DoctorofFortune

Last Thoughts on Launceston...

2010-07-24T21:06:00.000-07:00

Obviously that's not true. But, if you've never read/heard Dylan read "Last Thoughts on Woody Guthrie," you should. (http://www.youtube.com/watch?v=NVbr0y8zp68&feature=related)

Anyway, wrapping up things in Launceston, Tasmania, Australia. It hasn't been easy-- I feel more like I'm trying to flee the Nazi take-over of Paris than simply move. Partly because they scheduled me to work 7 overnights, two days off, then work the two days prior to my flight early the next morning. Hope all my 9-to-5 stuff is taken care of! Nothing like a good-bye scheduling kick in the teeth to make you feel appreciated... :) In any event, below are a few thoughts and a few shots about the job bits of this past year. It was said almost to the point of cliche, but certainly working with the staff at the hospital was the best thing about working there, and if we get to work together again in the future I hope we'll have kept our sense of humor!

Another day in the pit--Rob and Jeff obviously working hard. And below, a picture of much of the group and many of the groupies that make up the face of the DEM!

Why people first start working in Emergency (and likely any) Medicine is often very different from the reasons people continue to work in it. What was the US survey that just came out saying that medicine (& nursing-- the distinctions between them are increasingly nominal, effectively turf-posturing and financially motivated) was becoming an increasingly dangerous job? Why bother putting up with the abuse? Well, to wit:

"...Eliminate the patients for whom the 'aha!' moment of connection will someday arrive. Eliminate the patients for whom we have the capacity to transfer to others, who have the resources to go elsewhere for care and who would be happier and better off if they left. That leaves the patients whom all physicians would equally find difficult (if not downright detestable), and who for whatever reason-- lack of insurance or of other resources-- have no place else to go. If medicine were an ideal profession, we would divide among ourselves the care of these difficult patients as evenly as possible. We are far from an ideal profession, so many of us are able by virtue of specialty choice or location of practice to avoid having to encounter such patients for the most part. Others, who work in emergency departments or community clinics in low-income neighborhoods, get far more than their fair share. These latter physicians deserve our thanks and our respect. They often receive neither. Whether we have a lot of or a few of such patients to care for, that care demands professionalism in the strictest sense of the term. One opposite to professional is amateur, which in turn is derived from the word "love." The point of calling ourselves professionals is that we are supposed to deliver high-quality care for people for whom we feel no love or friendship. Military physicians, for instance, are charged by the code of military justice with treating wounded enemy combatants-- who perhaps a few minutes before were trying to blow up the army hospital-- with the same standard of care they would deliver to our own soldiers. These are demands of professionalism. The outrage we justifiably feel when these standards are breached indicates that we believe that these standards of professionalism are both appropriate and attainable. Abraham Lincoln once said, 'My father taught me how to work; he never taught me to like it.' Medicine is our work. Most of the time, for most patients, it is worth doing our best to like it; we take better care of more patients that way. When we cannot find ways to like it, it remains our work. We should do it as well as we can manage." -- Howard Brody, "Ethics Forum," American Medical News, July , 2006.

There are certainly a few of the locums folks who make their way back specifically to the LGH from time to time, and that in itself is proof that the staff working there are something special! Beer all around for the LGH Christmas BBQ...

As for myself, I'm still trying to rent a house in the US for my next gig/incarnation. The Louisiana Medical Board and the Australian Medicare Levy Exemption folks are my latest and greatest frustrations. I guess being an ER Doc w/ the attitude of "Well let's just get it done now" doesn't train you to be super-patient when dealing w/ other things. But what I certainly can say, is that if I'm ever in a nursing home, I want my drug chart to look something like this:

Yup, mostly just standard nursing home whatever, but at the very end there, hand-written, is the order for "one beer at night, prn [latin for 'as needed']." I seriously want whoever did this to be my doctor. Of course, the more savvy of you order-writers out there will notice, the "prn" indication is not specified, as in "paracetamol prn discomfort/fever." "prn ennui" would be my choice in this situation...

So, that's that. I just wanted to put a few pictures down here of some of the goodbyes and good folks that made up my last few days in Lonnie!

Trouble wears many faces. Most often suspiciously cute, innocent faces...

As above, but I would also like to mention the look Jake is sporting-- sort of an "astronaut with pashmina" feel to it...

Folks saying goodbye to Mel and possibly myself at the Jailhouse grill....

Here we see newly minted Australian citizen Young w/ her certificate, and here is Baby Possum giving me lessons in time-management....

"Time management," giving the impression of needing to be "looked after"-- I think these are the prices I pay to do what I think needs to be done at work. They're especially chafing to someone who values independence and self-sufficiency as much as I do... :(

"Presumptuousness and self-importance are the wounds this life imposes upon those privy to the wounds of others. The busy, capable doctor, well aware of all the burdens he must carry, and not in the least inclined to shirk his duties, may stumble badly in those small moral moments that constantly press upon him or her-- the nature of a hello or goodbye, the tone of voice as a question is asked or answered, the private thoughts one has, and the effect they have on our face, our hands as they do their work, our posture, our gait." -- Robert Coles, The Doctor Stories, by William Carlos Williams, introduction

So, anyway, there you have it. Transitioning back to the US, visiting some friends, trying to figure out what to do with myself. Jake admitted to me he wanted to take a picture of my goal sheet for my year in Tasmania (yes, the one that included "9-minute mile for 1/2 marathon" and "sort out life") from the fridge and ask me how I did. Must say, not all that well ('pot belly' does not equal 'core strength'). But such is life. I'll leave this stage of things, and perhaps sign-off w/ the following. See you down the road a piece...

"Serving is different from helping. Helping is based on inequality; it is not a relationship between equals.... When I help, I am very aware of my own strength. But we don't serve with our strength, we serve with ourselves. We draw from all of our experiences. Our limitations serve, our wounds serve, even our darkness can serve... Helping incurs debt... But serving, like healing, is mutual... I am as served as the person I am serving. 'Fixing' is a form of judgment...In fixing there is an inequality of expertise that can easily become moral distance. We cannot serve at a distance. We can only serve that to which we are profoundly connected-- that which we are willing to touch. This is Mother Teresa's basic message. We serve life not because it is broken but because it is holy.... If helping is an experience of strength, fixing is an experience of mastery and expertise. Service, on the other hand, is an experience of mystery, surrender, and awe." -- Rachel Naomi Remen, "In the Service of Life," 1998, reprinted from Noetic Sciences Review, Spring 1996

"And so the moral of the story /

I guess it's easier said than done /

Is to look at what you've been through /

and to see what you've become .... "Private Conversations," Lyle Lovett

Beer-Pong in Burbank? (& the "Wrong Trousers")

2010-06-02T01:33:00.000-07:00

It's been a while since I've gotten around to posting. I will just mention that I've made very little progress w/ the guitar playing, but am more on track w/ studying for the Boards. Though not hugely on track.

I did manage to make it out for an interview in the US for the next phase of things. Which is now rapidly approaching! (as I transcribe some of these "blog notes" onto the web, I've only got two week left in Launceston). In any event, I was in the airport at New Orleans and took the shuttle into the city center. Because of the time of night and so on, my "shuttle" actually ended up being one a three "Party Bus" mini-van-type things that operate in the city. The owner occasionally does late night shuttle duty for extra cash when there are no proms, so on. So yup-- lights, mini-bar, plush leather interiors, mirrored ceiling, insane sound-system.
Shared the ride w/ another guy coming from the airport. He was a great character who made practical props for movies (said he'd been involved with the last 2 Transformers movies and was working on the third(!?!) Definitely seemed like an ex-hippie who'd become mistrustful of the world through experience.

The upshot of the whole trip was that I've taken the job in New Orleans and imagine that will be the next big thing. Of course while staying in NOLA the big thing that struck me was that every third commercial on TV was for a personal injury lawyer (the oil spill, metoclopramide, asbestos and un-differentiated poor medical outcomes seemed to be the favorites at the time). Yikes-- welcome back to the USA.

Funny story. In the am when getting ready for an interview, I put on my suit in the early hours when it was still dark. Mind you, this was the first time I'd put on a suit since having brought the two of them to Australia (also brought some white coats I've never put on, but enough about that). In any event, I'm in the cafeteria making tea (What? Who am I? Have I been living in Australia?) and I look down and notice that in the dim light I've managed to put on the brown-grey mildly checkered pattern slacks and not the slightly blue-grey striped pants that went with the jacket I was wearing. The one time during the year I need to wear a suit. Sigh. Well, anyway during my apartment search, found out that Brad Pitt keeps a house in the French Quarter, so clearly I'll be in good company...

On my way back to the States, of course my plane from NOLA was late, so I ended up spenidng an extra day in LA w/ my good friend who's doing a Rheum fellowship there. She was on-call the day we wandered around Hollywood & Beverly Hills, doing the tourist thing. She got one (1) call during the day and it was about whether or not you could have white cells from a joint aspirate in OA. Yup, that was it. Tough life, I tell ya'... ;) In any event, we ended up in "the Valley" at a friend of hers house, and I was involved in the most epic beer-pong game ever played. It was ridiculous. I can't go into it right now, but extra-innings, penalty shoot-out-- the works. It reminded me of myself, Tim Shutt and Erich Kurschat chucking fallen acorns at a "no parking" sign across from the cottage at Kenyon in an attempt to illustrate the concept of arete in action. We came close, but the beer-pong was epic.

I think it's true that if you want to know something about someone, if you really want to get to know them, you should go traveling with them. Yourself included. There's a lot of good information there. First off, it tells you how and how well you plan. Often you don't have to be traveling, so there aren't many artificial deadlines or guidelines about how and when you get things nailed down. What criteria do you use to book your flights? Price? Date? How much is it worth to you to have a 3 hour shorter lay-over? $50? $100? Did you leave your hotel booking to the last minute? Do you want to have a car arranged? Did you look up the bus schedule in Ireland? Are you going to be sure to hit the tourist highlights from Lonely Planet or will you just see what happens once you arrive in Morocco? Do you happen to know that you will need a visa for Australia (not Austria) if you are planning a visit to Melbourne? These things matter, turns out. Not only for the current trip but in terms of what they say about you and how you like to plan for things.

Secondly, it tells you about your ability to be flexible with your plans. If one thing or another doesn't look like it's going to work out, how much does that bother you? And are you willing to accommodate other people's goals for the trip? Are they compromising to meet yours? I recall, fondly, when we headed out to the first Lilith Fair near Pittsburgh and our Danish exchange student began to complain about wanting to go home because of the rain. He was also complaining about why we were at this concert and not watching Brian Adams, but I'll let that discussion go for a bit. Meanwhile our friend who'd waited all day to see the Indigo Girls was dead set on staying put. At one point I was concerned that we'd end up w/ a dead Dane, but the tyranny of the majority won out.

Relatedly, travel is important because it reveals a fair bit about you when your plans don't go the way they're supposed to go. Travel that turns into a nightmare (or "challenge"-- perhaps I've revealed a bit about myself there...) tests resilience, resourcefulness, improvisation, communication, and importantly, patience. "God, grant me the strength to change the things I can, the serenity to accept the things I can't, and the wisdom to know the difference." I much prefer the Kipling line from "If," "if you can wait, and not be tired by waiting.."

On the Lonnie front, just two weeks left to go. Of course, one of those weeks is the overnight shift for 7 days in a row, so that's a fun kick in the teeth to send me off. But apart from that, Australia medicine is still keeping it real. The following is an actual quote from the first part of an Orthopod's letter back to the Pt's referring GP:
"Thank you for asking me to see this big man who has had 5 coronary bypasses, suffers from sleep apnea, obesity, diabetes and hypertension and lord knows what else."

Yup, that's in the medical record. Love it. Every now and again I'll write something like "his pattern of presentation to the ED for 'lost prescriptions' is becoming concerning and we may be unable to accommodate him in the future" or "her pattern of complaints did not seem to be consistent with any organic pathology with which I'm familiar." I tend to let people read my "and lord knows what else" 's in between the lines, I guess.

What's also great are the following options on our pathology reports screen:

In case you're getting concerned, the option of "dog" in response to the query "sex" is because our Path service would also do some of the veterinary work for the region.

I also loved this name for a day-care (creche) center here: "Dumped." What a name for a place where you drop off your kids!

And some things are just unfortunate in any culture. While "Urn-ie" might be accurate in terms of describing this machine as a small hot water heater, the evocation of "urine" is unfortunate. Though not entirely inaccurate-- my experience with this machine led to the worst cup of tea ever produced by human hands.

I'll get a good-bye Lonnie post up before I go!

Cheers,

--andrew s.

Bloody good time in Australia...

2010-04-26T08:05:00.000-07:00

Even, perhaps especially, the ER is a place that can make you laugh. And at some pretty interesting things. The other day a woman was brought in bleeding from a stab wound in the neck. Funny thing about blood-- it tends to draw attention to anything it's coating. I think perhaps the fashion world should take note of this. It is eye catching. And while someone standing in front of you spouting poetry or political slogans might at least generate passing interest or a fleeting emotional response, someone in front of you spouting blood is likely to command your rapt attention until the situation changes appreciably. Just one of those things, I suppose. What's also interesting about blood is that when it's splashed or splashing all over the floor, there always seems to be a "whole lot" of it in a way that separates it from other liquid spills. While there may be "a lot" of spilled lemonade on the floor, when asking someone to quantify how much of the same amount of spilled blood there is on the floor you are more likely to get a response along the lines of "Way, WAY more than there should be."

In any event, bleeding patient, everyone upset, etc. When we finally got things sorted and her up to the OR to get the wound attended to, she asked me (my fingers on her carotid), "Am I going to die?" ER doctors hate it when asked this because let's face it, if you've thought to ask me the question I'm probably asking myself the same thing (about you, not me) and more often than I'm comfortable with those patients unfortunately have about their condition what the psychiatrists call "insight." But this patient wasn't dying, and likely wasn't going to, all things considered. So, my response? "Frankly, at this point I'm more worried about all those heart attacks you caused down in the ER when you came in leaking red stuff all over the place." Yup, I'm a caring nurturer. Can't be helped.

Life in Launceston has been pretty good. The best thing about the place, and again the best thing about most places you go, actually, has been the people. It's a really good place to work from a staff point of view and most people that you meet are very friendly (just like in the brochures! :) Here are a few pictures from on of the other Locums' going away party. Frivolity ensued.

I'm relatively certain that the second picture should have the following in a thought-bubble as it's caption: "Quickly! To the Keebab House!" One thing I will say, curry and Thai food aren't all that bad on this side of the world (now Mexican food... :(

The Parents made a point of coming by and taking a few days off their busy schedule of non-stop cruises (Hawaii, New Zealand) to hit the Tasmania highlights. Now think about what you might schedule for your parents if they were to come visit you where you live... Not easy, huh? Well, they did great and Mom even managed to conquer the Dove Lake circuit walk (w/ Cradle Mountain in the background).

In spite of having only the one good leg! The knee replacement, courtesy of the current working US labor force via Medicare, is coming. Side note, only rule of parental trip-- no politics. Probably for the best. Of course, it goes without saying that the walk was rated as "easy" by the Parks Service, and on only one of the 13-scrillion pieces of literature/trip planning I came across did they mention the "apart from one moderate hill" bit. And that was only on the posted map when you got there! So we busted out the ski poles and Mom Robo-Copped it down the last bit. I feel that my providing Transformers-like sound effects for her knee brace really serves as a relaxing yet motivating accompaniment to her getting around.

We also put on rain coats and got on board a boat tour of the Tasman Peninsula/Island when we went down to Port Arthur to check out some well preserved reminders of the convict history of "Van Diemen's Land." Because of some pretty high seas it ended up more like a roller coaster than a leisurely jaunt around the bay, but I loved that. Here, Youngie plays the part of the Red Water-tight Ninja. And the scenery was of course amazing. Closest next bit of land? Yup, Antarctica.

We did a little sight-seeing and so on and then said adieu to the parents. I'm still inwardly amused by a fair amount of the signage I see here. For example, This particular art gallery is relatively difficult to find, partially attributable to their advanced "Cloaking Facilities" located at Visitor Reception.
"Impossible! No ship that small has a cloaking device...!"

And I still enjoy the Public Service announcements, which apparently are a cultural thing-- a friend says that in addition to a warning label the cigs in the UK have actual pictures of diseased lungs, etc. on the packages.

So, I'll leave off this posting with another poem, as well as some pics of what I recently found in my shoe one morning. I mean, where the heck am I? The Sahara?

For those of you who bought the special blog glasses, here it is in 3-D:

(aka out of focus)

The Calf-Path

by Sam Walter Foss (1858-1911)

One day, through the primeval wood,
A calf walked home, as good calves should;
But made a trail all bent askew,
A crooked trail, as all calves do.

Since then three hundred years have fled,
And, I infer, the calf is dead.
But still he left behind his trail,
And thereby hangs my moral tale.

The trail was taken up next day
By a lone dog that passed that way;
And then a wise bellwether sheep
Pursued the trail o’er vale and steep,
And drew the flock behind him, too,
As good bellwethers always do.

And from that day, o’er hill and glade,
Through those old woods a path was made,
And many men wound in and out,
And dodged and turned and bent about,
And uttered words of righteous wrath
Because ’twas such a crooked path;
But still they followed — do not laugh —
The first migrations of that calf,
And through this winding wood-way stalked
Because he wobbled when he walked.

