A First World Injustice (a vaccine rant)

The hospital system where I am employed contracts with a major vaccine manufacturer for a two year period in order to obtain discounts on vaccine products.  This is generally a win-win.  The vaccine manufacturer is able to guarantee the sale of lots of product, and the hospital gets a deep discount, improving overall profits.  Our vaccine contract is up this week.

A few weeks ago, our pediatric section had a monthly meeting where the upcoming vaccine contracts were discussed.  The family medicine department is invited to these meetings also, since they also care for children.  Usually, the hospital makes the decision on the vaccines because there is generally a clear direction for cost savings.  This year, both contracts were comparable, so the hospital left the decision to members of the pediatric section.  Only 8 members (out of at least 15 pediatricians and easily 20-40 family physicians) were in attendance, three of whom (including me) came from my clinic.  We currently have a contract with Company A.  We currently use Company A because there was a significant shortage of a vaccine two years ago, and only Company A had that vaccine in adequate supply.  That shortage has been resolved, but now Company A is experiencing another shortage of a combination vaccine that we give to small infants.  Company B also makes a combination vaccine that is used at the same ages.  There is no clear cost advantage between either company, and all the vaccines in question are appropriate, safe, and effective.

We stock two separate chunks of vaccines in our clinic.  There are vaccines purchased by the hospital that are given to private pay patients (for which we bill insurance companies), and another stock of vaccines provided by the government’s Vaccines for Children (VFC) program for children who have Medicaid or who are under or uninsured.  These vaccines are free to those patients.  The shortage of Company A’s combination vaccine only affects the children in the VFC program because our hospital was able to stockpile enough vaccine to cover our existing private pay patients.  The government, being the government, was unable to do the same.  If we renew our contract with Company A, we will have plenty of vaccine for our private patients, but not near enough for our VFC patients.  If we sign a contract with Company B, there’s plenty of vaccine for everyone, regardless of insurance status.

This seemed like an easy vote to me.  I was a little shocked to see my fellow pediatricians from other clinics vote to stay with Company A (5-3).  When asked why, it was because they didn’t want to deal with the hassle of switching.  I should mention also that my clinic sees a significant VFC population, somewhere close to 80%.  These other clinics are predominantly private pay clinics, mostly because of their geographic location in our city.  Our VFC patients won’t miss out on being immunized.  They just won’t have the advantage of the combination vaccine.  So, a private pay patient in our clinic will receive 3 injections at 2,4, and 6 months of age.  A VFC patient will receive 5 injections at each of those visits to obtain the same protection.  I don’t think that’s fair.

My colleagues and I work very hard in our clinic to ensure that our VFC patients are treated no differently than our private pay patients, even when it comes to little things like the number of shots they get at a particular visit.  There are a number of other complicating factors that I won’t go into, but suffice it to say, if we stick with Company A and the shortage, there’s a much higher likelihood that we will make errors in our billing or our vaccine administration, and that places patients at risk.  I won’t tolerate that risk, and neither will my partners.

We’ve filed an appeal with our Medical Staff Office, and we have been told there will be a new vote, by ballots rather than by show of hands at a meeting that no one really has time to attend.  This way, all stakeholders will be represented (including those of the family medicine department who also see a large VFC volume, as we do).  The contract must be signed in two days, and we’ve not seen a single ballot come across our fax machines yet.  I’m worried we’ll end up stuck with Company A simply because time runs out.

I am passionate about vaccines.  There are very few things that have improved the health of children like vaccines have.  I simply won’t compromise on protecting the most vulnerable children in my community.

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Day 18: The Most Important Lessons From Residency, Lesson 3

I am to tell you of a time when I felt passionate and alive.  This is how I discovered my calling.  My apologies for the lack of details in this post.  I do have to protect my patient’s confidentiality, even though I no longer care for him or even work in the same city.

A little boy arrived in the city where I trained and was brought from the airport directly to our emergency room because he was so ill.  He had just journeyed from a refugee camp in a small developing nation (French-speaking) where he had lived his entire life.  His family was from another neighboring country and fled because of war.  This boy and his two siblings were born in the camp.  During the process of their immigration to the U.S., this child was diagnosed with a very serious and potentially fatal condition which became active at some point during their journey.  He was admitted to the hospital, thin, fevered, with terribly painful swellings in most of his joints.  I wasn’t working in the hospital at the time, but knowing my interest in international medicine along with my earlier study of the French language, the hospitalist invited me to meet him and his family.  I was overwhelmed by their need, arriving in a foreign culture, speaking a foreign language, attempting to understand the repercussions of having a child with a very serious chronic illness all in a place that is completely unfamiliar in every way.  I stumbled over my French (rusty from over 7 years of disuse), eventually warming up to recall enough vocabulary to speak relatively competently.  I managed to learn some details of this family’s life and communicate a few important details when the staff interpreter was absent.  This boy’s parents shared some of their life with me.  When I asked what his father did for a living, he told me that for the past 9 years, he had begged and searched for food.  When living in a camp, there’s no place to work, no way to sustain a family.  His mother was so worried about E, not sure if he might live or die, unsure whether medications might help or make him worse.  His two younger siblings were happily oblivious to all of this and excited to make new friends.  They loved when we brought ice cream up from the freezer in the ER for them.  I brought some children’s books en francais that kept them occupied during long hospital days.  I burned CDs of French music that I had on hand and brought books from my French lit classes for mom to read and pass the time.  I was honored to have this role, one of friendship and not of medicine.  Since I was not responsible for his medical care while he was hospitalized, I was free to sit with this family and talk.  Poor E was terrified.  He received blood draws, shots, procedures.  He awoke from sleep screaming and thrashing, and during the day, he remained quiet and sullen most of the time.  I thought for awhile that he had given up.  A medical student, James, on the inpatient service made a particular impression on this boy, and I enjoyed so much watching little E learn to high five and wrestle and do all of the things that little boys should do.  James took him outside, played soccer with him and taught him to yell.  James did what none of the rest of us could do.  He brought this little guy’s spirit back.  After his discharge, I had the privilege of caring for this child and his siblings in our clinic along with several other refugee families.  We wrestled with a number of complications, and I relied heavily on discussion with specialists to form treatment plans, but he improved steadily, and by the time I left, he was thriving.

