Ditch Medicine

Sorry that its been so long since my last posting. The internet has been especially screwy the past few days and I haven’t been able to get this post uploaded. Its also been about 3 days since we’ve had running water at the house, but we manage. Our toilet is more like a chamber pot than a toilet these days. I literally spend 2/3 of my time and money at internet cafes waiting for pages to load (assuming they will load in the first place). I won't take so many things for granted when I get back home.

I realized that working in a clinic in the slums of Nairobi would be a departure from the way medicine is practiced in America. In fact, experiencing those differences were the reason I came to volunteer here in the first place. I just never anticipated how different things would be. The whole experience has been an eye-opener, and I’m only getting started.

Over here I see diseases everyday that I’ve only read about. I saw a scorpion bite yesterday. Anti-Malarials are handed out like candy. So are antibiotics, sadly, for the mildest sore throat, which only adds to the growing problem of antibiotic resistance. The only exposure most of us in the West will ever have to Tuberculosis or Typhoid Fever is through playing Oregon Trail. Over here is seems that every other patient has one, sometimes both, of these diseases. Have worms in your stool? Join the club; it’s just another accepted part of life here. I treated a man the other day with AIDS who told me he had been having unprotected sex with his second wife for years while he was aware that he was positive; he didn’t want the social stigma that’s still attached to AIDS. All of his friends and family would completely ostracize him, he told me. I asked him if he had had either of his two children tested for HIV. Not yet, he replied. It seems strange that there is still a stigma attached to HIV in a country where 6% of the population is positive.

I saw a woman today with Brucellosis, something you get from drinking unpasturized milk, a disease which is unheard of and unthinkable in the West. Her prognosis is not good. With every case I’m reminded of how easily most of these infections could have been prevented with basic sanitation and other basic public health measures. Needless to say, implementing the needed changes is something that’s easier said than done. On the other hand, I haven’t seen a single case of diabetes, heart disease, or COPD, diseases which I’m sure will become more prominent here in the coming years with the spreading McDonaldization of the world.

Even the health care sector isn’t immune from corruption. Bribes are just an accepted part of getting things done. Much of the money sent in by well-intentioned NGOs such as the World Health Organization is siphoned off to line the pockets of corrupt officials, with only a trickle reaching the people who need it most. Everyone knows it occurs but nobody does anything about it. The lab technician at the clinic told me how he was strong-armed by outside officials to cook the books to make it seem like he had performed more NGO-sponsored TB tests than he actually had. That way, the money that should have gone towards TB tests ended up as someone’s new drapery set and nobody is the wiser.

The way things are run around here clinically are also…different. You know, that cyanotic baby would really pink up with just a little bit of blow-by oxygen. Tough luck, even oxygen isn’t an option here. Want to see if that guy with the irregular heart beat is in A fib? You can only speculate, because an EKG around here is as conceivable a piece of medical equipment as one of those medic droids from Star Wars. Can’t start a line on a patient who really needs one? Grab a scalpel and do a venous cutdown, a procedure which has been rendered obsolete years ago with the advent of central lines and intraosseous infusions.

Some of the sanitation and safely practices would give our Occupational Health and Safety Departments back at home nightmares. Used syringes with needles are tossed in the trash can by the bedside. You read that right: Sharps containers are optional, even for HIV and Hepatitis contaminated needles. I’d hate to be the janitor there. Glove use seems to be more of a suggestion than a rule. I’m starting to get sloppy and have picked up some bad habits as well. I wore gloves when checking cervical dilation on an expectant mother (duh) but didn’t when mainlining meds into a HIV and Hepatitis B positive patient. We don’t have the luxury of sterile Tagaderms here, so tape is placed over the IV site without a second thought to secure the line. To sterilize instruments, I witnessed them being boiled in a simple pot filled with blood-tinged water from a recent birthing and then removed from the water with unsterilized hands. When I saw that, I didn’t know whether to laugh or cry. Hannah and I are thinking about pooling funds to get them a pressure cooker to serve as a poor-man’s autoclave. Sterility is an ideal, a seemingly unattainable one. They don’t do these things because they are sloppy; they do them because they are pragmatic and have to work within their given constraints.