This forest path became a lane,
That bent, and turned, and turned again.
This crooked lane became a road,
Where many a poor horse with his load
Toiled on beneath the burning sun,
And traveled some three miles in one.
And thus a century and a half
They trod the footsteps of that calf.

The years passed on in swiftness fleet.
The road became a village street,
And this, before men were aware,
A city’s crowded thoroughfare,
And soon the central street was this
Of a renowned metropolis;
And men two centuries and a half
Trod in the footsteps of that calf.

Each day a hundred thousand rout
Followed that zigzag calf about,
And o’er his crooked journey went
The traffic of a continent.
A hundred thousand men were led
By one calf near three centuries dead.
They follow still his crooked way,
And lose one hundred years a day,
For thus such reverence is lent
To well-established precedent.

A moral lesson this might teach
Were I ordained and called to preach;
For men are prone to go it blind
Along the calf-paths of the mind,
And work away from sun to sun
To do what other men have done.

They follow in the beaten track,
And out and in, and forth and back,
And still their devious course pursue,
To keep the path that others do.

They keep the path a sacred groove,
Along which all their lives they move;
But how the wise old wood-gods laugh,
Who saw the first primeval calf!
Ah, many things this tale might teach —
But I am not ordained to preach.

the great overland track

2010-03-18T00:24:00.001-07:00

People often ask me why I chose to come to Tasmania. Not least of all, Tasmanians. While the immediate reasons are relatively straight-forward (not sure where I wanted to be; was busy arranging time in Liberia when my Residency classmates were looking for jobs; thought "why not go overseas?" and not all that confident in my Spanish; signed up w/ an agency and was given a few choices), there is more to it than "why not?" In fact, I think that quite a few Tasmanians suffer from the "Statue of Liberty" phenomenon, in that if you are from a place you rarely end up doing the things that tourists do when they come to that place. For Tasmania, the "touristy things" are amazing opportunities for "bushwalking" (camping/hiking) and exploring the wilderness that is relatively untouched.

Much like my home state of West Virginia, the preservation of the wild is the positive that often (though not always and usually not without someone to fight for it!) comes with relative under-development. In fact, I find myself telling people here that I felt comfortable coming to this town in northern Tasmania specifically because it was similar to the town I grew up in back home in West Virginia. Go Big Reds.

With that as an introduction, I have on my refrigerator a list of goals for Tasmania. In addition to "improve posture," "drink two glasses of water a day," "run 9.30 min mile for 1/2 marathon," "normalize TSH level" and "Sort out life direction," on that slip of paper there is also the aspiration-- "Walk the Overland." Well, the TSH may be coming along, but the only one I've been able to cross off so far has been that last. And thank goodness for that.

The Overland Track is one of Australia's and certainly Tasmania's most famous walks. Similar to the Appalachian Trail in the States but perhaps more isolated, the track starts in the Cradle

Mountain National Park and makes its way south through the World Heritage area for 65 kilometers to end at Lake St. Clair. A lot of my pictures from the trip are also up on my Facebook page, but I thought I'd try to put some up here along w/ a little bit of context.

First off, the Players. Myself and my girlfriend YoungJoo started off in the morning, leaving my flat in West Launceston, loaded up and ready for adventure. Naturally she felt the need to bring along a tiny toy stuffed possum...

As with all great adventres, we first made our way to that most exotic of locales, the bus stop:

While game and having been on a few hikes w/ me previously, Youngie hadn't really done any extended camping or bushwalking at all before. This prompted the following photo in which I point out what is on my mind and the lack thereof once we actually get on the trail...

During the popular season in Dec-Jan-Feb-March (aka summer), the trail can only be hiked North to South. So we had to convoy down to the end at Lake St. Claire the night before, leave one of our cars, and carpool back. Because of the length of the drive, we ended up driving back in the evening, leading to the maiming of several species of Australian wildlife and the front end of my 98 Toyota Camry (anyone in Tassie in the market?)

The Track itself was fantastic and we got off to a pretty good start, crossing Cradle Valley and heading up to Marion's lookout, the face track to Cradle Mountain, and getting in to Waterfall Valley Hut on the first day.

This is a view of Crater Lake from the Overland Track on the way to Marion's Lookout, day 1.

Climbing up to Marion's Lookout, and then standing on it w/ Cradle in the background:

The last is Cradle Mountain as seen from the Cradle Plateau, "just" after Marion's Lookout.

To be honest things began to blur together a bit as to which day was when or where. And every time I stopped to use the camera I kept thinking of that line from Desert Solitaire where he exorts the tourists to see what is in front of them as opposed to trying to compose a picture about it. But here are a few shots, regardless. I recall one of the Parks and Wildlife workers mentioning that 60% of the species found in the world heritage area are found nowhere else (which explains the planked boardwalk!). Quite a few of the areas on the Cradle Plateau reminded me of the algific talus slope we saw in West Virginia as part of the Mountain Institute. A giant outcrop collapsed and buried a glacier underneath it, trapping and insulating the ice and leading to tundra-type flora in the middle of the Appalachians! :)

There were fair amounts of myrtle and deciduous forest as well, especially on our day 2 marathon!

Buttongrass alongside the track, day 1 or 2. I'd thought it had gotten it's name from the clumps in which it grows, but apparently the button-like appearance of the flowers is responsible. I didn't see any flowers-- I like my reason.

Here is the trail to Mt. Ossa at Pelion Gap, day 3. We left our large packs at the trailhead and spent aobut 4 hours climbing up to the top of Ossa, which is Tasmania's highest point and often snow covered even in early summer. The climb was a bit challenging in parts but not technical. There were certainly a few traverses where you thought to yourself, "I'm doing this on purpose?" Managed to get sunburned in spite of the sunscreen on this one. This is why bald guys like the big hats! :(

A side trip on day 4 took us to Fergusson Falls, just 2km North of DuCane Gap. A very nice Frenchman took our photo. I was of course envious in that he had two trekking poles and I only the one I'd borrowed from a friend of Youngie's. I am happy to say that one birthday later I now have a set of my own poles.

It was interesting in that at the trailhead to Mt. Ossa, it was this guy's pack that the crows had un-zipped and gotten into. By watching hikers from afar over time, the crows learned that food was in the packs and had worked out how to unzip them with their beaks!

It finally rained on us day 3 and 4. It's only fair-- the area we were hiking through at the time was temperate rainforest-- similar to the Pacific Northwest or cloud producing forests like Monteverde in Costa Rica, perhaps.

Here, in the distance you can just make out Young on the track, surrounded by enormous gum trees. This was day 4 or so.

Day 5 we hit the suspension bridge over the Narcissus River on our way to Lake St. Clair. A fair number of features in the area have names derived from ancient Greece. I think it started with an area termed "the Labyrinth" and people just kept it up from there. I particularly enjoy the warning sign...

We ended up having a spot in each of the huts we came across, so never had to use the tent we brought. But at least one couple in the group we started out with did get caught between huts and ended up using theirs, so it's definitely worth it to have one available. This is Narcissus hut, which is the last one we came across. It's certainly not the nicest, as some of them were amazing, especially considering there's nothing else around.

So this is me scratching my head at Narcissus after summoning the ferry to take us out. You can either walk or catch a ferry for the last bit, but you have to plan ahead for this. Because we didn't, we had to use the radio in the hut to talk to the ferry base. Hysterical, but also eeriely like that one scene in the Xbox game "Left 4 Dead" when you have to radio the boat to pick up your group of survivors from the zombies out in the woods. Yeah, creepy.

The beautiful, and non-zombie infested Lake St. Clair.

It is here I saw my first (and likely only) platypus in the wild! By the time I got my camera out, it looked like a ripple in the water-- sorry!

This is me next to a gum tree, also near Narcissus at Lake St. Clair, waiting for the ferry.

I don't know why gaiters are so popular with bushwalkers here. I myself never wore them when doing hiking in the States. I suppose they do help keeping socks/feet/boot tops dry. But I wonder if they're also more popular here as just another layer of snake protection. In the US, snake bites are unpleasant and will put a damper on your trip, but in Aussie some of the snakes are so poisonous that when you get bitten your pet goldfish dies, too.
And speaking of which, this is the only sign we saw regarding snake activity. It was posted at the visitor center at St. Clair. Yup, at the end of the hike. Thanks for that, fellas.

So, not to sound too much like Uncle Travelling Matt, there you have it, my nephew Gobo. I hope to get to do more of this stuff, and I hope Young enjoyed it as much as she said she did (btw, helpful tip-- winter rated sleeping bags are the way to go, but that's another story...) and would go again. After years in Baltimore and NYC, it was nice to get out of "the Big Smoke" and into the woods, where the wild things are. ;)

May the Road Rise to Meet You / May the Wind Be Always at Your Back /

May the Sun Shine Warm upon Your Face / the Rain Fall Soft upon Your Fields /

And until We Meet Again / May God Hold You in the Hollow of His Hand.

--aws

emergency medicine: kinda like an un-funny version of "Scrubs"

2010-03-17T23:49:00.000-07:00

Warning: the following is a complete waste of time!

I've always been interested in the social construction of health and disease, the supplanting of religion by science, the perception of healthcare and medicine by society. So it's interesting to see what people assume about you-- good or bad-- when it is revealed that you are a doctor. Also, some of it stems from the fact that so much of your time/development/personality goes into medicine that you can't help but view even your own life through a medical lens. As when JD in Scrubs looks at all of his friends in terms of what's likely to kill them. So, it's fair to say that at times my life does feel like an un-funny version of "Scrubs." (probably something from season 4-- was that the low point or what?). Anyway, interestingly, a survey of the ACP (Internists' professional association) a few years back asked what the most realistic medicine show on TV was. "ER" won at the time, I think primarily because it was the one most watched and most familiar to people. But "Scrubs," a comedy focusing on the absurdity of medicine and the hospital as work-place, came in a close third-- and this was after only one or two seasons...

Maybe because it's so related w/ questions of our own mortality and what it means about how or when we die, everyone has an opinion about everything medical or health related. Especially as we ?finish/enter a acrimonious "discussion" about how we'll be paying for it all-- or not.

http://www.theamericanscholar.org/to-die-of-having-lived/

To quote Sir Ken Robinson, "It is one of those things that go deep with people, you know, like money and religion, and other things."

http://www.ted.com/talks/ken_robinson_says_schools_kill_creativity.html

It is a universal preoccupation.

And so it deserves to be mocked.

I think ER in particular lends itself to a certain kind of gallows humor. And also a certain amount of frustration (there are facebook groups "911 is for emergencies" and "being drunk is not an emergency" started by fed-up providers) that is sublimated in this same sense of humor.

So, here are a few of my favorite medically-related comic moments from various internet sources. I'm sure you can think of a few others.

Man Stroke Woman -- hysterical British series starring among others Nick Frost from Shaun of the Dead and Hot Fuzz fame:

ER Gyn exam- http://www.youtube.com/watch?v=1wAYCgqc2uk

"May I be blunt with you?"- http://www.youtube.com/watch?v=_Eng-pRT9uA

Breaking bad news - http://www.youtube.com/watch?v=ka0_wc4n8oc

Intimate role-playing, nurse - http://www.youtube.com/watch?v=rZIb1VPEpEk

This is a good website where apparently you put in a script and they create a cartoon based on it. This ER patient is a composite (probably) but it's not far off! (thanks Dr. Boddie) - http://www.youtube.com/watch?v=_m64cy1MMPg

At big centers, we often refer to patients sent in from outlying (and often smaller and less-resourced) health institutions as being sent from an "outside hospital." As in, "this is a 45 yo M referred from OSH on 11/3/10 for cough w/ a presumptive dx of..." This is a vid from med students out at University of Pennsylvania detailing a few issues w/ some referrals - http://www.youtube.com/watch?v=xskFo75Wdhs

n.b. - "cathing" someone is a procedure that interventional cardiologists get paid a bit for in private practice. The other jokes are quasi inside jokes at the expense of the care providers being commented on. A favorite pass-time in medicine...

The outstanding movie Spies Like Us has hundreds of great moments. One great one is the "doctor" bit in which Chevy Chase and Dan Akroyd play spies pretending to be doctors - http://www.youtube.com/watch?v=AqBPOWpOg0o

Another great moment is when they do a surgery w/o knowing what they're doing, but I couldn't find it apart from in Czech!

The comedian Brian Reagan has a great take on his Emergency Room visit - http://www.youtube.com/watch?v=b-JRQXYy9wk

You can always count on Monty Python for good stuff. This Hospital Sketch from "The Meaning of Life" hits the heroism of the hospital administrator on the head - http://www.youtube.com/watch?v=lxOu1DyVQV8&feature=related

The Onion is fantastic for some of my favorite bits:

Preparing for a hospital stay - http://www.theonion.com/content/node/38410

kidney donation video - http://www.theonion.com/content/video/anonymous_philanthropist_donates

an excellent example of the need for "further research" in academic medicine in which studies of the overtly obvious or esoterically irrelevant can be the basis of an entire career -
http://www.theonion.com/content/video/study_multiple_stab_wounds_may_be

Organ and tissue donation, anyone? -
http://www.theonion.com/content/video/medical_miracle_man_lives_thanks to stolen heart

"You are only as old as you feel" -
http://www.theonion.com/content/video/worlds_oldest_neurosurgeon_turns

And finally, a few bits from Scrubs, which thru Season 3 was some of the best stuff on TV (I hear Season 5 picked up a bit) - http://www.youtube.com/watch?v=wLGT24NYguM&feature=related

Dr. Cox, my personal hero - http://www.youtube.com/watch?v=rRBq-6lVxzU&NR=1

Good luck!

--andrew s.

224 South Exeter is not that into you... and other stories

2010-03-07T18:45:00.000-08:00

unfortunate hair --> responsible man

It has been some time since I've been able to update the doctoroffortune blog, so I'd be surprised if it's still being checked. But, that's primarily because I've been having some fun and doing a few thins (hopefully) worth blogging about. Interestingly, I've also been pressured by friends to get my photos up on Facebook where they're more easily accessible, so it's kind of interesting to think of how the medium changes the message. Blogspot is a little slower in uploading photos, but obviously there's a larger space for narrative. How would this change how you tell a story, or which story you would choose to tell? Looking at what I've chosen to write about, and what pictures I've chosen to upload on Facebook, I think that the blog is more about my experience of the situations, or at least my observations of them, than the situations themselves, which make for better snapshots.

Ants at "Jonestown" They of course have developed some kind of immunity and are now again overrunning my apartment....

In any event, time has flown here. It's hard to believe that I'm having to start thinking about cancelling my salary packaging and so on-- I've not even gotten all the Christmas gifts out! But it has been fun. Below are a few pictures from the Launceston City Park event "Carols by Candlelight." Given the late sunset, it was still pretty sunny out for most of it. Also below are the lyrics of "Six White Boomers," which is about Santa using kangaroos to pull his sleigh. Yeah, no one here knew the words either...

www.tasgreetings.com/boomers.html

There've been a few concerts and so on in Central Park, including Symphony under the Stars, when the Tasmanian Symphony Orchestra would play. There was also the Festivale, which was a food/wine tasting shin-dig, at which I saw "Mariachi Australia." Kind of awesome & hysterical. I have Snr. & Snra Marlow to thank that I knew the words to "cellito lindo" and sang along in Tasmania. Life takes you weird places, anyway.

Of course, there are still the things that make me giggle inside. Like, for example, this ad for "homely" accomodation...

As far as the title goes, I'm not a huge fan of romantic comedies in general, but my old roommate Brian let me know about this scene in "He's Just Not That Into You" a few months before it came out. That's right, _before_ it came out. I'd moved up to the Bronx from 224 S. Exeter (or "sex-eter," as I pronounced it) and got the call from him that they were filming a movie and using our house as a location. So I finally got around to checking it out:

It's in this scene, and Jennifer Connelly pulls up outside her (our!) unit in a Baltimore townhouse block, walks up to the door, and -cut!- That's about it. The rest of the interior shots were done elsewhere. But first, a shout out to Little Italy and Vaccaro's cannoli and the bocce courts around the corner. So, apparently what happened was an Assistant Director got Brian's permission to film the facade. Then they came and replaced our rusty mailbox, improved the shaky fence, and put in a new screen door. They filmed the 3 seconds or so of screen time-- then took everything down and put back what was there before. I later learned that the place was supposed to be undergoing renovations in the movie. Ok-- three things. One, if you have to do that much work, why not just pick a door you liked better to begin with. Two, thanks for the comment on my place-- that you had to spruce it up to make it look like it was in need of renovation. And three, can we have some of that stuff back?

More soon....

--andrew s.

Shorn Sheep Look Ridiculous

2010-01-09T01:16:00.000-08:00

It's true-- but I wonder if they're ok with it because they're not as hot as their un-sheared flockmates? I didn't get pictures, unfortunately. The sheep which inspired the above observation were seen from the car, driving on a trip post-hike, so we were in a hurry and didn't want to stop for pictures.

The sheep field was also located next to a poppy field, which are pretty common here (I'm told Tasmania produces about 90% of the medical use opium/morphine for the Eastern Hemisphere). So not too excited to stop the care and approach the fences (the pictures give an inkling as to why...).