I wrote this confession not long after meeting this dear boy:

“I completely fell apart when I got home on Friday night.  My heart is overwhelmed by this family.  I don’t really mind that part so much.  What frightens me is that I think I might want to take care of children like E all my life (French-speaking and all).  I’m not really sure what that means for me yet, but I’m beginning to think I should stay in residency for a few more years.  I have so much more to learn.  Needless to say, I am feeling a little bit too contemplative this weekend.  You didn’t tell me that when I encountered the developing world that it would grab a hold of me like this.”

I’m still working out what this all means for me.  I do want more training.  I completed a 2-week international medicine training course which was phenomenal.  I met so many like-minded individuals there, some who have been missionaries for years, others who are, like me, just beginning.  I still keep in contact with many of the professionals that I met at that conference.  More intensive training will take much more time though, and I don’t know how to work that out.  I’ve thought about pursuing an MPH.  Most programs that emphasize the areas that I am interested in are out of state and available to me only online.  The challenge of getting a masters-level degree while working and parenting two toddlers just feels like too much (particularly with the $36,000 price tag I was quoted for one program).  I’d love to learn some more tropical medicine.  The course I’m most interested is in London and lasts 12 weeks.  How to get to London for 12 weeks with 2 small children and continue working?  I just don’t know.  I’ve studied up on missionary organizations.  I think I may have even selected one, but I still don’t know how to make the transition from this life to my next life to fulfill this calling.

Day 8: Thank you

A thank you letter to my attending physician, given the day of my graduation from residency:

 

How can I possibly tell you how you’ve changed my world since I’ve known you.  None of us knew what to make of you when you arrived, demanding growth charts and immunization records.  Quickly, I realized that mediocrity doesn’t work with you, only excellence, excellence, excellence.  Demanding as you are, your patience with my repeated questions (“why are we adding rifampin?”) encouraged me as an intern.  I could listen to your voice for days.  No matter the time, you are always willing to teach me.  I remember a late night when a child with unexplained fever for weeks arrived on our floors.  You spent two hours with me, explaining your thought process, helping me through mine.  As an intern, I casually mentioned going to Africa someday, although I’m not sure I believed I ever really would.  From that point forward, you reminded me practically every time I saw you that one day, I would go to Africa.  Hearing you say it convinced me, and before long, I really was going to Africa.    You surprised me the first time I saw you, an attending, kneel down on the floor to examine a child.  You’re not above kneeling, and I shouldn’t be either.  Your criticism of my notes seemed harsh, but you were also quick to praise when I got it right.  Now as I type my own progress notes, I hear your voice in my head, reminding me to address every problem, growth and development, and that dreaded immunization record.  You demand that we attend to the entire patient, not just their bronchiolitis.  Each child is more than a pair of lungs.  You’ve taught me to be thorough, to examine a patient from scalp to toes and look at every inch of skin for clues to their diagnosis.  I’ve watched you fight the good fight:  battles to rescue battered babies from their parents, to pursue palliation when continued treatment is painful and futile.  Above all, you persevere in doing what is right and best for the child no matter how hard it may be.  You challenge me to be a better pediatrician.  I remember the three best days a pediatrician can have.  You’ve taught them to me, and I’ve seen you work through all three.  I have loved serving alongside you and laughing with you (I love hearing you say “gerbil”).    You have been a mentor and friend to many of us.  I’ll miss popping into your office to chat over a cup of tea.  Your stories from chasing the pregnant Yanomami to losing a shaken infant in Moberly have inspired me.  You’ve taught me to think globally and act locally, and, whenever possible, narrow the antibiotic spectrum.  You are certainly not a baby killer, and thanks to you, neither am I.

