docs (or the “provider”) just fire the pill at them and everyone calls it a visit. It’s quick for the patient, saves the doc time, everyone’s happy. Unfortunately, the happiest of all in this equation is the yeast.

Fluconazole
Fluconazole

Fluconazole works by blocking an enzyme. That enzyme facilitates reactions that create the yeast’s cell wall. With the drug around, their cell walls get floppy(er) and don’t hold together as well.

But that doesn’t mean the bug is dead. Fluconazole isn’t some flaming thunderbolt from Mt. Olympus that blasts yeasts back to the Elysian (bread) Fields. The drug is fungastatic, not fungicidal. The weakened yeast is then susceptible to other bugs our our immune systems. Like a mob boss of the pharmaceutical world. It doesn’t do the killing, it just arranges, eehh, ‘tings.

These days, fluconazole isn’t as tough as it used to be. It doesn’t work like it did, often not with the strength it had. So tossing this pill at a yeast infection is a bad idea. Real bad.

Certain types of yeasts make poofy bread and good beer and they keep Jewish people busy (some would say crazy) during Passover. So they’re not all bad. But it’s an organism that we could do without. Fungal infections, when they become systemic, have always been tough to treat; more so than bacterial. And systemic anti-fungals have always been tougher on the body than antibiotics.

Under these circumstances, the best approach to recurrent yeast infection is NEVER to just go get another pill. You should firmly request that your doctor not only get a wet prep (which is merely looking for the presence of yeasts on microscope slide), but also order a culture of the yeast should any grow on the prep. From that culture, not only can the species of yeast be determined, but it can also be tested for sensitivity to fluconazole and other anti-fungals to see if the right drug has been chosen.

Recurrent yeast infections are beatable, but not if you’re lazy about it. For reasons that most men can understand, yeasts really, really like the vagina. If you don’t like ’em there, you’ve got to put more than just a little effort into getting ’em out.

Reader Q: Why Did You Sign with the Army?

Hi Dr. SW101,

Enjoyed reading some of your blog posts both older and the newer army related ones today. Lots of smiles and chuckles, Thanks.

Laughter? In response to this blog? That’s TERRIBLE. This was supposed to be serious stuff. Like taxes. This is information. Data. Recommend re-read.

I’m curious to know why you signed up?

I signed up for the Army for one major reason and one minor reason.

The major reason was the craven want of money. I wish it was something more patriotic, but the primary motivation was an offer of a loan repayment grant and monthly stipend during my years in residency. The Army required nothing in return during my training years. Faced with sneaking my 6-member family into a 2-bd apartment that allows only 4 people, I took the money. Instead of the apartment, I was able to put my family in a cute 3-bd home on a quiet corner two blocks away from my training hospital.

The second reason was patriotic. Despite my vehement opposition to the war in Iraq, and moderate opposition to the war in Afghanastan, I was fully aware that primary care was severely lacking in the U.S. Army at a time when young Americans were throwing themselves into war. Irrespective of how I felt about those conflicts, I remain an American. News of my countrymen dying or suffering partially due to lack of good medical care was something I couldn’t tolerate.

I have always been taken with depictions of how our nation pulled together and sacrificed during the second world war. Back then, those war efforts were truly a national affair. Virtually everyone gave to the effort in some fashion. And, I think a huge reason for the wealth and power we have enjoyed for the past 60 years are a direct result of those sacrifices made by our Greatest Generation.

Pretty Sure I Woulda Deserted

“Earn this,” CPT John Miller, dying from a mortal wound during the Battle of Ramelle, implored Private Ryan in the Spielberg movie. The message, as I took it, was our generation (and the Boomers before us) must understand that great sacrifices were made to allow us to live on the top of the world as we have as Americans. It remains our mandate to earn that sacrifice; it was made before we even deserved it.

So I signed.

I saw posts about officer training and an earlier one about trying to figure out the military scheme as a civilian. What got you in? 

I think you’re referring to how I got into the Army as a civilian. If so, the answer is website: http://www.usajobs.com. Everything runs through this site. I applied to this site in the winter of my senior year of residency, and forgot about it. Literally. When I was called by the clinic here in Germany for an interview in MARCH the following year, I had no idea why.
If you want to get a job overseas, however, this is one of THE best routes. You can’t work for the State Dept as a doctor until you’ve been in practice out of residency for 5 years. You can’t get a job with any of the aid organizations unless you know someone AND don’t need money. So, this is a good option because the pay is steady, only slightly beneath the national average, and comes with perks that don’t usually accompany private-sector jobs.
There’s lots of archane goofiness that come with Army medicine. There’s lots of unusual quirks that are a result of non-medical “commanders” decreeing all kinds of demands from on-high.
But, in reality, every managed care organization functions like this these days. I wouldn’t put Army medicine behind or beneath any of the major HMO’s (in principle, I haven’t worked with any of them). I think Army Med is about on-par with most of American medicine…approximately 18th best in the world.
Also wondering why Olympia was your first choice? You’ve said elsewhere that Ventura is probably the best FM program in the US. I’ve heard of a number of graduates going to Tacoma Family Medicine and lots of interest in Alaska, too. Can you comment on them?
I am very proud of my FP training program, and maintain the belief that it is one of the best programs on Earth, and THE best on all outlying planets. I firmly believe that Providence is one greatest healthcare organizations anywhere.
But in all honesty, I have to say that Olympia is not the best. Just MY best.
English: Statue of Father Junípero Serra. Vent...
Father Ventura, surely a surfer
Ventura is better. Better than anywhere else I know of (and I practically got a PhD in FP residency research during med school). The hands-on experience they allow there, assuming times haven’t changed, is second to none. The faculty are top-notch; some are dual-certified, etc. Facilities suck, too, which is great. I can think of no better means of preparing an FP to deal with a crappy, under-funded, under-supplied environment where the only thing you have to give to patients is your training.
I was told I had a shot there. What they told me likely sounded MUCH like what they tell EVERY short-white coat wearing minion worshipping at the altar of VCMC during their exit interview. But I still like believing I coulda made it in there. I never ranked them, however, because my large family would have needed to live in a box on the beach to afford the cost of living in Ventura. And, truth be told, since I could have reasonably placed that box at the point at Fairgrounds (read: KILLER surf spot), residency would have been AWESOME for me. Just not for my kids waking up with sand fleas in their eyes and facing yet another breakfast of seaweed and/or Wonderbread bologna plus peanut butter sandwiches at the local Rescue Mission.
One nuance Ventura is the dual FP/MPH program at Dartmouth which is as good as it gets if policy and health system design is your calling. Love it or hate it, the Obama Health Care plan wisely referred to the health resources utility research out of Dartmouth. Although barely ranked, I am of the opinion that Dartmouth is actually one of the best – if not THE best – MPH program in the country because the research and work they do is prescient, unassailable, repeatable, tested and longstanding.
Tacoma is a great program, but they have nothing on Olympia. Their city smells weird, their facilities aren’t any better than ours, and we do rotations at the Peds ER up there anyway. So I recommend ranking them 1/2 with the top choice going to the town you like best.
Alaska is probably a lot like Ventura. Sans wicked right point-break and unfortunate box.