Besides, it'd be a little dicey to go out of your way to spend extra time w/ sheep out in the field anyway. As I said to my friend Dale, “Cloning? I don't know-- I'm kind of leary of any scientific advancement that results from the Scotts doing strange things to sheep.”

Can you imagine if the fences broke down? A bunch of naked sheep, wandering around the countryside, high? Wobbly, naked sheep. We refer to the ability of high-addicts back home to just sort of stand there, swaying slowly side to side, eyes closed but never falling down as the “Heroin Tai-Chi." This could be a potentially difficult to deal with but at the same time hysterical agricultural disaster if these particular fences failed..

A few posts back, I mentioned the group Tripod and a performance of theirs on the TV program “The Sideshow.” Well, I didn't get my shift switched to see them in Lonnie, but I was able to find the song I was talking about online. Sorry for the earlier mis-quotes-- these guys are great. All scrawny, pale technophiles take note! It reminds me of the Onion online video commentary “Are video games doing enough to prepare our children for the coming apocalypse?” Also, watch for the appropriate use of the term “rooted.” “Bush-tucker” is a term for wild game. Sorry for the video/audio dysynchrony.

http://www.youtube.com/watch?v=xetsxpKjmQo&feature=PlayList&p=7F014126BB46D8FA&playnext=1&playnext_from=PL&index=14
For those interested, here is there homage to adult-aged males who still play Dungeons and Dragons on the weekends...

http://www.youtube.com/watch?v=0IgVPnhmVNE&feature=related

Similarly, Tim Minchin is another Aussie musical act that I've enjoyed since being down here...

http://www.youtube.com/watch?v=78XrI_2bPVA&feature=PlayList&p=E2C04E96920A17A5&index=3&playnext=3&playnext_from=PL

And I thought I'd add the following text from an email I received from a patient down here. It contrasts sharply w/ the experience a friend of mine (an OB) related of a patient opening up the initial conversation with the threat of a lawsuit. Yup, it's a different world...

"Dear [AWS], This is just the briefest note to express our appreciation of your advice and help when [E] presented at your emergency department with a Lt. basal pneumonia on 26-12 09. I am pleased to say she is responding well and almost apyrexial now. I hope to meet you sometime while you are here and will be in touch again. Yours sincerely, many thanks and best wishes, [...]"

Anyway, about to head in for another weekend of "babysit the drunk head traumas and hope no one herniates until the morning." Not to stereotype, but people love beating the hell out of each other out here. I mean, for a relatively moderately sized town, there are quite a few "bashings" a night (I heard "bashing" referred to as the cause of death of an off-duty cop on the news the other night. I guess in the States we'd say "beating death"?). So no guns, one stabbing, but plenty of blunt trauma on the weekends, which is a little unsettling. Makes me wonder if I've got post-traummatic stress disorder from my mugging... :)

A good friend of mine said, you know you're getting into a little bit of a self-pity mode about your relationships when pop songs start speaking directly to you (you know what? He was just pushing my love over the borderline..."). I think this relates to High Fidelity's point of "Did I listen to pop music because I was miserable? Or was I miserable because I listened to pop music?"

While not miserable or self-pitying, I thought I'd throw out these lyrics to a few of my favorite songs I was listening to again (gotta love the "shuffle") for good measure. 10-points for identifying the first, 20 for the second. Cheers, --aws

"Some say life / will beat you down / break your heart / steal your crown /
So I started out / for God knows where /
I guess I'll know / when I get there..."

we break and train our children just like animals
we fill 'em up with parasites of poison dreams and fear
We hand 'em false gods on a golden platter
then we remind them to wash behind their ears

We gave up our own dreams so the kid could go to college
then they grow up and resent us; accuse us of impossible psychological crimes
the normal relationship in Hell is about getting even
but you won't find that in your Sunday New York Times

Anger Sadness Hatred Envy--
these are just Fear wearing the same old cheap masks
You're doomed if you don't learn forgiveness, Sister
we're all driving around lost, we don't know who to ask

We're all stopping at abandoned gas stations to ask directions
there's no more road maps to tell us who the hell we are
raised on TV commercials, organized religion
following corrupt wisemen who've been navigating by
the wrong star...

We've reached the end of the road and find out no one else can make us happy
we've waged all the wars of drama and control
we've sacrificed it all for wives husbands money children false religion-- that old line about gaining the world but losing your soul.

Hiking: Western Tiers Region- Quamby Bluff and Meander Falls to Split Rock Trails

2010-01-03T21:12:00.000-08:00

So, was able to get out and around the island some these past weeks. It is actually very nice country, with an interesting range. Getting transportation arranged has been a bit, but now at the point of getting to see some of the island, which is great. My friend Young has been up for coming out to some of these spots, which has been good. Of course, the whole “hiking” (here, “bushwalking”) concept has taken some getting used to for her (“Yes, there will be insects and worms. Yes, we have to carry our food and filter our water. Yes, there will be mud” [ala Daniel Day Lewis...]).

Anyway, we first tried out Quamby Bluff, which was just a bit of a day hike a few minutes south of... the hamlet?... of Deloraine. Quamby was fun, but certainly after years of New York living my wood-walking legs needed to get used to things again. And yes, I really am that pale..

Later on, headed out to Meander Falls. The first bit was fun, and though the falls themselves weren't the most impressive things in the world, the terrain felt a bit more varied than that of Quamby. Because of a late start, once at the falls we had the option of returning via the same route or taking the Split Rock trail back to Meander Road. It was reported to be a tougher track, but faster. Yeah, not so much w/ the faster part. I think the only time I was ever really worried that I would die out in the woods was during a trip to Puerto Rico w/ my girlfriend at the time when we went off-trail for a bit, got lost, and a few hours day hike ended up as an almost overnight. Luckily captain Boy Scout had brought along some food and flashlights. Oh, and another important safety tip: if you're going to rural Puerto Rico, it's important to tell your travel companion that you have an anaphylactic allergy to banana before you go. Also, it might not be a bad idea to bring along an epinephrine injector. Just a thought.

Anyway, the least amusing part of the Split Rock trail was when there was an impromptu conference on the dolerite boulder scramble (marked by questionably maintained carins only for its length) that began with “This is terrifying. I don't want to do this anymore,” was punctuated with glucose repletion, and ended with “I know this is tough going, and I'm sorry and would like to let you rest more, but we really need to get off these rocks before the sun goes down.”

The most amusing part was how many times after that I said “Not far now..” (about 15 min intervals). I felt a bit like Papa Smurf ... http://www.youtube.com/watch?v=Vi0tje6xfWs

Still, some good pictures :)

And, 35 points if you get the reference made in this video (I couldn't even find a link to the scene in You Tube!). Yes, I recognize I said "underwater" river as opposed to "underground" river.

Cheers,

Uncle Traveling aws

“I cannot be held responsible for what my giggling little hind-brain may kick up”

2010-01-03T20:58:00.000-08:00

I found myself in a large performance space, with tiered risers and chairs and music stands arranged for the orchestra that was present. The amphitheater was filled with teen and pre-teen wunderkinds all playing violin. Along with myself, also holding a violin and bow, but not able to keep up with what was most likely Mozart's Eine Kleine Nachtmusik, K525, Allegro. So I just sat there looking at them. This is likely related to my college-age attempt to learn to fiddle, my current attempts to teach myself guitar, and the 15 year-old guitar playing psychiatric patient I'd seen the day before. After the session, I left the building and found myself walking up the slope from the Hill Theater at Kenyon College, still toying with the violin that I was carrying. I was asked if I played often by one of the early Harry Potter-esque younglings that was leaving with me. Nope, just learning.

I walked up spiral stairs that I recognized from the old Philip Mather Hall, entering a room reminiscent of one of the small-group seminar rooms of Kenyon College, perhaps Ascension?, complete with wood panels, large tables with high-backed chairs, and narrow neo-collegiate-Gothic-architecture leaded windows. You know, the kind that grace the pages of the Kenyon brochures (“Our student to teacher to cow to corn ratio is 3 to 1 to 2 to 17,000!”).

Myself, Junior Year, with Tim Shutt as Santa (Kenyon, 1997)

As I circled the table (“rectangled” the table?) to grab my seat, Mr. Campbell, my 9th grade Drama and English teacher at Jackson Junior High, looked up quizzically and asked, “Hunter transfer?” This was interesting because my only associations with Hunter College are a reference f om Terry Gilliam's “The Fisher King,” as a subway stop on the Upper East Side 6 train, and where my girlfriend completed a masters of Social Work-- the latter two being several years after Kenyon and at least a decade after junior high.
No, I was just attending as a “conditional” student-- meaning I signed up but could not be assured of a place in the class. I knew it would be good to take this apparently philosophy course for my personal education even though it wasn't my field and would be new for me. I might have to end up auditing, or taking it for no credit. Especially, Mr. Campbell pointed out to me, as I hadn't taken the required seminar the semester prior. He slid over to me a brochure of the same, which had former Kenyon President Rob Oden's picture on the cover.

The class continued with the student to my left, who turned out to be Wes Overby, a kid I knew from elementary school, but who looked like he did in high school (long hair, earring, I think a Metallica t-shirt) reading from a small booklet of what sounded like Austrian German philosophy. In Austrian German. All I know is that he seemed to be reading from the middle of the page up, to “heighten the emotional impact” of the text, he said, when Mr. Campbell pointed this out to him. And that at one point he said the word “auerwuff,” which I don't think is a real word, but which I transcribed in my book as “Airwolf?!?”

It was then my turn to read. I struggled over a few of the words, affecting a thick movie accent (half of speaking a foreign language is a fake accent anyway), before Wes and Mr. Campbell started helping me by pronouncing the words along with me. I eventually asked if the required seminar was one in which you were taught Austrio-German. Across the table, a stern looking blond body-builder type who had no business being a college student-- in fact I'm pretty sure he was the Austrian hit-man from “Tomorrow Never Dies,” the Pierce Brosnan James Bond movie-- sneered and took over reading.

So, interpretations? I'm open to them-- fear of trying new things? Too many movies seen? Too many shifts in a row? Let me know what you think. Today, I have to do some left over dishes, go grocery shopping, practice some guitar, do some of the CORD tests online for Board Prep, and head to the hospital to do some left over charts. Then hopefully head to the West Coast for some beach time. Obedient to some strange spell,

--aws

Merry Christmas!!

2009-12-23T19:48:00.000-08:00

Just remember, I get to open my presents about 16 hours earlier than my brothers...

:)

Merry Christmas!

2009-12-21T01:31:00.000-08:00

Apologies for the blog delay-- been trying to work a few things out here in prep for heading back home. Apparently, I'm in need of a "career." Who knew?

In any event, the days have brightened up and here the solstice in December is the longest day of the year. Back home, my brother is dealing w/ mountains of snow in DC. In HI, my other brother is I'm sure doing just fine (sigh!).

The TED website really is fantastic and I wanted to share the following link:

http://www.ted.com/talks/ryan_lobo_through_the_lens_of_compassion.html

We'd heard all about General Buck-Naked while in Liberia, though I never met him (obviously).

These are a few pictures from around the 'Merican Thanksgiving table:

And here are a few of the DEM Christmas Party:

Time has gotten away from me and I need to head in for another shift. Things are a little tough @ the hospital now w/ staffing issues, so that's an excitement. I'll likely be off camping for the actual Holidays (nothing says "Christmas" like scraping a leech off your skin w/ the back of your knife...), but hope everyone enjoys them at home. There's a postal strike on in Aussie now, so I'll pretend that's why I haven't gotten your presents in the mail!!! :(

cheers, --aws

Royale with Cheese...

2009-11-21T04:47:00.000-08:00

It's just the little differences, really. McDonald's is referred to as “Macca's,” Burger King as Hungry Jack's. The big things missing from my diet? Cherry coke zero, Diet Dr. Pepper and good sushi. No great loss, I hear some of you say, but do not underestimate these things. However, one awesome thing about the sushi/Japanese restaurants--

Yup, little plastic fish-shaped soy sauce capsules. They are awesome. And re-sealable.

In terms of the DEM (dept of Emergency Medicine, vs. ER or ED), there are also quite a few useful terms I've added to my vocabulary. My personal favorite is “acopia” (pronounced “a-cope-ia”), used to designate someone or someone's family member unable to deal with their issues (sometimes medical, often not) at home. It was apparently at one time an honest to God diagnosis that they would enter into the computer before a memo put an end to it-- formally at least. It's equivalent back home is my favorite (or, favourite) FTC for “failure to cope,” applied to patients in the same situation beyond the age-range of the more traditionally accepted “failure to thrive” diagnosis. Close seconds are the expressions “fronto-palmal” and “fronto-dorsal” to describe Pt “affective types”:

And the ever-popular “haema-chuk,” or what is spilled onto the floor when an upper GI bleed makes itself apparent. As an aside, to “root” for a team is an expression that has a very different meaning here and should probably not be used in polite company (though I'm curious to see what it would look like in practice...). To say you're a fan of a certain team in, Australian rules football, for example, you would say that you were a “supporter” of that team. “Root” is the unpleasant and impolite equivalent to “shag.” Similarly, “how are you doing?” is here “How are you going?” (how is “it” going does not exist), but I just can't get it in me to say, “I'm going well.” Saying so makes me feel like I'm making good time on some sort of river voyage. Not sure why.

Oh and a few other things. This sign is up in the utility room in the DEM. I tried to get it in focus, but it didn't come out right. It is a conversion chart for converting between kilogram and, wait for it, stone. That's right-- stone. As in, “He probably weighed about 13 to 14 stone.” I just have images in my head of a code in which someone is calling out drug dosages in “mgs/stone.”

For those of you who are fans of The Daily Show, you may recall their “Pantry of Shame,” which includes microwavable blueberry pancake-wrapped sausages on a stick and something called “Baconaise,” which is mayonnaise w/ bits of artificially flavored bacon already mixed in. Well, I saw this ad for Beconase, trade name of an inhaled nasal steroid, and couldn't help the mental

connection (much like the Ceylon industries bakery that produced the chocolate cookies mentioned in a previous Liberia post...).

I showed a co-worker here a section of my blog from back in Liberia that had my photo on it, and came in to sign out the next day with this as the computer wallpaper:
Apparently there's a website where you can upload your pictures and do things like this to them. With friends like these, who needs friends, right?

For those interested, I saw the group Tripod the other day on television. Like it sounds, three guys who do music and comedy. I noticed them while in Melbourne when I came upon an ad for their performance of “Dungeons and Dragons: the Opera.” I couldn't go because of my work schedule, but was really close to shelling out $300 for last minute plane fares... Anyway, they may be playing this upcoming Friday and I hope to swap shifts around to head out there. Some of the lyrics from the tv performance I saw follow. Imagine sort of a jazz quintet doing a little bossa nova number, the lyrics to which describe the lead singer's anxiety that as a bookish geeky technophile he likely does not have the skill set to compete under the new conditions created by the collapse of modern society...

“...when the polar icecaps melt and the oceans rise / just like in Waterworld, well / I'm pretty sure I don't have the upper body strength / for all that much rowing.”
“...And even if the post-apocalyptic dystopian wasteland of the future / isn't exactly like Mad Max, /
there'll probably be a healthy amount / of fending off marauders, / and I'm not very good / at
fending off marauders.”

Speaking of marauders, I awoke one morning to find this bad boy trying to die on my oven range:
He is a fine specimen of what I believe to be a “huntsman” spider, one of the rare varieties of Australian flora/fauna that are not imminently deadly to humans.

Interestingly, 10 of the 15 most dangerous snakes in the world live in Australia. Clearly, God does not want us here... :)

For the medicos out there, this is an interesting piece on the over-importance placed on medical care and documentation done for “medico-legal” reasons. I agree with his point, but the problem is as long as there's someone out there who's willing to say this or that to make a buck (which is always), it's going to be a long road to hoe.

http://journals.lww.com/em-news/Fulltext/2009/11001/The_First_Great_Lie.3.aspx

And this snippet is from the article referenced below which itself is extremely moving. But I enjoyed the emphasis this little bit puts on how our job changes our perspectives on things. Most people's jobs don't involve people dying every day, or pregnancy losses or broken relationships (“No, Miss. Regardless of what he told you, trichomonas is not something you 'just get' from having sex. Well, people who have sex with him could 'just get' it I suppose...”). I don't know-- for me personally it's led me to be a bit of a nervous Nellie when it comes to crossing cross-walks or having first aid kits and fire extinguishers in the car or not drinking on nights I'll be driving. But I also hope it's made me appreciate those moments I have with the people in my life, be more straight forward and up front about some things. Certainly this little bit is a reminder to be understanding of the people who've not had the same experiences you've had. The author is finishing describing the passengers/family involved in a collision in which one of the parents has died, and the other was driving intoxicated.

“The son has abdominal pain, which ultimately proves to be from a small bowel perforation. One laparotomy later and he's fine. (The most traumatic event of his life, possibly ever, and it warrants only 2 sentences. The ED has shifted my perspective so far that my own kids won't come to me for their minor [“trivial” to me] injuries. “Dad's only interested if there's an exit wound,” they say. This can't be good for me, my family, my patients.”

JR Suchard. Unhappy Birthday. Annals of Emergency Medicine 54(4). October 2009, Page 627

Finish off with some pictures of the Gorge, where the kayak championships were held recently, and a view of the North Esk River as it comes in to the Central Business District of Launceston.