Abuse

Today is my 5th wedding anniversary.  I began the day hopeful, wanting to get through my work as quickly and as smoothly as possible so that I could go home and enjoy a dinner out at my favorite local restaurant with my husband.  Just after I arrived, my nurse, Belinda, said to me, “A’s on the schedule today for a follow up.  I’d better call his mom to remind her to come in.”  A is a two month old baby boy who I’d followed closely in the weeks prior to Zambia for failure to thrive.  This baby wouldn’t gain weight for anything.  His mother always seemed a little distant, detached.  She never held him.  He was always on the exam table while she sat in a chair.  She never seemed to know the answers to my questions, “How many ounces of formula does he eat?”  “How often does he eat?”  “Does he spit up?” “How many wet diapers in a day?” “Any diarrhea?”  She never gave me or Belinda a consistent answer.  In the meantime, this baby wasted away before my eyes, wrinkled skin sagging on his arms and thighs.  Finally, I convinced the local hospitalist to take him as an impatient, because I couldn’t seem to help this child at home.  Ultimately, this child was diagnosed with a condition which generally causes profuse and forceful vomiting (though mom never reported any vomiting).  I was still very suspicious of her abilities as a caregiver in spite of this medical condition.  So, Belinda calls to remind mom of her follow up appointment.  She says that she’s forgotten, but she will come.  Mom arrives with A and with the baby’s aunt.  Belinda calls them back to a room, obtains vital signs, and undresses the baby to weigh him.  Then she comes to my office and says, “There are bruises all over him.”  I enter the room immediately and find 2 month old A with purple streaks on his arms, back, chest, and abdomen.  I asked mom what happened, and she tells me that A was wearing an outfit that was too big for him, and he slipped from her grasp.  When he slipped, she tightened her grip on him, pinching his skin between her fingers.  Right.  A’s aunt then pulls me aside to tell me that she’s seen drugs in the home.  She is trying desperately to preserve her relationship with A’s mother, to try to help her find rehabilitation.  At this point, I have to tell A’s mother that they will not be leaving the office until I have a safe place for A to stay because I’m quite convinced that someone has hurt him.  A’s mother tells me that’s fine, but she needs to leave for a little while to see her boyfriend.  She leaves, but not until after she’s had a cigarette in my bathroom across the hall from the exam room.  A waits with me in my office for 3 hours until child protective services arrives to take custody of the baby.  I don’t really have any words for this.  On one hand, this is a victory.  I’ve removed a child from a dangerous situation before he was seriously hurt.  On the other hand . . . A’s mother is a teen who was abused as a child.  She was shuffled around to different foster homes throughout her childhood until her early teens, when she met the foster family who claims her and loves her now.  She’s made terrible choices and became a mother at a very young age, but how could she possibly be equipped to make good decisions with the upbringing that she’s had?  Would any of this have happened had she had a loving family and the security of a stable home?  How does anyone fix this?

Kawama Clinic Part 2

After returning from Kafue, better rested, we met for devotions early for our 5th day of clinic.  Bill prayed and asked that the neediest patients would find their way through the gates to us.  Every day after, it seemed that each patient who entered had an urgent need.  My day started with a young lady with congenital heart disease.  I gave her $17 to see a cardiologist in town.  My second patient was severely malnourished with kwashiorkor, and I had several other severely marasmic infants.  We had so many that were sick that a church member arranged to drive them all together in the church van to the hospital.  One mother brought her infant daughter to me with all of her prior health records.  This infant had grown well and nursed well until her mother developed a serious infection in her eye.  She was hospitalized for several weeks, and during this time, she was unable to nurse her baby.

Her father fed her porridge, but the baby lost weight.  By the time her mother was released from the hospital, she had no more milk for the baby.

I met one boy whose mother told me that her son had been normal until just before he turned two.  Then his head began to enlarge dramatically, and he lost the ability to walk.  Since then, his condition has declined, slowly but steadily.

We began keeping a list of patients who could be helped by the Cure Hospital in Lusaka.  We hope that the church will be able to transport families there monthly for treatment.  Mary, one of the midwives from the church, kept a list of our skinny children to follow up for us after we left.  I have some hope for what we do because I  know that the local church is there behind us, trying their best to raise money together to finish the things that we start.

 

The following morning, Bill again prayed that the sickest patients would somehow squeeze through the gates.  My first patient was a 13 year old boy, carried in by his father.  He was completely unresponsive that morning when his father tried to wake him.  He was comatose, and cold.  As it turns out, this boy sleeps on a concrete floor alone.  Generally, the family sleeps together at night, but since he has gotten older, he has wanted to sleep away from his parents and younger siblings. He had no covering, and the temperature during the Zambian winter dips into the 40s at night.  We filled latex gloves with hot water and stuffed them in his clothes and transported him along with 3 other sick patients to the hospital in the church van.  Once he’d received some glucose and warm IV fluids, this boy was doing cartwheels in the hospital halls.  Later in the day, I met a 5 day old baby with ophthalmia neonatorum, a serious infection in the eyes which can cause blindness.

This is easily preventable with eye ointment at birth, but this infant had been born at home.  For another $2, this little one was transported to the hospital as well.  We treated his mother’s infection before she left the clinic.  Carla had a 3 month old baby arrive with severe jaundice and a rock-hard liver protruding from her belly . . . even in the U.S., conditions which cause this are difficult to treat.  Many children with hand and foot deformities came for help; all were added to the list of children to send to Cure.