Despite all the craziness, I love it at this clinic. I actually think the craziness is one of the things I love most about it, the same thing I love about being a paramedic. I have autonomy and I’m learning a lot everyday. Everyone calls me “doctor,” even though I constantly correct them that I’m not one. I’ve given up on that and have just come to accept it. I always hear the sisters saying “doctor, come quickly to see this patient,” or “doctor, can you start a line on Felix in the other room?” Dr. George basically lets me do anything I’m comfortable doing. Every expectant mother that’s come through so far has either delivered after I’ve left or had a complication that couldn’t be managed at the clinic. But the next birth that comes through I get to deliver. I’ve also learned a lot from the lab technicians. I can now do a Widal test for Typhoid Fever, an acid-fast sputum stain for TB, and a Romanovski stain for Malaria and can interpret the results. I’m learning about the drug regimens for TB and Malaria, which can get pretty complicated.

The great thing about this clinic is that stuff gets done with minimal hassle. Patients walk in and get the treatment they need within a few minutes and then walk out the door. They pay what they can and Dr. George takes many patients pro bono. Everyday five orphans are sent from a local orphanage to get checked out by Dr. George. When we see poor starving African children on TV back at home, we tend to comfort ourselves by telling ourselves that these kids don’t know any better, that their situation is all they’ve known for their entire lives and misery is relative. But the sad reality is that most of these kids are in pain and agony for much of their lives and just stoically deal with it because cheap, simple treatments may be beyond their grasp.

Over here, insurance, HMOs, and malpractice are the last things on our minds. We practice medicine the way I imagined doctors practiced medicine when I was a child. Back home, it’s disheartening to see doctors spending two thirds of their day behind computer screens catching up on charting or whatever else instead of interacting with their patients. I’m sure that’s not how they want it to be either, but that’s their reality. Here the patient’s interests come first, just as it should be. Lab tests are ordered because we think they might shed some light on the patient’s condition, not because we’re trying to cover our asses in the event that someone might sue us down the road for missing a one-in-a-million diagnosis. People don’t come to us seeking drugs. We don’t have time for people who’ve chipped their nails and want medical attention and someone to hold their hand. You think I’m joking about that, but ask anyone who works in emergency medicine how often things like that happen.

Since being here, I’ve recognized how much waste is involved in the delivery of American style health care. I think of the armful of waste generated when starting one measly IV back at home. Do we really need a product insert, a box, a blister pack, and other superfluous packaging for one pill? I also often think of the money wasted on useless procedures and tests and how far that money could go over here. During my ICU rotation in medic school, I saw a man who was slated for execution in a few months. He had spent over a week in a $13000 a day intensive care bed (funded by taxpayer money, of course) because he had attempted to hang himself. He was essentially brain dead with zero chance for a meaningful recovery but was being kept alive just because we as a society are not yet advanced enough to accept euthanasia. Deworming one child costs 70 cents. Let that sink in.

I can see myself doing something like this with my life; traveling the world and using my skills and knowledge to help those who need it the most. I still love emergency medicine and I’m glad I trained as a paramedic before becoming a doctor, but I can see myself burning out on it after a few years. I already resent humanity a little more than I did before my paramedic training. I’ve seen the jaded doctors who work in some ERs, callous to whatever happens because they have to be just in order to just get through the day. Is that really how I want to end up when I’m older, viewing patients as an annoyance rather than a chance to help, teach, and learn? There are only so many times you can deal with ungrateful drunks and crackheads without it affecting you. It’s hard not to hate the world when you see a drunk driver walk away with a few scratches while the innocent family of the car he hit lost a father and a husband.

Of course, I’ve seen some horrific things here that I’d rather not talk about in this blog because no amount of writing can begin to do them justice. I’m not sure one can understand certain things unless they’ve witnessed it for themselves firsthand. These are the things I’ll take with me to the grave and will think back to for the rest of my life, but I think I’m a better human being for having witnessed them. I’ve already changed and its only been a week. We’ll see where the rest of this trip takes me.