Nice to have a little appendicitis to finish out the day

2009-10-13T05:34:00.000-07:00

The past few days have been a little rough for a few reasons. I have to admit I'm not a huge fan of being the doctor to people I know or co-workers. It almost never goes well because you know the person, and even when it does it makes the follow-up awkward or difficult. One of the things about DEM is that it is not kind to those who re-think and wonder if they've made mistakes. Because, let's be honest, they probably did. I like the passive voice that makes its way into medical documentation. It seems like an attempt to diffuse responsibility in poor outcomes (ie “the bowel was entered inadvertently during the procedure”) in the process destroys physicians' writing abilities. Eschew the passive, say Strunk and White! So, it is kind of nice when you have a clear-cut case that you manage well-- like an appendicitis-- probably even more so than a tough case that you finally figure out after a lot of work. Poetry in action...

"But then there are the other times, when everything goes perfectly. You don't think. You don't concentrate. Every move unfolds effortlessly. You take the needle. You stick the chest. You feel the needle travel -a distinct glide through the fat, a slight catch in the dense muscle, then the subtle pop through the vein wall - and you're in. At such moments, it is more than easy: it is beautiful." –Atul Gawande from Complications

Recently went down to the local fair (“show” here). I keep telling people Tassie is a little like WV, where I'm from, and the show more or less proved it. It was a pretty typical fair situation, with little portable rides and toss-and-win games. But what was a little extra awesome was the agricultural flavor to it. There was a dog show that breeders came from across a few different states in Tassie. Favorites included the huskies and the Tasmanian “labra-doodles” (hypo-allergenic & non-shedding, apparently; http://www.labradoodle.com.au/ for those interested). Also ideal were the “suspend your child from bungee cords over trampolines,” the wood chopping competitions, the chainsaw sculptures, and the horse jumping (English saddle). Some of the pictures are attached.

Also, with all the rain down here, it had to happen sooner or later....

In other news, recently found out that an Attending and friend from my residency passed away. In the words of another good friend via email, “in case you haven't heard, today the ground shook.” This doc was one of the first EMTs that graduated through the NY training system, then went on to be one of the pillars of the system where I trained. No graduate from our program was untouched by his personality, or failed to tighten up their sign-outs when he was the one coming one-- and that included the grads who had become Attendings! One day I was wearing striped socks and working alongside him. Another Attending approached and asked “Did you see the guy with the shoulder?” His response? “Ask Dr. Seuss over there.” I remember in particular an episode when I was running Fast Track cases by him. A schizophrenic patient was there for unrelated complaints, but he seemed a little disorganized and distracted, though not actively psychotic. Still with vestiges of my undergraduate empathetic self intact, the conversation went something like this: “This guy seems all right, but I don't know-- there's some things that are a little off, he's got some flight of ideas and loosening of associations...” “Christ, the guy's not suicidal or seeing monkeys or anything, send him out!” Thus was born the eponymous “Sensori-neural Simian Criterion for Patient Reliability,” which I've used ever since-- anyone seeing monkeys should probably not be discharged.

So, in honor of Dr. Gary Lombardi, I'll post a few of the thoughts I've had when thinking about the best of my profession. I'm sure Gary would make fun of me for it...

First and foremost, EPs have to be physicians. But their most important contribution or skill, unlike surgeons (surgery) or ophthalmologists (eye exam/Rx) for example, is communication. EPs are resuscitation specialists, certainly, but surgical resusc is also in the purview of surgeons, medical resusc in the realm of internists or intensivists. So, while the spectrum of the initial management of critically ill patients is certainly our emphasis, it is our personal skill at communicating during and about the care of the critically ill, or potentially ill, or not-so-ill-but-think-they-are that sets us apart as “good” doctors or not. As team leaders during a resusc, patient flow managers in a crowded department, providers of potentially critical patient assessments to consultants over the phone, re-assurers to patients being d/c'd, it is our ability to manage information and risk, in situations in which both can be incomplete or unknown that others count on. We are the improvisational obstetricians and the midnight therapists. We are the weekend dermatologists and the after-hours sonographers. We know which pills and why and will make sure you get them. We will get the iv, the pain medication, the tube, the turkey sandwich. We are emergency physicians, and you will do our best to get you our best.

-------

As an addendum, the following anecdote was emailed to a list of graduates of my program by one of the same. It's spot on. --aws

Gary Lombardi was an imposing individual, a bit hot-headed at times, and fiercely protective of his staff. One night, about 2:00AM or 3:00AM in the middle of a very busy shift, a gentleman was acting in a somewhat menacing and combative manner toward the staff. When Dr. Lombardi heard about it the veins on his temples throbbed and he started pacing about urgently. Finally he went over to the cube, threw the curtain open, glared at the gentleman lying there, and shouted, "Do you have a problem? Maybe you want to share that problem with me! What do you say? You want to share that problem with me?" The patient was stunned into silence.

Several minutes later one of the nursing staff tugged at his shirt. "That was the wrong one. It's the guy next to him, the one to the right of him." More pacing. Veins nearly popping now. He went over to the neighboring cube, threw its curtain open, glared at this new gentleman, and shouted, "Do you have a problem? Maybe you want to share that problem with me! What do you say? You want to share that problem with me?" He too was stunned into silence.

Then he leaned back a bit, glanced into the first cube, opened up the curtain about half way, stared at the first gentleman, the one whom he had mistakenly addressed that first time, and said, "And I'm keeping an eye on you too, buddy."

Oh, how I miss the Bronx! And Gary Lombardi. How I miss him!

For medical practitioners only...

2009-09-26T04:23:00.000-07:00

So clearly this is terrible. And obviously me finding this even a little bit funny means I am a terrible person. But, I mean, _come ON_!!!

Emergency response pendant implicated in cases of strangulation, FDA warns.
MedPage Today (9/23, Petrochko) reported, "The Philips Lifeline brand of emergency response pendant may strangle its wearer if it becomes snagged, the FDA cautioned." This holds especially true for "patients who use wheelchairs, walkers, beds with guardrails, or other objects that could entangle the object." Already, "at least six occurrences of serious injury or death have occurred since 1998 when the device's cord became caught on something."

Sigh...

Merrily We Go Along...

2009-09-19T02:47:00.001-07:00

Huh. Not much to tell recently. Working a lot because several of the other Registrars have asked to switch shifts w/ me to take exams and so on. I've been doing a few things, including my first solo Bier's block the other day. Getting the system down at work. To be honest it's still a little odd to me. “Bacteremic dialysis patient? Sure, give him some vanco and I'll follow it up in my office.” I guess you can handle it that way... And mental health services in Tassie are just beyond my understanding. Oh, the view from the hospital toward my house...

Let's see-- what else? The Daily Show is back on the web; every few days I watch an episode of Battlestar Galactica on mail-order DVDs. Finished a book a friend gave me about an emotionally distant physician who can't make a romantic commitment and then contracts TB (yeah, some people are hysterical). Made it to lesson 7 on “Introducing Guitar: Book 1,” which is just beyond “Mary had a little lamb,” though here the tune is called "Merrily We Go Along." The cold/swine flu/pneumonia complex has gone, and I'm now no longer short of breath walking to and from work, so I'll start exercising again (goal: 9:00 min mile for ½ marathon...). The ants have been subdued and a study schedule posted. Plans have been made for my first trip to Melbourne for a medical procedures seminar. Now, time to get a car to see about doing some hiking here in Tassie-- already marked some trails.

Attached are a few pictures of the environment. Many houses have this elaborate trim which is apparently typical of Victorian architecture (and knowing is half the battle). What I love is the one for sale sign that mentions the benefits of "Inner City Living." That's awesome.

All's well so far. There are definitely some frustrations at work, battles that should've been fought, etc. But all in all it's not too bad. Now that I'm feeling a bit better, it's time to do some exploring.

For those who don't know, a little wisdom from Queen and Bowie...

'Cause love's such an old fashioned word

And love dares you to care for

The people on the edge of the night

And love dares you to change our way of

Caring about ourselves

This is our last dance

This is ourselves

Under pressure

Cheers,
--aws

Down time

2009-09-08T04:56:00.000-07:00

So, still under the weather in Launceston. Not so good. Being sick sort takes the wind not only from your lungs, but also from your sails... The good part is that sleeping all day is easier in Lonnie than in NYC. No one's jack-hammering or refurbishing next door, so that's good.

As a result of not feeling all that well, been spending a lot of time on the internet at my favorite sites. For those interested, I've copied the links of a few of my favorite TED talks below. Don't know TED? Seriously, check it out. It's part of why having an internet make sense!

Also, in keeping w/ my first post ("Questions of Travel"), I've copied Robert Service's "The Men That Don't Fit In" below as well.

In terms of work, I guess I really do like the procedures and so on better than the rest. We (finally!) had an intubation the other day and I was so happy! Unfortunately, because the closest required specialist a 2-hour ambu ride away, it may have been simply a prolongation of the inevitable. Still, it kind of balanced out some terrific misses I've been making recently. Sigh. Anyway, hope all's well.

--aws

There's a race of men that don't fit in,

A race that can't stay still;

So they break the hearts of kith and kin,

And they roam the world at will.

They range the field and they rove the flood,

And they climb the mountain's crest;

Theirs is the curse of the gypsy blood,

And they don't know how to rest.

If they just went straight they might go far;

They are strong and brave and true;

But they're always tired of the things that are,

And they want the strange and new.

They say: "Could I find my proper groove,

What a deep mark I would make!"

So they chop and change, and each fresh move

Is only a fresh mistake.

And each forgets, as he strips and runs

With a brilliant, fitful pace,

It's the steady, quiet, plodding ones

Who win in the lifelong race.

And each forgets that his youth has fled,

Forgets that his prime is past,

Till he stands one day, with a hope that's dead,

In the glare of the truth at last.

He has failed, he has failed; he has missed his chance;

He has just done things by half.

Life's been a jolly good joke on him,

And now is the time to laugh.

Ha, ha! He is one of the Legion Lost;

He was never meant to win;

He's a rolling stone, and it's bred in the bone;

He's a man who won't fit in.

http://www.ted.com/talks/ken_robinson_says_schools_kill_creativity.html

http://www.ted.com/talks/dan_gilbert_asks_why_are_we_happy.html

http://www.ted.com/talks/barry_schwartz_on_our_loss_of_wisdom.html

http://www.ted.com/talks/benjamin_zander_on_music_and_passion.html

http://www.ted.com/talks/malcolm_gladwell_on_spaghetti_sauce.html

http://vimeo.com/moogaloop.swf?clip_id=2539741

http://www.glumbert.com/media/everydaynormalguy (ribald lyrics)

http://www.ted.com/talks/vusi_mahlasela_sings_thula_mama.html

http://plagiarist.com/poetry/

and of course http://www.theonion.com/ and http://www.thedailyshow.com/

For those of you interested in the saga of my pants

2009-08-30T08:51:00.001-07:00

Reproduced below. I'm not sure if I feel worse being robbed of a good pair of pants or of the recognition that I am, in fact, hysterical....

Email to North Face's parent company, VFC something or other--

Funny story, actually: I was abroad doing some medical work when on a rare day off I went to the beach. I was wearing my North Face Paramount convertible pants at the time, converted as shorts. Suffice to say, I was mugged. To my dismay, the attackers made off with a few items including, for reasons unclear to me, the right leg of the pants (the left, I guess, they didn't feel they could sell?). Luckily, my phone was kept safe in the front right hip zippered pocket (which can now legititmately be advertised as a theft deterrant) and all ended well. Except that I am currently in the position of having a very nice pair of shorts and one left gaiter. I would obviously much prefer to have the whole thing intact. How would I go about obtaining a replacement R sided leg for a 34-inch inseam Dune beige Paramount convertible pant? I bought the item in the US, but have since moved on from Africa to Australia, so I'm not sure how to provide proof of purchase (it was originally through REI...). I'm not sure if there is even a supply of the pant legs laying about somewhere. I'd love to have the set whole again, though, as they are my favorite pants for work in the Emergency Department as well as play (why I was wearing them at the time of the incident, in fact...). Looking forward to a response. Cheers, --andrew s.

Response(s)--

Hi Bernie, Pls kindly review the case with customer below. thanks! Best Regards,Jessica

Good Evening, Andrew

Thank you for contacting us in regards to your The North Face product.
Unfortunately, we do not supply spare part to replace the missing right foot of the convertible pant.

Below stores are some places where they still stock this convertible pant for purchases:
Paddy Pallin, Anaconda, and The North Face retail store on Pitt street, Sydney.

Hope this info will assist.

Kind Regards
Bernardus

Bernie, turns out, has the title of "After Sales Manager." If nothing else, I feel gratified knowing that responding to my email gave him something to do with his day...

Cheers,

--aws

Oh, PS-- On a separate note, in looking into this, I found out that REI discontinued their line of Granite-style(?) canvass pants. These were, without question, the pants that have made me happiest thus far in my adult life, and my current pair are torn and mildly blood-stained. Shattering.

View of the Launceston dryer/living room combo-- shorts and accessory gaiter; the lonely Granite pants (my study area in background...)

Thousands dead in Launceston...

2009-08-30T01:25:00.000-07:00

Ugh.

I hate taking antibiotics-- they are for the weak. What kind of hypocrite would I be if I told my patients there's no need for antibiotics and then took them at the drop of a hat? Besides, I absolutely believe that the end of humanity will come in the form of wars over water and resistant bacteria (or flu...?). So, it was with a great amount of soul-searching that I finally started a course of macrolides the other day. I'd been sick for almost 16 days (initially just a little swine flu...) and getting worse. Finally I was asked to stop coming to work because I was making the patients feel bad for me. Luckily, I have a few days off to convalesce. To be fair, I guess I would've diagnosed me with sinusitis or pneumonia (no chest xray, but I guess it's pretty bad when you can hear localized rales in yourself?) if I'd come in. The big thing was I was sleeping all day whenever I was off. Eight-to-ten hour shifts and I'm asleep from one to the next! What kind of New York (medical) Resident am I? Getting a little better, and no longer an infectious risk to patients (don't work for a few more days). But unfortunately I haven't felt like doing anything except laying around at home, not accomplishing any thing (car, salary packaging, running/gym...).

And I'm assuming that's when they knew it was time to strike...

Yup, completely frickin' overrun. Don't worry, after making the video I had the stamina to dispose of the bodies, so that's nice. But the live once are still crawling over the computer and in the Gatorade. I only just was feeling like walking down to the store to pick up the traps, which so far do not appear to be all that useful. I've heard it said that by mass (not just number) there are more ants on the planet than people. Well, that's certainly the case in my apartment.

So funny little anecdote: I was working with an Irish-derived locums the other day, and the ICU team comes down to talk to us about the case. We're around the PACS and talking about the case when the Aussie ICU guy says "Whoa, I didn't realize I'd have to bring a translator!" The team started laughing and I didn't get it until I realized that here, the Irish guy and I are the ones with the accents...

For the ED docs reading-- just a tiny example of how we do things differently here. 88 yo woman feeling unwell for a few days. Found to be in new afib, cheap pneumonia on chest XR, and very cheap troponin leak. You guessed it-- ED ROMI, po abx as an outpatient, start metoprolol/aspirin, and check in w/ GP in 2 days to see if afib persists and discuss A/C. WHAT?!?!? I guess that's one way to handle it... The big differences are not ones in medicine, just practice. It's a little like having the rug pulled out from under you. ED is all about disposition and what/where to do/send next. Since that's a little gone for me, I feel like I'm starting residency all over again. I keep getting frustrated that I'm sometimes allowing the fact that I don't know a lot of things (not necessarily about medicine, though sometimes that, but also management here) erode my confidence about things I do know. Common practice on how to handle persistent neck pain in a low risk MVC w/ (-) imaging? Tony once accused me of using “the Shannon Criteria” for clearing a collar. The SC for c-spine pain was basically “I don't buy it.” Here, I've been reluctant to use that criteria, but what do I say when the consult does? I guess it takes the burden of responsibility off of me, but 1) not really (still my patient and I the treating doctor) and 2) it makes the consult think I'm wasting their time. And, due to erosion of confidence, make me think I'm wasting it, too. Sigh-- so that's frustrating.

But, now that breathing is improved and hemoptysis ceased, I'll be on my feet again to run the Burnie 10 km and learn guitar (oh that's right-- you heard me...). There's always a positive. To quote myself from the other night, “Hey, if a patient's going to smack you in the face with a urinal, just be glad it was pre- and not post-.” Medicine is so glamorous and sexy.... Until the next time. --aws

Ever Forward...

2009-08-20T20:35:00.000-07:00

Hi there,

So, interesting few weeks. The Registrar position in Aus EDs is kind of like the Jacobi 4th year “pre-attending” position in that you run your side of the ED and check in with the Attending (here “Consultant” or “Specialist,” sometimes both) whenever there's a problem. The primary difference in Lonnie is that my “side” is the department, and the Consultant is usually at home at night. If considering coming out here, make sure you're scheduled/billed as a Consultant... Here's a picture of my schedule for the month (shift days in yellow)...