 

The evening before our last day of clinic, as we drove back to the Lothian House, the van carrying all of the church volunteers (our interpreters) hit a child who ran into the road as they left Kawama.  The driver got out of the van to see if the child was hurt and was immediately encircled and beaten by the crowd that had gathered.  He and the child were taken to Kitwe Central Hospital for treatment.  The church members stayed there with the child’s family all night; she only had minor injuries and recovered well.  In the morning, Mary brought her to the clinic to be sure she was well.  Even after being up all night, the church volunteers arrived in good spirits, singing praises and blessing us as we began our last day of clinic.  The crowds were particularly desperate on our last day.  Several of the sickest people in the

crowd were trampled as the mob stormed the gate; once they managed to break through, and several people ran inside.  Chad, our 6’4” blond security officer, ventured outside to pick up those who were injured in the stampede.  We worked as quickly as we could to see as many patients as possible.  When we finished, we had seen 2826 patients; Matt had given away over 600 pairs of reading glasses.  Even so, there were still hundreds who had not made it through the gates.
Ta kwaba uwa ba nga Yesu

 

Ta kwaba uwa ba nga Yesu

Ta kwaba uwa ba nga Yesu

Ta kwaba uwa ba nga Yesu

Ta kwaba, Ta kwaba ka be

 

Na yenda, yenda

Konse Konse

 

Na fwaya, fwaya

Konse Konse

 

Na shinguluka

Konse Konse

 

Ta kwaba Ta kwaba ka be

There’s No One Like Jesus

 

There’s no one, there’s no one like Jesus

There’s no one, there’s no one like Jesus

There’s no one, there’s no one like Jesus

There’s no one, there’s no one like him.

 

I’m walking, walking

Here, There

 

I’m searching, searching,

Here, There

 

I turn around

Here, There**

 

There’s no one, there’s no one like him.

 

**General translation:  I’ve gone around everywhere searching, but I’ve never been able to find anyone like Jesus.

Kawama Clinic Part 1

“The need of the hour, as far as I’m concerned, is to believe that God is God, and that He is a lot more interested in getting this job done than you and I are. Therefore, if He is more interested in getting the job done, has all power to do it, and has commissioned us to do it, our business is to obey Him … reaching the world for Him and trusting Him to help us do it.”  –Dawson Trotman

 

Our team got up hopeful that we might have our medicines back to us by the afternoon.  Festus had been told that the proper officials would release the drugs from customs at around 8 am, so, surely, we would have them in the afternoon.  Bill started us off that morning by reading to us from Dawson Trotman’s “The Need of the Hour.”  He read a section of the essay about the Mar Thoma Church, which is the largest Christian Church in Southern India.  It traces its origin back 1900 years to the work of Thomas, the disciple of Jesus.  When Bill had finished reading, one of our team members, Lovely Philipose, raised her hand.  She said, “I am a product of that church.  My family is from that part of India, and my family is Christian because of the church that Thomas started.”

 

Dr. Bill set us to work sorting last year’s leftover supplies.  Usually, there are one or two bags of supplies left over from the previous year’s team.  This year, we had nine bags left over to sort through.  Dr. Bill told us that at the end of last year’s trip he thought it was odd that there were so many leftovers . . . it was certainly a blessing since we had no other supplies at the time.  We spent the morning counting out analgesics and cough

drops, and by lunchtime, we had counted all the medicines that had been left over.  We headed for clinic that afternoon, a half-day late and short on drugs.  Festus still hadn’t arrived with our supplies.  The crowds at the gate were overwhelming, and the people were obviously frustrated at our delay in getting there.

 

Kawama is much larger than Mulenga was.  We had ample space for pediatrics, a generous though mosquito-infested room with 6 cribs, each with one side lowered for use as an exam table.  This worked well for babies and small kids, but our adolescents were a bit cramped.  The clinic’s usual healthcare workers were strangely absent.  The medical assistant who met us on our arrival informed us that the healthcare workers in Zambia were on strike, negotiating their salaries and benefits with the government.  Every hospital and clinic in Zambia was essentially shut down because all of the nurses, medical assistants, lab techs, and x-ray personnel were on strike.  Only a few doctors stuck

around to attend to duties in the hospitals.  Many people walk for miles just to reach the Kawama Clinic, and Kawama is staffed by nurses, not physicians, so many of them hadn’t had an opportunity for healthcare since the strike began, two weeks before we arrived there.  We arrived at a critical time.  Patients had been discharged early from the hospital, and others had simply been denied care because no one had come to work.  Shipments of the clinic’s regular supplies had also been delayed, so there were no reagents for routine lab work, and medications that we typically buy in-country (anti-malarials, anti-parasitics, etc.) were in short supply.  Our first afternoon, I treated children with pneumonia, malaria, ear infections . . . I enjoyed practicing my few Bemba phrases on my patients and listening to them practice their English.

This is worthwhile work.  I found joy in this work.  In some sense, I felt relieved to be working where I had been called.  I sometimes feel like the past two years have only been anticipation and preparation to return to Africa.