While so far no overnights alone for me (5 in a row coming up), I'm headed in that direction. Mostly it's just seeing patients, assisting with difficult cases (and certainly getting assistance), and hearing cases presented by RMOs (Resident Medical Officers) and Interns. The hang ups continue to be the fact that many lab values are in unfamiliar units (a glucose of 7 is ok, apparently) and that I'm reading my own films during the day. I still call folks over every now and again to get a second opinion, but my little follow up book is now a few pages full of films to see if I'm any good at calling pediatric,.. sorry, p_a_ediatric pneumonia. No diphenhydramine in the country-- the anti-histamine of choice is promethazine (phenergan). Also, roxithromycin is the available po macrolide (no resp. quinolones like moxi, which is odd. I'll have to double check that). Ticarcillin as opposed to piperacillin, and no etomidate. I'm using a lot of propofol for simple reductions and so on. Speaking of which, doing quite a bit more from a “procedure” standpoint than I'm used to doing. The other day during a “Fast Track” shift, I saw 2 thumb dislocations (one was a morphine/fentanyl/midazolam after nitrous and local lignocaine (what I call lidocaine) flail), one tibial fracture, one distal fibula frx I had to _cast_ and one acute kidney rejection, to name a few. It's been interesting. The use of Bier's blocks is also a new one to me, so I'm still working that out. I've done three cardioversions (one w/ amio) and one Peds arrest. No bedside sonogram, and to get one after hours and weekends we have to call in the radiographer and the radiologist. There's a lot of “can this wait till morning?” and “Have the r/o ectopic (granted, low prob, but that's why we get the tests) return tomorrow for her sono” which I'm not as familiar with. Also, had my first "swine flu" pneumonia/ARDS case the other day. So far she's doing well (we've had ~ 3 inpatient deaths so far). An additional flu clinic has been set up for people w/ "flu-like" symptoms (the commonly heard rejoinder to many of these complaints is "stop your s-whining!" [sound it out...]).

So I'm glad I picked this place in terms of the pathology not disappointing. It's busy enough to challenge some management issues, there's no buffer of "senior residents" to take away onerous procedures, I'm doing almost all my own psych and Ortho stuff (yay latter, boo former) and arranging a lot of outpatient cardiac work ups, which I'm trying to get comfortable with. No real trauma so far (rare year in which penetrating trauma cases reach double digits...) but for the most part that's fine-- those cases are really only "find the hole and plug it" anyway.

To a person so far all the patients, even the “problem” patients, have been very polite once you get past it. I actually had a guy thank me for convincing him not to sign out AMA and get evaluated. “Thank you.” Who knew?

Obviously I still have a lot to figure out about this place and Medicine in general. Everyday I have 2 or 3 things I absolutely need to get home and read about (few for several on that count). So that's cool. I'm still a little hesitant about stuff I shouldn't be (ie stuff that two months ago I was not having difficulty managing), and my conversations with others are a little tentative. Much like a wobbly, new-born colt trying to find his legs, I'd say. But I'm getting used to it. Having a few instincts confirmed as I go along, which is nice. So far, I think things look like they'll be fine, and I enjoy walking to work in the morning.

Still finding places to run. The area is like the bastard child of Parkersburg and Vienna crammed together, w/ the topography of North Hills, so even hour long runs are gruesome right now (hey, just spent 2 months in Africa w/o any exercise!) You can see my street in the pics here, w/ the hospital in the upper right distance (~ 15 min) of one.

Swung by the gym the other day and everyone is in better shape than me, so that's just great. Working on that as well. In fact, my list of Tas goals (posted on the fridge) include a 9:30 min mile for 1/2 marathon distance, getting in shape, improving posture, finishing some review material & Board Prep, and normalizing my TSH. We'll see about that last!

Thanks for all the emails and Skyp-ing. Look forward to those every day!

Until the next,

a few weeks in...

2009-08-09T05:22:00.000-07:00

It's cold here-- about 4 C in the am and 14 at a high. But it is also their depth of winter, so it's not going to get any colder. I've got the power and hot water set up finally, but the heating is still not working. Got a bank account, cell phone, internet (finally) and will start working on bathmats, window insulation, drivers license, etc. (right now driving without, which is interesting on the left...).Had a meeting with the ED director yesterday am (I'm writing this at my 09:00 on Fri am) and saw some of the ED. No one wears scrubs- the nurses' uniforms are like school uniforms (slacks, button shirts, sweaters/vests) and the docs wear their normal clothes. I'm thinking I'll have to break in the whole scrub top thing...

Tasmania is about the size of Scotland or Sri Lanka, ½ the size of Lake Superior, a bit smaller than Ireland, and has a population of around 1 million people. It's about 5-10 years behind the times, depending on who you ask. Launceston or “Lonnie” is the second-largest city in Tas, just behind the capital to the south, Hobart. There's an interesting history there, if you're inclinde to read up on it. Suffice to say that there continues to be a bit of a rivalry btwn the two centers. Lonnie has an immediate “greater” population of about 100K, which is less than Hobart. However, the north of Tasmania, an area served by the Launceston General Hospital, is home to the bulk of the population, spread out as it is, so the hospital can get a bit busy. With the flu season, confirmed to be at least partially H1N1, the past and current months are shaping up to be the busiest in the LGH ED (about 122 visits in a day, up from a prior max of 102).

One of the biggest set backs is that The Daily Show full episodes are not available in Tassie/Lonnie via the wireless... The countryside is quite amazing. The climate is temperate and forests still take up most of the island, so there's an opportunity for some “bushwalking” or hiking/camping. So far I'm walking pretty much everywhere in the city, as things are that close. Between Hobart, the capital, and Lonnie is mostly grazing (yes, sheep) country. In the city, the air is cold, and scented with woodsmoke, still a major source of heating for many in the city. The overall impression is that of Scout camp-- walking outside in the morning surrounded by the crisp fog and hint of woodsmoke, it's easy to recall mornings in Camp Katoga headed up to the Trading Post. The other memory this place evokes in me is that of the northern desert/forest of Argentina (I forget what the area was called, but it was north of my friend Augustina's home in Tucuman...) They say that smell is the sense most tied to memory... Finally, the pastoral/rural picturesque architecture and overcast skies makes me think of old BBC-America shows that my mother watched on Saturday mornings-- usually involving a “pepper-pot” old English lady solving murders.

The medicine is interesting. Just little “Royale with cheese” differences. Brand names for drugs are obviously all different. The formulary is a little different as well (roxithromycin is the macrolide of choice), and practice is very different. For example, I don't think I've ever sent home an 86 yo with chest pain after two (-) sets in the States. And I've certainly never done a Bier block on a 79 yo for her Colles frx! But, there you have it. So far I've had a woman come in in rapid afib, degenerating to sick-sinus with long episodes of asystole (you read that correctly) that increased in symptomatology and length, and a woman who showed up in shock with cyanosis, mottling, cold extermities, and perfectly intact mental status and vital signs. Still not sure about that one... apparently no brown snakes in Tassie (60% of the mainland's fatalities) and no useful history from her or her family...

People are very nice so far. By now writing the blog after my second week here (1st working week), I've met a few folks and have gotten the place and the other stuff pretty well set up, but not yet out about town very much. I've put up a clothesline inside the living room, which makes me look pretty classy... There's a 10 k race (how far is that, anyway?) in October I thinking about dying on, and apparently a mixed-martial arts club in town. We'll see... :)

I've included an email I wrote to a friend of mine asking about my ED work experience over here as it may give another POV.

Hey ---,
I'm trying to continue blogging what's up here in Tassie, so if that'll be helpful it'll be at www.doctoroffortune.blogspot.com
To try to answer your question, though, it's been good so far. I've been working for about a week as a Registrar, which is basically equivalent to a Fellow. I was told this is because I'm not Board Certified, but I'm not sure about all that. The Consultant/Specialists (“Attendings”) in Emerg where I am, and in most places it sounds like, tend to not overnight in the hospitals. They get called in for major things. So far, haven't been on overnight by myself, so not sure how that will work. The drugs are a little different, the abbreviations very much so (GORD for gastro-oesophageal reflux), and the follow-up practices different as well. The other day I was corrected for ordering an afterhours sono on a Pt to r/o ectopic in a preg vag bleeder. It was felt it could wait until morning, as she was hemodynamically stable and not peritoneal. They would've had to call in the consultant radiologist and apparently that's not easily done (“that HCT can wait until the morning-- we'll just observe the intox 82 yo potential head trauma until then...”). So that's taking some getting used to. Obviously no separate Peds ED...

I guess the bigger city trauma centers are more like what we're used to, but I don't imagine they're in much need for locums. Lifestyle is fine, though taking some getting used to. The environment and social scene where I am is a bit like where I grew up, so it's something I understand if not entirely enjoy-- things close down pretty early. But it works for me for now, hanging out, reading, getting back into some extra-curriculars I'd let go. Pleasant enough co-workers, though I do get the feeling that people say “no worries” when actually there's room for improvement if they would just tell me where!

So, hope that's helpful. Moving overseas was expensive and kind of a pain in terms of getting banks, post, internet, new phone, buying new electronics done. But the whole thing's been interesting, which is all I'd hoped for. Let me know if you have other specific questions, and I'll be happy to try to point you in the right direction...

On to Tasmania

2009-07-22T10:09:00.000-07:00

Hey there. I'm getting back to the blog-- sorry if it's been a while. I got back in the States without a problem on July 5th. Spent about a week packing up the rest of my stuff, moved it down to storage at my lil' bro's (thanks Jon/Kelly!), and went to FL to hang with the 'rents. Now, headed out to Tasmania. I'll be spending a year there at Launceston General Hospital as a "Senior Registrar," which is like a Senior Resident/Fellow equivalent position in the US. Because I'm not Board Certified, they wouldn't accept me as a "Consultant" (ie Attending/Specialist). It's kind of a silly quirk, especially considering I just learned that an affiliate of my old program is now advertising a position that pays two-and-a-half times what I'll be making in Australia!! Whatever-- it's the experience. That's what I'm telling my creditors...

So, in any event, feel free to stop by if you're visiting Austral-Asia any time in the next year... I've uploaded a few pictures of my theoretical apartment, which is just a few kilos walk (Yay metric system!) from the hospital. As a result of the cost and time lost in heading back and forth between the States and Aus, I think I'll postpone taking the Board Exam for a year. Apparently I can do this and still not have to start counting my CME activities for certification. We'll see. It'll be nice to have that money and vacation time to hang out in New Zealand, Japan, Thailand-- whereever-- if I can have it. It probably also makes sense in terms of not really having studied for the stupid thing...

Anyway, so let me know if you have suggestions about what needs to be seen/done in Aus, where I need to head to next, etc. I hope to keep updating the blog, but if I don't it's either because my life has gotten way too interesting or waaaay to boring... Cheers,

--aws

Monrovia 5-0, or how I became a Liberian Crime Statistic

2009-07-22T09:18:00.000-07:00

I thought I'd include the above pictures in this, my last entry about Liberia. The left is a jello mold that was discovered by Rachel and myself while looking for a pan to cook lentils in. We found it, and she said, "Why would they make a jello mold of President Tolbert?" It is of course Harry Potter, but I understand the mistake, given the uncanny resemblance. So, Harry is pictured with three leaders of Liberia for comparison (I'd think Doe before I thought Tolbert...) for Rachel's benefit.

The right picture is of our competition-- the medicine man (or manor?) is apparently a big herbalist who can cure more sicknes ses. I'm not one to argue. But it does highlight the reliance on "country medicine"-- which is herbs, etc. that are eaten or applied to improve illness prior to coming to the JFK ("just for killing") hospital. So, by the time they get there, the question is raised as to whether the liver damage is from the original illness or the country medicine used to cure it...?

So anyway. The last 48 hours in-country were... interesting.

The last week there I had been asked to review some material for the Ministry of Health's supervisor training. It was actually a bit of a bigger project than I'd realized, but was able to complete some changes to their training manual in time for a brief talk on emergency care that Thursday morning (I mention this in the video of the medical side in the ER during my discussion with Deborah). It was suggested after that morning that I go do something fun in Monrovia, given that I'd spent a lot of time in the hospital while I was there. So I thought I'd go see one of the beaches that I'd been told should be relatively safe.
You see, some of the beaches in Monrovia, especially around the hospital, aren't all that secure and are known for their criminal activity. Kind of like alleys in the States, you really don't have any business being there, especially at night, especially alone. (Of course some private beaches that are patrolled are fine).
But, let's face it, I'd gotten kind of bored and was looking for something to do besides work. So, in the early afternoon of my penultimate day, I headed out to one of the beaches that was recommended as relatively safe. I wandered around the beach for a bit and was heading back when I was approached by a group of guys. There were about 6-8 of them, and they initially asked me a few questions in order to surround me. They started yelling and grabbing my arms, while two of them waved around broken bottles and one a pair of kitchen scissors (you know, the kind with the orange handles that your mom has laying around somewhere). They gave me a few cuts to make sure I wasn't going to try anything ("uhm, there are 7 of you-- I think you win today...") and took my wallet/money and my digital camera. Through the course of the encounter, it became pretty clear these guys weren't really all that dangerous, so I followed them a little bit and asked them to drop my wallet and id, which they did. It was kind of like in the Big Leibowski-- "Are these men going to hurt us, Walter?" "No, Donnie; these men are cowards."
After all that I called for the driver from the hospital to come get me. (My phone was in one of those "change" pockets that are sometimes in jeans or "travel pants" in the hip pockets..) So Mr. Moore, one of the drivers from the hospital, and one of the hospital's plain-clothes security guys (Frances I'm pretty sure) came. We eventually located the guys who took my money (they were still in the area apparently playing craps with a bunch of US bills. Yeah, not all that subtle).

We drove back to the police station to pick some of them up and took them back to the beach. I was in this way part of my very first Liberian stake-out. Which quickly became my very first Liberian foot-chase, as the guys' lookout recognized one of the plain-clothes cops and sounded the alarm. Everyone scattered and myself and the driver in the van went around to try to cut off escape routes while the police and hospital security guys (as well as Mr. Moore, who-- as those of you who've met him might have guessed-- loved every minute of it) chased them through the little alleyways.
Eventually we rounded up about 5 guys (the 6-7 on the beach became 12 or so when we found them again) and took them to the main police station. I identified the ones I could and filled out a statement. During this, of course, they were in the room, tied together with the tails of their t-shirts. "White Man-- look at my face! It wasn't me!"
Got back to the hospital, and fortunately since I know a good ER doc got taken care of. The next day, I was told my camera had been found. Apparently there are only a few people in that area of Monrovia who can fence a digital camera, so both were followed and the one arrested. Obviously this effort wouldn't have been put into things if I weren't part of the hospital where the administration is so connected to the President, so I'm grateful for that. So in any event I survived the experience and did a little more work that last morning before packing out. An interesting aside, when I got to Brussels I checked the photos on my camera. They include the following picture of the guys who stole the camera from me. I guess they took a few shots of themselves for posterity... ;)

Video diary overload!

2009-07-05T12:51:00.000-07:00

Hi there! Got the ol' camera back so thought I'd post a few of my close-to-last-day videos!
This first should be a quick look at the breezeway/classroom where we'd talk some to the Nurses in the morning. It's also a hall of the hospital that we'd use to walk to and from the main patient care area of the hospital and the dormitory.

This next one is a quick trip through the Trauma side of the ER. Nothing too exciting going on.

This is a quick look at the medical side, and a discussion with Deborah, one of the Head RNs

Here is a video of a trip up to the floors

Finally, this video shows a quick look at the medical wards and ICU, w/ Drs Toomey and Borbor

I tried to whip-pan (yeah, that's right-- it's an industry term) so that no one could be identified... Skills of an artist, or cinematographer. Trogdor. :)

Hysteria, Lazarus, and No mo' Flomos -- medical stuff

2009-07-05T12:14:00.000-07:00

I had thought this text had uploaded, but I guess not... hmmm.

So some of the more interesting stories I'll try to list here.

One thing I was impressed by was the number of “hysterical reactions” or pseudoseizures that came in to the ER. I suppose I shouldn't be. I mean, I'm hesitant to diagnose depression in the Bronx (“Hey man, it's not your attitude/outlook or brain chemistry-- I agree with you, your life sucks.”) where at least you're not getting dysentery or malaria 3-4 times a year and your poverty does not preclude getting a ride thanks to public transportation. So why shouldn't there be a relatively high burden of psychiatric disease in a recently post-conflict poverty stricken nation? About once a day a girl/young woman would come in, not speaking, or unconscious, or staring. They'd usually get a dose of quinine before I was able to resuscitate them with an advanced ER procedure known as a “sternal rub.” (yes, think of it like a noogie-- except in the center of the chest. Really annoying and likely to cause you to come out of your psychologically induced coma). I can't argue with the quinine, though. Top diagnoses for acting screwy, depending on age, were cerebral malaria, HIV, hypertensive encephalopathy, and hypoglycemia.

So, they'll tell you in Liberia that the language is English. Not quite. Most people do speak a kind of “pigeon” English. I think it's equivalent to the way some Dominicans speak Spanish. Letters/sounds left off here or there, different idioms, etc. So it's not always easy. We actually started on a phrase book for the people after us. “Tryin' small small” means “getting somewhat better.” “Running stomach” means “diarrhea.” “O'Ga!” means “My Goodness, this is really painful.” And, interestingly, “Fell off” means “passed out” or “became unresponsive” or “felt weak.” (“Fell out” is sometimes used in the Bronx-- any others people know about?). So, when I came across this young man who “fell off” and has been “weak” since, I initially didn't think much of it. Get a malaria smear, give fluids, dextrose, etc. However, sometimes, “fell off” means something much more literal and in keeping with how I use the phrase. Sometimes, “fell off” means “this guy fell off the roof he was working on, landed on his head, and hasn't really been able to move his arms or legs since, so we brought him here in a wheelbarrow with his neck hanging over the back of it.” Overcoming this linguistic barrier I feel, was, in retrospect, key to his eventual care and disposition...
I decided to start calling him Lazarus. After ~ 6 weeks on the floors, getting intermittent physical therapy, he's able to stand on his own again (Partial cord syndromes, his diagnosis, have a good prognosis a few months out). He was so happy to see me when I went up on the wards that he got up and sat down several times to show me. He may not be playing soccer again anytime soon, but he's walking, so things could've been worse.

I always enjoyed Michael Jackson as much as the next person (Rock with You, Don't Stop Till You Get Enough, and Billie Jean are overplayed, The Way You Make Me Feel and Smooth Criminal underplayed), but certainly didn't get all bent out of shape when he died. (It was ridiculous, BBC and Al Jazeera- London desk were covering news, while “the Situation Room” was on Michael Jackson all-day all the time for what seemed like a week. Yay America and your declining world relevance!) Liberia, like most of the world, however, felt differently. There were two days there when everyone felt a little sadder, was a little quieter (not easy, in Liberia) in mourning for the King of Pop. In particular, one young man came in to the ER the day after the announcement. Seems that upon hearing of the death of the King, he let out his best “Dangerous”-era “O!/Hoh!” and dislocated his jaw. So, after I finished laughing at him, myself and the medical student grabbed and yanked. Not so successful, and well past the end of my shift, so I gave him some muscle relaxants and figured I'd try again in the am. Apparently, he'd relocated during the night and was able to be discharged by the overnight team. I guess it wasn't a bad dislocation. Not a Bad, Bad, really really Bad, one anyway.

I feel I should break up the text here with a picture I only got at the end of my stay, as it was from the OR. Often surgery is the diagnostic modality of choice here, so there is a certain significance to claiming that an abdomen is "surgical," especially for kids. In any event, they had thought this tyke had a typhoid fever perforation, but on opening the peritoneum, turns out it wasn't the case. Here you can see the surgeon taking out the worms (ascaris) from the small hole in the small intestine before repairing the hole and putting the kid on antibiotics and anti-helminths. Enjoy!

Early on in my stay, I was given the Liberian name “Flomo.” For almost 5 weeks, I tried to get people to tell me why I was given this name. Louie was called something that apparently means “owner of a town,” and as far as I could tell, both Marcia and Rachel were called “Kebbe,” which is a name from Lofa county. Lofa is one of the biggest counties and quite a few people who moved to monrovia after/during the war for protection are from there. It is common knowledge among hospital staff and I assume Liberians in general that Lofa women have the biggest backsides. I'm not sure how this is appropriate, because if either Marcia or Rachel attempted to tie their children to their backs with their Lappas, the way most Liberian women do, their kids would slide off to the ground. Sorry if I'm telling you something about yourselves that you didn't know Drs., but it's true.
In any event, I too, it was decided, needed a name indicating I was from Lofa County. (and yes, the children would slide off my skinny Irish ass as well, though I don't think that entered into the decision making process). So, I was called “Flomo.” The name had shown up a few times as either a first or a family name, so I was a little familiar with it, even though I was told it didn't have a “meaning” per se. But, over the course of my time there, I noticed something-- Flomos died. Like, a lot. Chances are, if you were named Flomo (first or last) and you made it to the JFK ER, you were not getting out. I mentioned this a few times to the nurses, and thought maybe a different name would be better. They all loved it. To the point where they would say in the morning “Hey, it's Dr. Flomo! Do you think he'll leave today?” One time I felt particularly uncomfortable when a nurse in triage (full of people, mind you, any number of whom could've been named “Flomo” to varying degrees), explained to another nurse that “Dr Shannon doesn't like to be called Flomo because Flomos always die.” Ha ha-- not so funny if you are overhearing this conversation and just registered your uncle, Flomo Flomo from Lofa county. And if you were Flomo and triaged to bed 19, just frickin' forget about it. Bed 19 was not kind to Flomos. Or to anyone else, for that matter. Come to think of it, Beds 19, 10, 8, 6 and 5 were just not good beds to be in. So, I instituted a “No Mo' Flomo” policy in the ER, which the nurses also loved. I would not be called “Flomo” on days I wasn't feeling well, and all Flomos under my care had to have rock-stable vital signs before I would see them-- even if this meant lying to me.

--aws

Radio Silence- pictures of ME!

2009-07-04T00:10:00.000-07:00

I apologize for being negligent on the blogging front. TRUST me, though. Some interesting things have been happening, and I've had an action packed last week and few days. Suffice to say, I hope the scar lasts so I can pretend I'm a bad-ass... I'll post a few things in the next few days. BUT, I'm on my way home to from Brussels now, and will be back in contact shortly. A few teasers... Myself and Dr. Fowler enjoying the official hospital Jollof (or Jollah-- I saw it spelled a few different ways) rice in the cafeteria, and Joseph, Dr. Borbor and the ward nurses checking out a sonogram on one of our ICU patients. Hmmm, with the Brussels internet, maybe I'll risk posting a video before the plane leaves... Oh, no, can't-- long story as to why not, involving the Liberian National Police, my undercover operation, and the aforementioned scar. Oh, apparently the flight is oversold and they're looking for people to stay in Brussels tonight... This is God testing me after the events of the past 3 days-- Lord, no worries. I have learned that discretion is the better part of valor...
--andrew

The Death of Peanut

2009-06-29T14:09:00.000-07:00

I don't know when I started referring to Preemies as "Peanut." It might have been from an Attending at Hopkins, but I think it was probably from Dr. Atherly-John at Jacobi. In any event, I've added it to my medical lexicon ("munchkin" refers to infant-post infant-early toddler, and "rugrat" refers to anything that's likely to pull things off the dinner table up through early adolescent) to described the half-baked "petri-dishes with asthma" that get me sick every Peds ED rotation. Yeah, I'll be a great father.

Anyway, Peanut came in at about week 2 of life. That said, he was born at about 36 weeks, so he really was just out of the gate. He was premature due to oligohydramnios and placental insufficiency caused by maternal malaria. Apparently on pathologic examination the placenta is just full of the little parasites (the which, my marine biologist brother tells me, are more closely related to algae than any other organism...) such that there's actually an increased echotexture on sonogram. Anyway, like any maternal infection without prenatal care, it's not good for baby. So peanut was born 2 weeks ago, and was brought in with a fever to 102 F. He was ridiculously fragile, and had the build of one of the anole lizards we kept as pets when I was a kid and the skin of your 92 year old grandmother. But for all that, looked great. Dehydrated? Sure, a little. But pooping, peeing, breathing, eating. How much more of a repertoire are you asking of this little guy? His breathing was fast, but symmetric and clear, and his airway was fine. The belly was beautiful, all things considered. So I started Peanut on fluids, anti-malarials, antibiotics, and for the love of God keep breastfeeding. So, Peanut was chillin', decked out is his over-sized onesie and toboggan hat (these little puppies must come standard issue from baby/mother boot camp because they are everywhere).
Interesting aside. There was one patient that I was flipping through the Nurses' notes on and came across an awesome phrase. She wrote that “the patient was observed chilling in bed.” Awesome. I immediately had images of a large pair of over-sized sunglasses that make people like Lindsay Lohan look like an owl, a reclining beach chair and an umbrella drink. I surmised that if this were true, we could probably discharge the patient. Turns out, of course, the nurse was referring to the patient as having rigors or “chills,” which can sometimes happen as a result of fever or bacterial infection. Not as much of a vacation scene, but the image was certainly one of those moments that gets you through the day.
In any event, in spite of all the deck stacking against him, Peanut was doing fine. He'd had no fever in 2 days, was eating and so on, and continued to look like a peanut-sized rose. Day three in the late morning I was called over to the crib by the med student, because the mother had gotten her attention. There was Peanut, all wrapped up and fragile and tough and cute. And not breathing. And pulseless. When a kid goes down, chances are it's respiratory in nature. They haven't had a lifetime to abuse their hearts and their respiratory (and neuro-respiratory!) status is relatively tenuous, so it's think lungs before you think heart w/ them (though there has been some recent evidence disputing that).
In a room full of sick kids and their mothers, with a child who never really had a chance and his mother. I gave him two quick breaths, and sent the student for a bag and his chart. The morning note from the other MD was dated about an hour and a half earlier. Things had been fine: Afebrile, good response to interventions, feeding and voiding well. Continue current management. I pulled the slack of the swaddled blanket over Peanut's onesie, toboggan and face, and I told his mother that her child was dead. She borrowed my cell phone to call the family. I wrote the note, with time of death about 13:10. It is common practice to put tetracycline eye ointment in a neonate's eyes after delivery, to treat any potential infections acquired during transit through the birth canal. I thought about how it was entirely possible that since that time, the little boy's eyes had never been opened except when I looked into them when I first met him, and then again on the day he died. There were more patients to see.

video diary 2

2009-06-21T08:42:00.000-07:00

So hopefully the above video works out. I'll try to do more of them as I can.

Nothing earth-shattering to report. Things still go. A little more time outside of the hospital than I've become used to because our program director, an ER doc working out of CT and a relation to the President, came into town and now we have access to a car pretty readily. So that's been interesting. Worked on the medical department's grand round presentation for Monday (tomorrow) which is a case of hypokalemic periodic paralysis. They couldn't get a K level, but the EKG looked like hypokalemia, so that's how they made their diagnosis.
Here, surrounded by people who have the books but not the scanners, I realize that I should've done a lot more reading in residency. I guess I knew my program would be more "running around doing" than "sitting around thinking," and that's why I went with it, but dang. I must've become mentally challenged at some point because I can't remember a single I supposedly learned. What have I been doing these past 4 years?!?!? Maybe studying for the Boards will help solidify some of that...
The medical students are looking for me to teach them and I'm a bit at a loss. I want to spend my nights reading the Rosen's that's been left in the dormitory common room...

Take care!

--aws

coughing up a diagnosis... (medical stuff)

2009-06-21T08:28:00.000-07:00

ok, so this was awesome. I walk into the ER yesterday and start discharging Pts like a fiend (filled up immediately after, and today was even worse chaos). There was one lady who was seen by the O/N doc, a semi-private who sometimes takes call to fill gaps (though one day didn't show up at all!) and dx'd w/ enteric fever/typhoid. I go in to see the lady, stacked Monte style three abreast in one little room. She looks ok for an elderly Liberian woman and says she feels ok to go (not as useful an indicator of being ready to go as you might think...). Anyway, I write up her d/c stuff for standard abdominal pain meds, including anti-helminthics. I realize I forgot to do her abdominal exam, (it wasn't documented from the prior doc either) so I go back in and have her lie down and start pushing on her belly. I'm starting to think "you know, she's a little distended..." when all of a sudden she complains of "water" in her chest, and looks like she's about to vomit. We sit her up and give her a pan just in time to catch this diagnosis:

Round worm (ascaris) is an intestinal helminth/parasite. Her burden of disease must've been pretty extensive-- they live in the intestine, so by the time they're coming out your mouth you have quite a collection going on. So yeah, totally awesome.

--aws

more medical stuff

2009-06-16T14:35:00.000-07:00

A few more medical pictures.

Below is a kid s/p Road Traffic Accident (RTA) with a broken L humerus and dislocated elbow. These were overlooked initially, though in the rush to pay attention to his R shoulder laceration that bisected the deltoid and exposed the rotator cuff, but left the joint capsule intact. Because he couldn't afford surgery and was above 5 yo (for free/reduced cost care), we closed him in the ED after an attempt to reconnect segments of his delt. Days later, he's adducting that arm ok, but a tissue defect remains...

Interesting sono here-- this woman had so much ascites that her pelvic organs (uterus, tubes & ovaries) are outlined beautifully floating in the fluid in her stomach (this is normally not the case!). Just had to take a picture of the sono screen.

Hmmm, oh, here are a couple TB cases. The first is a woman coughing up blood and with R chest pain for a while. There's a small density with some central clearing on the upper right close to the lung periphery. Not much else causes a "cavitary lesion." There's also a guy who was cachectic (ie skeletal) and had had cough for several months. His nodular infiltrate is pretty good for advanced TB, and he was begun on meds.

So a few others will wait. Got called out of conference to do a pericardial centesis on the floor (so, how many of these have you done, Doctor?) and continue to see a lot of "end-stage NOS" A woman came in the other day with complaints of no urine output for a week and on sono had the worst bilateral obstructing hydronephrosis I'd ever seen (retroperitoneal fibrosis due to TB?), and another woman presented with hepatosplenomegaly and enormous kidneys (medical renal disease --> HIV nephropathy? HELP!!!). So it's been interesting. But, for the most part the kids bounce back, so that's good. Oh, one last bit. Remember, when you're working in an international setting, even when the patients do bring in their medicines, it's not always helpful...

All good things,
--aws

It's nice to be wanted...

2009-06-14T07:26:00.000-07:00

Some pictures: To the left, the picture of club beer and Louis' feet. Taken during a Robertsport excursion (the location of "Sliding Liberia"). The likely apocryphal story is that during the 13-20 or so years of intermittent fighting the Club Beer brewery was the only institution in the country in continual operation. It's nice to find something people can agree on...

The center pic is one of the beach view from the tent we stayed in at Nana's Lodge. In the distance under the tree you can just make out one of the young Liberian fisherman checking out the ocean. Wonderful composition, Andrew. Why yes, it is. Thanks for noticing.

And finally, our Pepsi tends to be from Dubai, and our Coke from Lebanon (pictured) or Algiers...

I'll have to get a picture of it for you, Lee, but if you feel like something is amiss during your time in Liberia, perhaps it's because your chocolate biscuits are being manufactured by... CYLONS!! Yup, the Ceylon distributing company of Singapore-- biscuits so human-like you won't be able to tell the difference.

So I was taken out to my first Liberian night club last night. The other one was closed for renovations, so we went out to Deja vu, which is a music pounding neon-lit bar/dance floor. It was about a $5 cover (which is not a little here) and there was an issue with paying with one of the old 10s. Apparently now they only take “big-head money” (the new bills). I'm assuming this is because they weren't as accustomed to $US prior to the change up? More likely the “new” (it's been what, 10 years?) bills are the standard and the old ones are different, and therefore unacceptable in some ill-defined way. Ie if you're not sure, someone who is doing something different is probably trying to “juke” you in some way...

Anyway, it was nice on the inside-- comparable to a standard American club. Not smoky, not crowded, and packed with provocatively dressed Liberians. A little background-- we'd just gone out to a little bar after a late dinner & were listening to some live music. One of the nurses, myself, one of the other HEARTT docs, & a Liberian friend. Interestingly, we met a guy there who was with the UN Security Sector Reform mission. I think he put it well-- people are nice, but they're still in survival mode. Everything is about what can someone else do for them. In particular, white males. And that's understandable, given recent history. It's all about the hustle. Apparently the “Bath and Leisure Center,” a Chinese-run establishment (and yes, it's what it sounds like) and other NGO-based comfort/service industries just follow the UN wherever it goes. So there's this interesting dynamic between aid groups and this aid and aid-worker based economy in these post-conflict areas. I'm told an interesting book on this kind of thing written by some former Doctors without Borders folks (I think) is titled “Emergency Sex.”

So, we decided to go to this after club. And the nurse decided to go home. Leaving me, Rachel and Ben, a Liberian telecom business man. And it was like I was thrown to the wolves. Wolves who wanted money. About 30 seconds after getting a drink and separating from my friends by ~ 10 yards, I was approached by a girl who started talking to me. She said her name and had a pretty well-thought out/detailed back-story. Living in Europe, back visiting for a few days, first time at the bar, etc... It was kind of an interesting sociological experience.

Throughout the evening, I heard a lot of plausible if improbable back-stories from girls with names of questionable veracity such as “Venus” and “Promise” (though, to be fair, two patients of mine in the ED over the past few weeks have been named “Baby-girl”). Apparently it's pretty common practice for girls, even those with regular jobs or students, to kind of look for foreigners to attach themselves to while they're in-country in the hopes of money for school, some meals/drinks, etc. You get what you can and you don't know what that is until you try, I guess. I think it's an offshoot of the same kind of situation as the “Older-white-male-former-aide-worker/ex-pat-and-the-younger-local-girl” phenomenon that skeeves me out a bit. My brother Lee said it's the same in Thailand. Everything and everyone is for sale, and there are no moral implications to buying a stick of gum, a bottle of water, a mosquito net, a shoe-shine or a “something else shine.”