 

By the end of the day, our medications had still not arrived.  They were finally released from customs at 4 pm.  Festus had planned to take a city bus with our things to Kitwe, but since it was going to be getting dark, he was worried he wouldn’t be able to recognize and protect them from theft on the long way there.  He had to hire a private car to take him with the bags back.  All of this took some time, and he finally arrived in Kitwe at about 4 am.

 

June 25, 2009–On our first full day of clinic, we were short on interpreters, so clinic work was slow-going.  I met several families with children with severe developmental delays, children who have never spoken or children who are unable to sit up or walk.  It’s hard to know how to help them.  Zambia has no physical therapy or speech therapy.  I don’t have any medications that can change this.  Sometimes there was an explanation.  One child had survived meningitis as an infant.  Another child had kernicterus from

severe jaundice at birth (this is almost unheard of in the U.S. with available treatments).  Other times I had no reason for a child not to develop properly.  All I had to offer these families were vitamins and prayer.  I also saw my first child with kwashiorkor (a form of malnutrition), and I tended to several severely marasmic babies (a different form of malnutrition).  Each was sick enough to go to the hospital.  I gave each mother some soy flour, vitamins, ORS, and bus fare and prayed that they wouldn’t be turned away from the hospital because of the strike.  As the clinic was winding down for the evening, a woman arrived in active labor with her first child.  Lovely, our family medicine resident, delivered the baby.  During the labor, Mary, a Zambian midwife, asked for a bottle of orange Fanta.  Bill looked around but only found a bottle of water.  Mary set her jaw and repeated, “No, FANTA.”  When Mary asks for Fanta, Mary gets Fanta.  Apparently, Fanta supplies all the energy a laboring mother needs to give her baby life.  Mary

checked the baby’s heart rate periodically with the fetoscope and assured us that everything was fine.  Bill and I helped resuscitate the infant, a baby girl. Everyone else crowded outside the delivery room, peeking in to catch a glimpse of the birth.  Zambians don’t usually name their babies for several days, so I don’t know this child’s name.  She is probably the most photographed newborn in all of Zambia.  After the baby was dried and weighed, we gave the mother a bag of ibuprofen for her pain, and she put her baby on her back and walked home.

 

June 26, 2009–The following day, we worked almost non-stop.  I spent most of the day on my knees examining the kids.  We were overwhelmed with malaria, pneumonias, and malnutrition.  I had a little girl with an elbow injury.  No x-ray was available because of the strike, so Bill helped me make a sling from a torn sheet to protect her until she heals.  Before lunch, a second baby was born.  The mother asked the “nurses” who helped her during the delivery to name the baby.  After listing lots of Biblical women, they settled on Rachel.

 

Matt and I ate lunch with James and Dan, two of the Zambian pastors.  Recently, James traveled to the Congo to help with a mission there.  He told us he saw many miracles there.  Sick people were healed, and many came to know Christ.  While he was there, he was arrested and beaten because the local government felt threatened by his work there.  In one day, the case was taken to the high court in the Congo, and the charges were ultimately dropped.  James was able to stay in the Congo, and he witnessed many more miracles while he was there.  James doesn’t get paid to be a pastor, and he didn’t have the benefit of attending seminary, but he is committed to what he believes is the most important work that he can do.  James believes that there is so much corruption in African government that the only way to help Africans is through the church.

 

In the afternoon, I saw a little girl who was unable to walk after having meningitis as an infant.  Her mother has lost her last 5 babies during the 6th month of her pregnancy.  I prayed for them both.  I also met two month old HIV positive twins.  They need anti-retroviral drugs, but the government won’t dispense the medications until the babies have baseline labs done.  The labs can’t be done because there are no reagents because of the strike.  Ridiculous.  I also met a 15 year old girl who I think has tuberculosis.  I wasn’t able to confirm it because there were no supplies to collect and analyze a sputum sample, and without confirmation, she can’t have treatment.  I drained an enormous toe abscess in a little boy.  He didn’t appreciate it much.

When I made the incision, pus sprayed everywhere, including on my clothes (I was lucky to have gloves; no gowns or anything else available).  I gave him sunglasses to make peace when I was done, but he still wouldn’t smile for me.

 

June 27, 2009–Early in the morning, Chad (our security officer) spotted a baby in the crowd that he brought to me immediately.  Evaristo Kasonde, a one month old baby boy, hadn’t nursed in two days.  I knew immediately that he was sick.  He was in obvious respiratory distress, and his soft-spot bulged outward on the top of his head (which shouldn’t be, considering how dehydrated he was).  His mother told me he’d had fever at home.  He whimpered and whined.  We tried to place an IV but we were completely unsuccessful.  I gave him an IM dose of Rocephin, and someone from the church drove them to the hospital.  I gave mom $2.00 to get back home once they were released and $5.00 to gain emergency admission to the hospital.  In an emergency, you have to pay extra.  Imagine knowing that your child is in desperate need of medical attention, and travel to the hospital costs you two days’ salary, and to be seen in a timely manner, you have to pay a whole week’s income.  That is a desperate situation.  I still don’t know what happened to him.  Later in the day, I saw 11 month old twins who weighed 6 kg (about 13 lbs).  They each had the developmental skills of a 3 month old.  I wanted to test them both for HIV, but of course, the lab was closed due to the strike.  They only ate breastmilk and porridge.  How in the world can I change that?