On the one hand, hey, everybody gets something out of that situation. People are operating at different levels in Maslow's “Hierarchy of Needs,” and will do what they can to satisfy the impulses for food, shelter, security, sex, etc. (I think self-actualization is the last one on the list-- anyone get there yet? Please write back and tell us what it's like). And a girl I dated once worked as an exotic dancer to get through school, so I've heard about this from a few view points. Exploitation and opportunity. The broader implication for women in society versus the very real implications of not having enough to eat. The physician's responsibility to do the most/best for an individual patient versus the public health perspective of what is or is not cost-prohibitive to a society's health care system... There's a well-known tendency is psychology of people to have different interpretations of a given situation depending on which role they play in it. "The Fundamental Attributional Error" is the tendency to assign to someone in a situation ("disorganized patient presentation and late for rounds) personal attributes as the reason for their behavior ("he's lazy and unprepared"), though when in the same situation themselves to assign outside agents ("traffic, alarm clock broke, the patient can't give a good history," etc) as primary.

So certainly it's difficult to judge people for doing what they can to make the best of their situation. But there is a certain amount to be said for recognizing the enormous informal power differential between the two people in that ex-pat/local relationship and acting accordingly, and I think that though morality may be relative, you should stick with the set of morals you've picked for yourself and go with it.

For those interested in the particulars rather than the abstracts of that evening, let's just say that I did not avail myself of the opportunity to support a local business project or pay any school fees or stimulate the informal business sector. Nor did I take advantage of a potential opportunity to reinforce on a micro level the over-arching behavioral change model messages regarding safe-sex practices. The neo-liberal guilt I am currently suffering as a result of these failings is, I assure you, more than punishment enough.

Though there was one very entertaining cat-fight-- “That girl's a prostitute!” “Who are you to say I am a prostitute? You are a prostitute!” (scuffle, scuffle; Security Guard bodily picking up and carrying one small Liberian girl to the exit) "Um, I guess I'll have another Jameson & soda...?"

till the next time...

On meeting the President and ED VIPs

2009-06-14T06:38:00.000-07:00

I'm not a huge fan of the concept of VIPs in the ED. As far as I'm concerned, the only categorization should be based on severity/stability (“sick” vs. “not sick”). Perhaps this makes me too much of a socialist? But it's also true that any time as a health professional you're asked to see someone as a favor, you run a significant risk of the interpersonal/social situation informing and overwhelming the clinical aspects. One will almost always end up doing too much or two little when emotionally involved. And besides, I think the motto of the Osler firms (the medical service at Hopkins) was “aequinamitas,” or “equanimity” pretty much sums it up. It's the characteristic of a physician to maintain composure and remain un-impassioned or prejudiced no matter what or whom came to him/her. I'm glad you're powerful/influential, but if you're not sick or in pain you have to wait. One of the errors providers make is to think that patients or their families are being “annoying” when they keep pestering you about their case. It's like the survival mode-- if you don't speak up, you could be forgotten. If you don't push yourself to the front of the line, someone else will and you'll get left behind. It's understandable, especially when people don't understand what part of their care is important and what part isn't (Ok, guilty on this one-- I really don't care that there's some blood backing up in your iv tubing. It's gravity and the most benign thing likely to happen to you during your ED stay. Besides, if you're conscious enough to tell me, you may not even need it).

It's a two-way street, though. I mean, I'll let you know when I get the labs back-- every time you ask me is time I can't use to do something about those results, if need be. (Trust me, your ED doc would love to discharge you-- really, no matter how cute you think you are, we'd rather you be home. But constantly checking to see if you can go home will in no way change the order of things we have to do in a shift such that you'll go home before I get that child over there breathing again. Just try to understand that, and I'll try to understand when you don't. One of the things ED providers always fantasize about is going to each of their patients' places of work (ok, big assumption there) and following them around asking questions implying they don't know how to do their jobs. :) One of my favorite responses that I think every time but have rarely said is to ask the insistent/entitled patient to get a note signed by all the other patients that they should be seen first, and I'd be happy to do so... Goes over better in my head than in real life.

Anyway, got called over to the hospital on a “day-off” by one of the Pas to help with a patient. So, I should never really get called to the hospital, and so when the call came I threw on some clothes (was about to take a shower) my flip flops and grabbed my stethoscope. I saw her, in the VIP room up on the floor, and made a few recommendations. Turns out, though, that she is a former head of the interim government of Liberia and close personal friend of Ellen Sirleaf. And it turns out the President wanted to visit that afternoon. So, t-shirt, flip-flops, jeans, bed-head and all, I met a woman whose historical significance (as the first elected female head of an African nation) is certainly in the same range as President Obama's. Yeah, I made a winning impression, I'm sure. ;)

Not uplifting?!?!? / Fauna of JFK

2009-06-14T06:16:00.000-07:00

So, thanks for the emails and the comments on the blog and the general well-wishes. I also want to thank my Jacobi friends (ok, mostly Chertoff...) for all the pictures from Graduation. Wish I could've been there. I'll miss my Jacobi buds.

And, thanks to Schultz for the pictures from the Kenyon 10 year reunion! So good to see you guys-- sorry I couldn't make it!

It has been commented that the postings have been “depressing.” While likely true, this is mostly my fault. You'll notice pictures are primarily of things and situations and cases. I think this is partly because I'm taking, and therefore not in, most of the pictures. And, probably also because I don't imagine people who aren't here are going to be interested in random pictures of people. And maybe it's because my personality is such that I focus on situations and goals and “the work” and less on “the relationships.” That probably is true of me, but I also hope some of it is because the good stuff I like to live while I'm there having it, and the pictures of it sort of fall by the wayside. I'd like to think that's true, anyway.

So, this is a wholly positive posting to counter the "not uplifting" naysayers...

The kid in the bed smiling was hit by a car, a pretty common reason kids come in. While I was examining his leg, he actually sat up in the cot, grabbed my elbow and bit me. I looked at him, attached as he was to my arm, and said “Really? You're biting me now? I can't believe you're biting me.” He laid back down. But now we're friends, because pictures don't lie.

He also introduced me to a phrase I've been hearing a lot with these kids. Introducing the concept of pre-examination analgesia/sedation, I often draw up a bunch of meds in front of them. To a toddler, they all scream out “White Man, don't juke me!” I have learned this means not only “trick” or “get the better of” but also very specifically “Don't stick me with that needle,” it's most common usage. I enjoy that this verb has evolved to serve so specific a purpose. I'm reminded of the verb enratonar, which Chris Stoltz from high school and I found in one of the Marlows' old Spanish dictionaries. It is a verb (regular conjugation) meaning “to become sick (vomit) from eating too many rats.” I'm pleased not only to imagine that this was a common enough occurrence to warrant an entire dedicated verb, but also to think that there existed such a thing as eating an appropriate number of rats...

Speaking of which, the two mice in my room (I've named them “Lassa” and “Hanta” for reasons close to my heart-- don't worry, hemorrhagic fever is mostly a late rainy season phenomenon. Mostly...) recently finished off the rest of my trail mix (thanks, Dorrit II). They are pretty acrobatic in that they enter the room by climbing down the window-side of the 7 foot dark red curtains that hang over and next to my bed. I would hear this progressive scratching on them at night and used to wonder, but then I hit the noise with a flip-flop and one of them, Hanta I believe, fell from the other side. So now it's kind of reassuring to know they're there.

And while on the topic of interesting fauna, the biggest example of the common Hobo or Aggressive House Spider I have ever seen, Nemesis, is no more. He's documented here, living in the supply closet designated for HEARTT equipment.

The other day I was looking for c-collars because the President of the country was going on a trip and one of the admins thought it'd be a good idea for us to lend them some (I'm not kidding), and Nemesis jumped out of a box of cardiac monitor adhesive leads (We have no cardiac monitors). And maybe I screamed like a little girl. Look, I'm wearing my Keanes, which offer no protection, ok? So one of the patients on the trauma side of the ER came over and killed Nemesis for me, as I cowered in a corner. Not really cowered-- I was trying and failing to squash him with an old Harriet Lane handbook. Still, this surgical patient thought I looked like I needed saving. Score one for manliness, USA.

Oh, and the reason I'm giving a talk about rabies to the medical students is because this little beast was in the common lounge in the medical dorms the other night when I'm trying to post to this blog. It's not enough to hope there's power and signal and time, now I have to hope there are no bats.

Ok, soldiering on...

Picture fest

2009-06-09T14:19:00.000-07:00

So, back at the restaurant with good internet. Hope a few pictures upload. The first is of me next to the medical incinerator. :)

This next is of the crack JFK rapid response fleet. My assumption is that they have not had tires for about 5 years...

Dr. Toomey, one of the Residents who stayed on at JFK after her internship year there, is hugging Marcia Glass good-bye here, as Dr. N'jo (I think that's the spelling...) looks on. This room is the site of morning report.

Here is how the Rads department brings new meaning to the term "wet read." Problematic with the films is sometimes they dry with streaking or there's wrinkling of the film, so some pretty wild artifacts are created, making them tough to read. Also, more than one view is hard to get (it also costs the same per view!) and they are often put on the same sheet to save film. Try telling the Pt that the film is inadequate and they have to buy another!A few shots from the ED, including Louis leaving the HEARTT closet negotiating the "off-road" wheelchairs of JFK, and the trauma side "resuscitation area." Note the portable O2 compressor and suction (oomph-poor suction...) pump. They are donated from separate sources and one always needs a converter, depending on where you wheel them...

Surgical laundry day is awesome. I keep meaning to buy the ED flystrips-- I assume the same is relevant to the OT (operating theater)...

Lastly, this is where I spend most of my time. It's a desk on the medical side of the ER. The AC is nice, but note the condensation streaking down the curtains into the fuse box and out to the floor. Yeah, I'm thrilled by this. Fortunately, every day we have a different administrator come into the room, see the problem, and say they'll take care of it. This recurring situation will be featured prominently in the upcoming feature "WTF @ JFK."

Anyway, hope to have more up soon. No big news-- the clinical issues continue, and I continue to be confounded/astounded by the whole payment prior to service thing here. Working on working on it. Small small ("a little bit").

Slaughter house 9-to-5

2009-06-06T13:53:00.000-07:00

Re-read the below recently-- pains a fairly grim picture, but from the folks who have been here, things have been worse. So progress is happening. A favorite quote from Robert E Lee...

"My experience of Men has never disposed me to think worse of them, nor indisposed me to serve them; nor, in spite of failures which I lament, of errors I only now see and acknowledge, or of the present aspect of affairs, do I despair of the future. The truth is this: The march of Providence is so slow and our desires so impatient; the work of progress is so immense and our means of aiding it so feeble; the life of humanity is so long, that of the individual so brief, that often we see only the ebb of the advancing wave and are thus discouraged. It is history that teaches us to hope."

It's pretty impressive here. I'd say the “pathology” is “interesting,” but most if it doesn't live long enough to become so. It's a pretty standard occurrence to be called out to the drive-up receiving area by the triage nurse to pronounce a patient dead in the car. That way, the family isn't charged for the ER visit. Often a relatively young person will arrive in extremis, clearly a few days into the process, and all I can really do is watch them die. Sometimes not even that, depending on how busy things are. Usually they were recently seen (hopefully at another clinic/institution!) and sometimes have been taking some mystery pills for unknown reasons. So the family asks me at least for answers, if not hope. Why? What? Who's next? I don't know what to say. We have little ability to check basic chemistries, beyond a BUN (2 day turnaround), no microbiology, no functioning autopsy service. DOA, 2/2 BIA (dead on arrival secondary to born in Africa...?).
Often they appear gaunt, occasionally minimal responsive to noxious stimuli. More often than not I write for an HIV test (HIV, malaria smear, hemoglobin sometimes come back the same day...), whether or not I think they will last for the results (or the sampling). To a person, the family complains of them “Not eating.” A week is average.
So I write the standard orders for first dose quinine, ceftriaxone (or amp/gent, or benzylPCN or ampicillin, depending on review of systems and ability of the family to pay, as well as D50, fluids, paracetamol (please stop giving malaria patients NSAIDs IM! Platelets, platelets platelets...). Maybe I'll catch a septic patient right when it could matter. Maybe I'll put my hand on a belly and get the patient to OB or surgery. Maybe the social worker will approve emergency surgery so it can happen now, and not after sitting on the medicine ward for two days, filling with blood or pus. Maybe the kiddo will perk up, complete a quinine course po and go home. Maybe.
But the worst days are when I'm wrong. The baby looked ectopic to me on sono; the spleen suspicious for abscess. I thought that TB patient was stable to go back to chest clinic, where they had his meds and chest x rays and records. But I was wrong. Or I still don't know. Patient sat on the wards, and died a few days later-- no feedback, no closure. DAA 2/2 BIA (died after admission, secondary to born in Africa).
I guess I sound melodramatic, but perhaps blogs are supposed to be evocative? The truth is, I start out in morning report, trying to make something useful out of them. I'm then in the medical ER 9-5, w/ a PA on the surgical side during that time (I wander over now and then and try to suture or reduce something). The interns/residents here haven't really taken to signing in or out the ER patients. I track them down and tell them if there's someone critical in the ED. Any spare moment I have I try to teach something to the PA students. Anyone who will listen, really. Take my book, take my pen, look at my video on splinting from the NEJM! I've said before to a med student here, if there's anyone taking care of anyone in Liberia in 40 years, it's going to be from the group of people who are training now (or people they have trained). They are the reason I came to Liberia. Maybe if I inspire someone to try harder, learn more, be upset when people die, then maybe I'll have done something with my time here. And that may be the real hope for those of us BIA. For any of us, really.

Video diary...

2009-06-06T12:45:00.000-07:00

Sorry to take long between posts. The internet is very slow and now, over the weekend when I don't go in as much, the power will be out in the dormitory compound until Monday... So, I've started to collect "post thoughts" and will upload like crazy when I can. I've also started to put together a video diary of sorts-- ala “Grizzly Man” I can only hope, though, that Werner Herzog narrates... For Lee-- "That's Sirius, the dog star. That's some serious stuff." And "Grape Soda Strategic Night Maneuvers."

I'm learning how to use the camera I got recently, so hopefully this video will load up. The internet is a little speedier at the restaurant down the road from the hospital. So, I braved the weather in my boy scout poncho and made the trek down. Rachel, another HEARTT doc, showed up yesterday to do some OB/GYN research, so I'm learning a little more about getting around Monrovia as well. Between the dark, the difficulty/danger in securing car transport, and the now torrential rain (Rainy season began 3 days ago-- nothing, then -BAM-, rain that would embarrass your mother) it's tough to get around.

Hope the video uploads. The following posts are for a few of the "in the know" JFK-ers...

IMCI = IMBM (“it must be malaria”)

Interesting evening tonight. You know your country is up a creek when the Haitian ENT doc says he's never seen anything like it before. “It is very very estrange.” “That was, zomething zpecial.” “It is very very curious for this to happen in a hospital.” “How can you do it without materiales?” "How do you dilate without seeing what you are dilating?"

The Security guys now have blue blazers and little yellow badges. They stop the Liberians and ask to see inside their plastic bags. What are they worried about them sneaking in or out? Seriously. I was stopped the other day and they looked inside my computer case. Am I stealing an African baby? Do I look like Madonna?

Of Hippos and Cheetahs....

2009-06-06T12:38:00.000-07:00

picture of a quiet day on the trauma side...

So, www.ted.com is a great website full of a bunch of talks on various topics (a few of my favorites can be accessed through my Facebook page..) It's a meeting of a bunch of folks out in Monterrey who every year get together and discuss-- whatever. A few years ago, the topic was Africa-- basically all kinds of aspects. One speaker in particular caught my attention with his metaphor for the crisis in leadership in Africa. I believe he was from Kenya, but I'm not sure (and no, Kenya does not compete in lacrosse with Earlham and Dennison...). There are two types of leaders in Africa, he said. There are the young, hungry immediately post-student or student generation who are looking for things to change and change quickly. Who see the world forgetting Africa and are looking to catch Africa up to take its place among nations (though granted, this could take generations). He referred to them as the Cheetahs. Then there are the other African leaders. Concerned primarily with their own station, and therefore the status quo. Who take no initiative and at times block innovation to maintain their position. Who can only see the watergrass in front of them and do not look to the horizon of the future. These are the Hippos. More often than not, he observed, the Hippos tend to be in charge and entrenched (ever tried to move a hippo?). And it is their weight that is a part of the problem holding Africa back.
I found that observation to be interesting, and not just relevant to Africa. Leaders tend to be like parents-- the big challenge is knowing when to step aside and let what you've built or raised come into its own. Of being confident enough in yourself and your work to let it outlast you (and of ensuring that you are building something that will outlast you, that, in the end, will make you unnecessary). And that's the challenge. As we grow old and “experienced,” professionally, we are every more concerned with our own mortality or career longevity. Frailty begets conservatism and fear of letting go. This is probably adaptive-- you bounce back less when you osteoporotic (metaphorically speaking, of course).
In the end, I think it was said best by Lao Tsu: Go to the People. Live among them. Love them. Learn from them. Serve them. Plan with them. Start with what they know. Build on what they have. And when the best leaders leave, the people will say, “We have done it ourselves.”

What I find interesting is that it implies/assumes that the best leaders leave. What happens to them then? One can only hope they were able to be part of something that they are proud to see outlast them.

medical stuff

2009-06-02T00:35:00.000-07:00

So, I was debating how much vs. how little of the medical stuff to put up on the blog. Both for patient confidentiality/respect (most of the "interesting cases" end up dead or disabled, and I feel awkward about taking the picture...), but also because some readers are friends/family who are not medical folks may not be interested in seeing it. So I've decided to be sparing and clearly label medical stuff posts as such.