 

We finished 3 1/2 days of clinic frustrated, exhausted, and looking forward to a few days rest.  We learned that night after dinner that the travel that was supposed to take about 4 hours to get to the national park was actually going to take about 9 hours . . . just one more bump in a rough Zambian road.

Good Friday

“It’s Friday. Jesus is hanging on the cross, bloody and dying. But Sunday’s coming.”  –Tony Campolo

Good Friday is a full day in my clinic.  We’re open, and schools are closed.  That generally means a busy day because parents prefer that their children don’t miss school.  On my schedule, I had a flurry of well checks and seasonal allergies.  I noticed that one of my favorite little patients was coming in, just before closing time.  I’d gotten to know him well when he had an unexplained fever last fall.  Every day his mother brought him to me, and a rare but famous textbook pediatric condition evolved before me, day by day.  When I was certain of his diagnosis, I admitted him to the local hospital.  He responded well to his treatment, and four days later, he was toddling around at home as if he’d never been ill.  This was early in my career, and it was my first important diagnosis and my first victory.  A diagnosis was made, serious complications were avoided, and my patient was well, all in a day’s work.  So, I was a little surprised he was on my schedule because his scheduled follow up appointment was still a few weeks away.

As soon as my 22-month-old patient arrived, I was worried.  He looked as if he’d been dipped in white candle wax except for his bright blue eyes.  His skin was paler than his curly blond hair, and the whites of his eyes were unnaturally white.  All those little blood vessels in his eyes had been erased.  I only noticed because they weren’t there.  His mother brought him to me because he had seemed to tire easily, and she’d noticed some bruises on his legs.  As I bent to examine him, I found swellings everywhere.  My fingers felt a firm liver edge under his ribs, a spleen tip below his belly button, round nodes in his neck.  I heard a harsh heart murmur that he’d never had before.  I explained to his mother we’d need some blood work, told her not to worry, I’d call her with results later in the evening.  I didn’t tell her what I feared.

Within the hour, my partner called me.  Since he was on call for the weekend, he’d been paged by the lab tech.  All of my patient’s cell lines were failing.  His red blood cells and platelets were dangerously low, and his white blood cells were skyrocketing, a mass of renegade soldiers staging a coup against his body.  This confirmed what I already knew.  My patient has leukemia.

My partner helped me make arrangements to have him admitted to the children’s hospital while I called his parents.  This is the worst news to give over the phone.  I was an earthquake, shaking the foundations of this family with all this information.  I felt I should have prepared them better in the office, but can a mother ever be prepared to learn that her child has leukemia?

This all occurred as my husband and I were driving home to spend Easter weekend with our families.  Ordinarily, I love to celebrate Easter.  It is the foundation of my faith and the reason for my hope, but it is hard to celebrate hope when you have made a devastating diagnosis.  Heartsick, I grieved over this child and his family.  I felt a little silly because none of this was happening to me directly.  It wasn’t my child or my family, but I could not separate myself from him.  I wanted to be with this family.  I wanted to help this small-town family navigate the streets of the city, sit with his mother in that exam room as she learned about his prognosis, and translate for her when she’d heard too much doctor-speak.  Sitting in my mother’s kitchen later that evening, I couldn’t think of anything else but this child and the lengthy treatment before him.

Is there really anything good about Good Friday?  Good Friday is the culmination of sin and the murder of a savior.  It is a dark day.  Sunday gives us hope.  On Sunday, we learn the truth, the final outcome of all Christ’s suffering.  For my patient and his family, every day is still Friday.  They’re still waiting for Easter morning.

The Most Important Lessons from Residency: Lesson Two

“The LORD gave and the LORD has taken away; may the name of the LORD be praised.”  -Job 1:21

What follows is not for the faint of heart . . .

I learned the second of the most important lessons on the worst day of my residency.  To understand this better, I also need to explain the two weeks prior to this tragedy.  I was a second year resident working solo in the PICU (yes, all my worst experiences involve the PICU).  My attending was a locum tenens attending who was filling in for our regular intensivist.  He strolled into the unit each day at the time that he pleased.  He scrolled through his yahoo page as I presented patients.  He found me too incompetent to write orders for my patients or make any decisions about their welfare.  At the same time, my department entered into a power struggle with the trauma department, each with different ideas about how best to care for critically injured children.  I saw elevated blood pressures and recommended treatment to the trauma attending.  My attending did not support me.  The trauma team ignored me, except when they forgot to write orders or fill out paperwork when they would call and tell me to take care of it.  I was worn out, tired of fighting, and alone.  The only saving grace of that time was my favorite attending who stopped by every afternoon to fill her tea cup from the unit’s hot water tap.  She always stopped to encourage me.

My second Saturday in the unit, I offered to take a shift for a friend who needed the weekend off.  The unit was quiet, and I finished my pre-rounds quickly and waited for my attending to arrive.  At 8:15, just after he strolled in, we were paged to a trauma in the emergency room.  A two-year-old with severe injuries from a minor car accident was unresponsive in the trauma bay.  He had been sitting in the front seat, unrestrained, and the car’s airbag deployed when his mother rear-ended another car.  The trauma team quickly assessed him and slid him through our CT scanner.  My attending barked orders for dopamine and norepinephrine infusions while the others worked.  This toddler had a ruptured spleen, an immediately life-threatening injury, so the trauma team rushed him to the operating room for an emergency splenectomy.

My attending and I returned to the PICU to wait.  Within the hour, the child was brought back to the unit, a large, oozing incision spanning the length of his abdomen.  The trauma attending pulled my attending and I aside.  While in the OR, the CT reconstructions of the child’s head and neck became available.  The child had irreversible swelling of his brain, completely blurring all normal structure.  He also had an 8mm displacement of the first vertebra, completely severing his spinal cord at the base of his brain.  These are injuries that are incompatible with life.  I heard this, and my attending heard this.  He was standing with me.  This is why I have trouble understanding the events which follow.

I understood this child to be dying, succumbing to injuries that were beyond repair.  He arrived back in our unit with his blood pressure dropping despite his three pressor infusions, his heart rate slowing.  Despite his dismal prognosis, rather than discuss the depth of his injuries with his family, my attending began aggressive life saving measures.  Within minutes, we were in a full code because the child’s heart had stopped perfusing his body.  We took turns crushing his heart between his breastbone and spine, artificially producing a heartbeat.  He received multiple infusions of drugs designed to “jumpstart” the heart.  His severe abdominal injuries caused him to bleed within his abdominal cavity, from his incision site, and from a laceration on his tongue.  The bruises on his face blackened and swelled.  We called for all the blood products available from the hospital’s blood bank, infusing them so quickly that there was no time to warm them before pushing them into his body.  His heart rate returned for brief moments, but the code was always resumed.  We did these things to this child for three hours, even though medical literature is clear that after 15 minutes, the chance of survival is very poor.  Finally, my attending demanded that the trauma team take the child back to surgery.  Thankfully, the trauma attending refused, stating what seemed obvious to the rest of us, that continuing this treatment was futile and cruel.  Refusing, my attending continued his efforts until the child’s parents asked to hold their son.  Even then, his heartbeat continued erratically for over an hour because of the volume of drugs he had been given.  I sat by the monitors, hoping this child’s spirt had left him long before we began all the painful things we had done to him.

My attending had nothing good to say to me that day or any day that month.  He remained critical of everything I did, not trusting me with even simple orders.  That Saturday in the PICU, I saw the ugliest side of medicine.  I watched a child die from preventable injuries, and I watched a doctor inflict unnecessary pain and suffering upon this child and his family.  Numb, I drove home that night thinking only one thing:  blessed be the name of the Lord.  I realized that day that unspeakable tragedy occurs on this earth every day.  It occurs irrespective of social class or available medical care.  Humans are fallible, and they sometimes make terrible decisions, but I serve an infallible God.  Regardless of all of these things, my God is still God.  He promises to right this world some day.  Blessed be his name.

Unbelief

“Stop doubting and believe.”  John 20:27

Yesterday, I had my very first frustrations with my job as a pediatrician out on my own.  I always dread Fridays.  On Fridays, it seems that parents begin to panic about each of their children’s sniffles and sore tummies because the weekend is on the way, and the clinic is closed (gasp!) two days in a row.  So, from the beginning, we’re adding patients onto the schedule, and before long, I’m seeing two patients per 15 minute appointment.  Yesterday was no different, except that my patients parents were unusually uncooperative.  I had FIVE families who refused to immunize their children.  I usually at least welcome the chance to explore their fears and provide education about the safety and value of immunizations, but by the fifth one, admittedly, my patience was exhausted.  I found myself gritting my teeth, pleading with families to protect their children.  One mother accused me of taking kickbacks from the vaccine manufacturers and the government.  She truly believes that the only reason I recommend vaccines is to fill my bank account.  If that were the case, I’d be vacationing in the south of France by now.  Another mother demanded to know why I wished to poison her child with immunizations which are clearly the root of all evil in this world (and the conspiracy behind the plagues of autism, cancer, the Black Death, Ebola, and the common cold).  Seriously?  I only spent eleven years studying to learn how to heal children.  I’d hardly waste my time trying to poison them.  So, I already felt like a piece of burnt toast, but a few other families came in to finish tarnishing my faith in humanity.  One father canceled appointments for his two poorly-controlled asthmatic children, informing me that I’d never given them their prescriptions from their last visit (in fact, they were called-in to three different pharmacies at his wife’s request).  Never mind that he and his wife smoke in the house with their wheezing children nearby.  I also received a note from a dermatologist who saw one of my patients in his clinic for eczema.  He informed me that the family “didn’t get along well” with me, and never picked up any of the prescriptions I’d called in for their child.  He proceeded to recommend the same treatment that I had already prescribed.  I had no idea that this family was unsatisfied with their treatment.  They hadn’t asked questions, and they didn’t appear unsettled during the visit.  In my head, I know that all of these things, refusal to immunize, failure to follow through with prescribed medications, cancelled appointments, are probably rooted in the parents’ fears, personal agendas, and understanding.  I still feel like a failure, though, because it is my job to educate them about their children’s conditions to empower them to make good decisions for their children’s health.  I was frustrated and angry at my inability to communicate to them what all of my education tells me is the right thing to do.  That evening, I drove home hurt by their lack of trust in me.  I soaked in my own self-pity.  Then I heard my Lord whisper, “If you are this upset by their lack of faith in you, how do you suppose I feel when you do not trust me.”  It was so quiet that I almost missed it, the still, small voice that Elijah heard.  I recalled so many promises, “plans to prosper you and not to harm you, plans to give you a hope and a future,” “he will give you the desires of your heart,” “your heavenly father knows that you need them . . . all these things will be given to you as well,” among others.  Who am I to doubt the will of a benevolent God?