Many docs back home said I'd probably see some "crazy sh*t." That's certainly the case. But mostly it's been the solutions, improvised or absent, to the medical issues that have been crazy. For starters, it had been common practice to diagnosis & prescribe, order labs, xrays etc. for a patient, and then have the patient or family pay for all that prior to it being dispensed. Even in emergencies. "Can't afford an appendix or SBO surgery right now? Ok, we'll wait until your relative shows up with the cash..." Even if that's 2-3 days! (of note, surgical emergencies, unlike wine & cheese, do not improve with "aging," though I have found them here to give me migraine headaches...) Luckily, that's improving.

The major burden of disease here is malaria for the younger ones, and trauma for young adults. As indicated by the stats posted earlier, I would not want to take my chances being born (infant mortality) or getting pregnant in Liberia either (though the latter might make for an interesting blog in and of itself...).

Uh-oh, late for morning report. The pictures will have to wait!

Ok, a quick one. Our differential was buruli ulcer (cutaneous mycobacterium) vs. traumatic ulceration of filariasis (elephantiasis) in a Pt later diagnosed with AIDS...

Def-con 5

2009-06-02T00:30:00.000-07:00

This is a priority one alert: I have just been informed that the medical dormitory is out of toilet paper, and may not be resupplied until Friday. Emergency gauze pad and kleenex rationing will commence. This is not a drill, repeat.

Oh, and there are honest to God beach-sized crabs living in the storm drain. WTF.

Comings and goings...

2009-05-30T08:43:00.000-07:00

So when I signed up I was given the impression I might be alone on the ground in Monrovia. That didn't change until about 3 days before I left when I finally got an email saying not only would I be picked up at the airport, but that a bunch of people would be here. That being said, over this past week they've all left. Thanks to Louis from UofChic ED, jonathan from UofChic IM, Tammie and Tricia from UMass Peds, and Marcia from Tulane IM (this crazy chick has been in Liberia since January! Either committed or should be...).

The rumor is that one of this past year's first HEARTT Residents will be coming back a few days before I leave in July. Hope that's true. So much of this kind of stuff is "medical tourism," without even a continuing presence, let alone a self-conscious effort to emphasize development work. Hope hope hope. Hope for something good to come of your time, the breaths you take. Hope for people to be better than they expected to be. Hope some things matter, after all. We'll see.

But thanks to my new friends. "May we always remember the people we have been; may we ever be ready to meet again for the first time."

We are living in a Liberian world, and I am a Liberian girl, er, I mean, boy...

2009-05-27T00:31:00.000-07:00

Sorry it's been a while since posting-- there's more and more kinds of work here than I anticipated...

So, where are you again? Liberia, West Africa. Oh. So, where are you again? Well, read on. I've tried to put it into sections, as well as a section specifically on JFK Hospital, where I am now, and a few key numbers after that. A lot of the below information comes from the 2006 and 2008 UN Country information, but from what I can tell, not much has changed...
Oh, and some media on Liberia: movies- Liberia: America's Stepchild, Sliding Liberia (we met Alfred, who's featured in the movie) books- Through the Liberia Storm and Liberia: the Path to War (both written by a Nigerian MD who's here with us now), also Blue Clay People, and This Child will be blessed (I think, the autobiography of Liberia's president, Ellen Johnson Sirleaf, who is the first female head of state in Africa)

COUNTRY OVERVIEW

Liberia is situated in West Africa, bordering the Gulf of Guinea, Côte d'Ivoire, Guinea and Sierra Leone. Lying just north of the equator, the country has a tropical climate and is one of the wettest in the world, with an average annual rainfall of more than 5,000 mm in Monrovia. Liberia’s population is currently estimated at 3.4 million with an annual growth rate of 4.9 percent.1 Average life expectancy is 39 years2 and an estimated 50 per cent of the population are below the age of 203. 95 per cent of Liberians belong to one of 16 indigenous tribes.4 The

remaining population consists of Americo-Liberians and so-called Congo people, descendants of immigrants from the United States and Caribbean. An estimated 40 per cent of the population hold indigenous beliefs, 40 per

cent are Christian and 20 per cent Muslim. 5 Liberia is rich in natural resources, including iron ore, timber, diamonds, gold and potential for hydropower. Despite this natural wealth, it is among the poorest countries in the world measured in terms of per capita income. Liberia is not currently rated on the Human Development Index (HDI) given the lack of data. However, its HDI rating in 1999 was 0.276, down from 0.311 in 1996, placing it second from the bottom on the list of countries.6 The economy of Liberia reflects the toll of the war. Per capita GDP stands at US$ 163, a dramatic drop from the 1980 level of US$ 1,269. Foreign debt exceeds US$ 3.7 billion (650 per cent of GDP). Unemployment is estimated at 85 per cent, with nearly half the population existing on less than US$ 0.50 per day. Some 86 per cent of the poor live in rural areas7. Liberia’s economy is dominated by agriculture, which accounted for 52 per cent of GDP in 20058 - or a commanding 77 per cent including forestry.9 Only 12 per cent of GDP is generated from the industrial sector.

1 CIA World Fact Book, June 2006

2 37 year for males and 41 years for females

3 UN Liberia Human Development Report DRAFT 2006

4 Kpelle, Bassa, Gio, Kru, Grebo, Mano, Krahn, Gola,

Gbandi, Loma, Kissi, Vai, Dei, Bella, Mandingo and Mende

5 CIA, June 2006

6 MDGR, 2004

7 ibid.

8 IMF 2006

9 CIA, June 2006

ECONOMICS

With the end of the war and restoration of security, the economy has begun to improve; increased activity in urban areas has contributed to an estimated GDP growth rate of 5.3 per cent in 2005, double that of the preceding year. However, current growth is neither equitable nor based on sound management of national

resources. Issues of sustainability will emerge unless conditions become conducive to private investment and public expenditure is directed towards reconstruction and job-creation.

Food security requires that ‘all people, at all times, have physical and economic access to sufficient, safe and nutritious food to meet their dietary needs and food preferences for an active and healthy life.’17 For the vast majority of Liberians, this is not the situation today. At least 810,000 are receiving food assistance through

resettlement, school feeding, food for work and institutional feeding programmes. The agricultural sector is fundamental in an economy based on natural resources. Liberia’s conflict largely destroyed an agricultural sector

already weakened by previous government policies subsidizing food imports at the expense of local producers. Widespread displacement of the population also adversely impacted agricultural production and the food security

situation. Today, approximately 95 per cent of urban food needs have to be met through imports, including rice and other staples.

HEALTH:

Conflict led to the forced movement of health workers and professionals into IDP camps and as refugees to neighbouring countries. Health facilities were looted and vandalized and medical supplies became

unavailable. As most parts of the country were inaccessible and national security was given the highest priority by the government, funding stopped and health services collapsed. The problem of skilled health staff cannot be

overemphasized. Liberia today has only 26 medical doctors in clinical practice. Insufficient skilled personnel, poor referral systems and inadequate health facilities are of great concern as are the lack of essential drugs and supplies, including reproductive health (RH) commodities. The decline in health services came with increased health problems arising from the conflict, including hunger, disease and the spread of HIV/AIDS. As levels of poverty and hunger rose, many young girls resorted to prostitution as a means of survival. This led to a range of health problems including sexually transmitted infections. Regional conflict, and the movement of fighters across borders, coupled with the use of sexual violence as a strategy of combat, further exacerbated the HIV/AIDS situation. The vast majority of Liberia’s public health care continues to be externally supported. The

national budget for health has in real terms declined considerably since 1990 and resources committed to the sector are insufficient to provide a basic level and quality of service.

Priority health issues: Within the range of health problems facing Liberia the United Nations identifies the following priority areas:

1. Maternal Health: Despite an absence of reliable data on the current maternal health situation, figures from the 1999/2000 Demographic and Health Survey showed Liberia to have one of the highest maternal mortality

rates (MMR) in the world, estimated at 578 per 100,000 live births – more than twice the 1986 estimate of 260.23

Access to maternal health care services, especially basic and comprehensive emergency obstetric, antenatal, and postnatal care and RH services including family planning, and information and counselling remain grossly

inadequate - especially in rural areas. The Liberia Safe Motherhood Needs Assessment puts institutional deliveries at 11 per cent. The referral system is close to non-existent. Unwanted pregnancies resulting in complications and unsafe abortions are common. Maternal nutrition is also poor. All of these are responsible for high maternal mortality and it is highly unlikely that Liberia will meet related MDG targets by 2015

given the current conditions.

2. Child Mortality and Health: Data on newborn morbidity and mortality are not available and programmes for newborn care are lacking. Available data indicate that infant mortality rates remain high, estimated at 157 per 1,000 live births.24 Liberia is unlikely to meet the MDG target to reduce child mortality.

3. Malaria: Malaria accounts for up to 10 per cent of all deaths in Liberia. Malaria cases increased from 35 per cent of clinic visitors in 1997 to 50 per cent in 2000. Strategies for controlling malaria prior to the conflict mainly involved prevention through bed-netting and insecticide application, with a limited amount of

prophylaxis distributed for pregnant women. New strategies are required and much work remains if Liberia is to meet the target of halting and beginning to reverse the incidence of malaria by 2015.25

4. HIV/AIDS: National prevalence of HIV/AIDS in Liberia is not known but some estimates put the infection rate as having doubled from 4.2 per cent in 1994 to 8.2 per cent in 2001.26 Prevalence rates among women are higher than men, with the infection rate among pregnant women aged 15 to 24 rising from 4.2 per cent in

1994 to 12.9 per cent in 200027. Though antiretroviral (ARV) treatment guidelines have been designed under the Global Fund Programme, healthcare providers lack the necessary expertise and apparatus for managing HIV/AIDS cases. Prevention of HIV/AIDS requires the joint effort of the entire society and is therefore discussed at greater length as a cross-cutting imperative.

5. Nutrition: Nutritional status deteriorated significantly as a result of the years of conflict in Liberia. In 2002, 46 per cent of the population were estimated to be undernourished.28 Malnutrition is pervasive among children under five years of age. Children also suffer from anaemia and vitamin A deficiency. Micronutrient deficiencies were also prevalent, with 86 per cent of children aged 6-23 months anaemic and 53 per cent deficient in vitamin A - exacerbating the condition of those suffering from malaria, diarrhoea and acute respiratory infections.

Numerous other diseases also affect Liberia’s population. It is estimated that 29 per cent of children 0 to 59 months of age suffer from acute respiratory infections such as pneumonia. Diarrhoea accounted for up to five percent of inpatient and out-patient consultations in 2004.29 Tuberculosis rates are estimated at four per

1,000. Certain diseases such as schistsosomiasis impose huge costs on the agricultural economy.

Mental health problems are prevalent and there are no programmes to adequately address adolescent health issues.

John F. Kennedy Medical Center:

JFK Medical Center, located in the central Sinkor District of Monrovia, is the academic teaching hospital of Liberia and is affiliated with the University of Liberia A.M. Dogliotti College of Medicine. From 1989-2003, Liberia suffered from continuous armed conflict. Prior to that period, the hospital served as the center for clinical training for adult, pediatric, surgical, nursing, and allied health services. However, the conflict greatly damaged JFK Medical Center’s capacity to provide care and training, and even led to the hospital’s periodic closure. Fortunately, with a return to peace, and thanks to the commitment of its staff and leadership, JFK Medical Center is rebuilding. Efforts are under way throughout the hospital to restore its previous health services and resident training programs.

ECONOMIC INDICATORS

GDP at current market prices (US$ million) (2005) 574.5

GDP at 1992 constant prices (US$ million) (2006) 433.2

Unemployment rate (%) 80

Private sector employment (2006) 74,774

Public sector employment (2006) 58,500

Informal sector employment (2006) 470,000

GDP per capita (in 2005 US$ prices) 163

GDP growth rate (2006 estimate %) 7.8

Inflation rate (est average 2006 %) 4

External debt (US$ billion) 3.7

Domestic debt (US$ million) 700

National budget 2006/07 (US$ million) 129.9

Average lending rate (%) 16.4

Net remittances (inflow minus transfers of money, US$ million) 54.2

Imports (US$ million) 443.8

Exports (US$ million) 180.8

Total trade value (US$ million) 624.6

Trade deficit (net trade value, US$ million) 263

SOCIO-DEMOGRAPHIC INDICATORS

Population size (projection in millions) 3.6

Population growth rate (%) 4.6

Life expectancy at birth (years) 47.7

Illiteracy rate (%) 70

Infant mortality rate (per 1,000 live births) 157

Under five mortality rate (per 1,000 live births) 235

Maternal mortality rate (per 100,000 live births) 578

% population below poverty line (living on less than US$1 per day) 76.2

HIV/AIDS prevalence rate (%) 5.2

Human Development Index 0.319

Total geographic area (km sq) 111,370

Total land area (km sq) 96,320

Coastline (km) 579

POLITICAL INDICATORS

Government Republican

Presidency Executive

Legislature Bi-cameral

Senators (30)

Male 25

Female 5

Representatives (64)

Male 56

Female 8

Executive (Cabinet Ministers)

Male 15

Female 5

Proposed size of the National Army of Liberia (AFL) 2,000

Proposed size of the National Police and security forces 6,000

Sources:

1. Human Development Report 2006/Interim Poverty Reduction Strategy Paper (iPRSP)

2. Second Review of Performance under the Staff-Monitored Programme, IMF

3. LISGIS, Liberia National Population Panel 2007

(Population estimate of 3.6 matches with the target developed by NEC for local elections in 2007).

4. Bureau of the Budget/Ministry of Finance

5. The President’s 2006 Annual Message, 29 January 2007

6. Annual Report 2006, Central Bank of Liberia

7. WHO Report 2006

Getting there is half the fun

2009-05-20T15:27:00.000-07:00

Hi there,
Made the trip from JFK to Brussels on American Airlines, where an Italian drummer and I compared (unfavorably) US to European and South American airlines. I wagered the plane would be roomier from Brussels to Monrovia, and a few hours later, I was right. Travel tip: 100 ml is the max size for carry-on liquids in Brussels. So I was deprived of my shaving cream, sunblock and, most distressingly, 30% DEET bug spray.

No matter, soldiered on, found out via email I owe New York taxes for 2008, and arrived at Roberts Intnl airport without a problem. One of the hospital drivers met me there and after 45 min on the road, made it to JFK Hospital! More to follow, though the electricity and internet are touch and go...

"You are a traveler at heart; there will be many journeys"

2009-05-12T12:06:00.000-07:00

The title comes from a fortune I got from a Kenyon College AMARK food services fortune cookie and have kept with me since. I like it. Below is a poem introduced to me by an old friend. I think it speaks to anyone who's thought deeply about travel and work in the "developing world."

Questions of Travel -- Elizabeth Bishop

There are too many waterfalls here;
the crowded streams
hurry too rapidly down to the sea,
and the pressure of so many clouds
on the mountaintops
makes them spill over the sides
in soft slow-motion,
turning to waterfalls under our very eyes.
--For if those streaks, those mile-long, shiny,
tearstains, aren't waterfalls yet,
in a quick age or so, as ages go here,
they probably will be.
But if the streams and clouds keep travelling, travelling,
the mountains look like the hulls of capsized ships,
slime-hung and barnacled.

Think of the long trip home.
Should we have stayed at home and thought of here?
Where should we be today?
Is it right to be watching strangers in a play
in this strangest of theatres?
What childishness is it that while there's a breath of life
in our bodies, we are determined to rush
to see the sun the other way around?
The tiniest green hummingbird in the world?
To stare at some inexplicable old stonework,
inexplicable and impenetrable,
at any view,
instantly seen and always, always delightful?
Oh, must we dream our dreams
and have them, too?
And have we room
for one more folded sunset, still quite warm?

But surely it would have been a pity
not to have seen the trees along this road,
really exaggerated in their beauty,
not to have seen them gesturing
like noble pantomimists, robed in pink.
--Not to have had to stop for gas and heard
the sad, two-noted, wooden tune
of disparate wooden clogs
carelessly clacking over
a grease-stained filling-station floor.
(In another country the clogs would all be tested.
Each pair there would have identical pitch.)
--A pity not to have heard
the other, less primitive music of the fat brown bird
who sings above the broken gasoline pump
in a bamboo church of Jesuit baroque:
three towers, five silver crosses.
--Yes, a pity not to have pondered,
blurr'dly and inconclusively,
on what connection can exist for centuries
between the crudest wooden footwear
and, careful and finicky,
the whittled fantasies of wooden footwear
and, careful and finicky,
the whittled fantasies of wooden cages.
--Never to have studied history in
the weak calligraphy of songbirds' cages.
--And never to have had to listen to rain
so much like politicians' speeches:
two hours of unrelenting oratory
and then a sudden golden silence
in which the traveller takes a notebook, writes:

"Is it lack of imagination that makes us come
to imagined places, not just stay at home?
Or could Pascal have been not entirely right
about just sitting quietly in one's room?

Continent, city, country, society:
the choice is never wide and never free.
And here, or there . . . No. Should we have stayed at home,
wherever that may be?"

Only a test

2009-04-30T23:03:00.000-07:00

Hopefully more will come of this over time-- I'm just glad to have figured out how to establish the blog-presence... Even so, preparations are underway, and I hope to return to this as soon as I can to make it worth following! Cheers,