“The will of God is the gladdest, brightest, most bountiful thing possible to conceive, and yet some of us talk of the will of God with a terrific sigh– ‘Oh well, I suppose it is the will of God,’ as if His will were the most calamitous thing that could befall us . . . . We become spiritual whiners and talk pathetically about ‘suffering the will of the Lord.’ Where is the majestic vitality and might of the Son of God about that?”  –Oswald Chambers

The Most Important Lessons from Residency: Lesson One

“Slaves, obey your earthly masters with respect and fear, and with sincerity of heart, just as you would obey Christ. Obey them not only to win their favor when their eye is on you, but like slaves of Christ, doing the will of God from your heart. Serve wholeheartedly, as if you were serving the Lord, not men, because you know that the Lord will reward everyone for whatever good he does, whether he is slave or free.”  –Ephesians 6:5-8

When I decided to become a physician, no one took me aside to tell me how difficult it would be.  Residency has been the biggest struggle of my life.  It challenged my mind, my physical stamina, and my character.  Med school spoiled me with eight to noon hours, breakfast in PBL lab, full weeks off between blocks.  Sure, I had to study, but I’d been studying my entire life.  Biochemistry is certainly harder for me than Walt Whitman, but studying was not unfamiliar to me.  My clinical rotations required some call, some extra hours, but, aside from surgery, I didn’t mind gathering vital signs, writing up histories, and chatting with patients.  I was completely unprepared for residency.

July 1, 2005, I became a resident of the Department of Child Health at the University Hospitals and Clinics.  I knew where to find the lab, how to navigate the underground tunnels, the codes to enter the intensive care units.  In short, I felt at home in the hospital and in the department.  Pride always comes before a fall, they say.  I was only assigned one patient on my first day.  He was and still is the sickest child I’ve ever known.  This boy had 13 different medications being continuously infused into his little body.  I was responsible for knowing every dose of medication, every IV line, every dip in blood pressure, every fluctuation in his electrolytes, and the result to every culture he’d had in the four preceding weeks.  I was humbled quickly when a student nurse misunderstood a comment I made to his family.  She told his nurse, who told my attending, who stopped speaking to me from that point forward.  I didn’t realize that the natural assumption when dealing with interns is to assume that they are at fault.  This child was my responsibility, so anything that happened, within my control or not, was my fault.  As the weeks went on, I became responsible for other patients as well, and when my fellow interns weren’t nearby, my attending held me responsible for their patients as well.  For every order for medications or labs that I wrote, I was responsible to personally tell the family, the nurse caring for the patient, the clerk, the phlebotomist, and the lab.  I worked a 30 hour shift every fourth day, and my other days were 14-16 hours long.  I still didn’t have enough time to finish everything for each of my patients.  Between morning PICU rounds, ward rounds, conferences, radiology rounds, afternoon PICU rounds, and the meetings our senior residents scheduled to criticize us, I had very little time to attend to my patients, the little ones I had studied for 8 years to care for.

So, I found myself frustrated with my inadequacy.  I was unable to please my attendings and my senior residents.  I was unable to complete the work for each day for lack of enough time, and the hours I spent at home I spent catching up on precious little sleep.  On the rare occasion that I was off and awake, I was complaining.  My dear pastor overheard my struggles, and he casually mentioned that he thought it would be good if we spent some time studying what God has to say about work.

The following Wednesday night, my pastor presented Ephesians 6:5-8 in our regular Bible study time.  Then I realized who I was.  I chose medicine.  I chose residency.  I was a slave to my residency, and I needed to stop thinking that I had any freedom in the matter.  God looked at me, and he gave me grace–grace to accept criticism from my attendings and floor nurses, grace to keep moving when I had no strength or desire to do so, grace to help me see that rather than grudgingly serve my superiors, I should joyfully serve my savior.  In short, I learned to suck it up and give it to God.

Suddenly, residency became a little bit easier.  I stopped struggling against everyone around me and started looking for what they (attendings, patients, nurses) were trying to teach me.  I started listening, and I learned.  Honestly, I didn’t see any change in myself until I viewed my evaluations (6 months into the year).  My ward evaluation from July from my favorite attending was scathing.  She found me unteachable, unruly, and difficult to get along with.  Two months later, the same attending commented on my evaluation that she could not believe how much I had changed and how quickly.  I know now that this transformation had nothing to do with my effort or my studies and everything to do with God.