just some things on my mind today

(These are the experiences, opinions and views of the author only and may not reflect those of the majority.)

Just yesterday, I was handed a book on the history of surgical pathology, and in it were some autobiographical notes by one of the prominent founders of the field. And as I was reading about his experiences in medical school and his training beyond, I grew excited. Medicine back then was fun. We are, by the way, in the first half of the twentieth century. I began to compare my education with his and must admit that I am bitterly disappointed. I began to think, what is it that I really learned in medical school? I learned how to read a book and ace a test. I learned how to get up really early and function, albeit maybe not well, in a sleep-deprived state. I learned how to be ignored and treated like I was invisible and be okay with that. I learned how to write a detailed note on a patient, often copied from the previous day with minor changes in vital signs, etc. I learned how to follow directions, obediantly and submissively. I learned how to go through the motions of doing a physical examination on a patient. From an outside observer (the person grading me), it appeared that I knew what I was doing, but I was never taught (with few exceptions) the significance of going through these motions. I learned how to order tests, lots of them and was taught that tests will give you answers. I learned how to wade through massive charts to find information. I learned how to dress, act and talk like a professional, how to wear a short white coat stuffed with books and penlights and papers on which I had scribbled notes, heavy on my shoulders, weighing down my spirit. I learned how to please people, what I had to do to get a good grade and how to make patients happy (usually). I learned how to not get sued. I learned how to say, "Hi, my name is Dr. ____," which may not sound that difficult, but is. I learned a lot. So what am I complaining about? I didn't learn the most important thing (at least to me), that which the prominent early twentieth century physician spoke of in his training, and that is the art of medicine, how to truly examine a patient and solve a problem and think and ask questions. Yes, I learned medicine from books, but not from my patients, with the exception of my short experience in Africa, and yes, I am bitter. I think we can do better. I think we should do better. My experiences in clinical medicine are a major reason why I have chosen to leave it. In pathology, there may not be living, breathing patients, but at least I can still do real medicine. Had I gone to medical school 100 years ago things may have been different, but today this is the best I can do.

desiderata

Go placidly amid the noise and the haste, and remember what peace there may be in silence. As far as possible without surrender be on good terms with all persons. Speak your truth quietly and clearly; and listen to others, even the dull and ignorant; they too have their story. Avoid loud and aggressive persons; they are vexatious to the spirit. If you compare yourself with others, you may become vain and bitter; for always there will be greater and lesser persons than yourself. Enjoy your achievements as well as your plans. Keep interested in your own career, however humble; it is a real possession in the changing fortunes of time. Exercise caution in your business affairs; for the world is full of trickery. But let this not blind you to what virtue there is; many persons strive for high ideals; and everywhere life is full of heroism. Be yourself. Especially do not feign affection. Neither be cynical about love; for in the face of all aridity and disenchantment it is as perennial as the grass. Take kindly the counsel of the years, gracefully surrendering the things of youth. Nurture strength of spirit to shield you in sudden misfortune. But do not distress yourself with imaginings. Many fears are born of fatigue and loneliness. Beyond a wholesome discipline, be gentle with yourself. You are a child of the universe no less than the trees and the stars; you have a right to be here. And whether or not it is clear to you, no doubt the universe is unfolding as it should. Therefore be at peace with God, whatever you conceive Him to be. And whatever your labors and aspirations, in the noisy confusion of life keep peace with your soul. With all its sham, drudgery and broken dreams, it is still a beautiful world. Be cheerful. Strive to be happy. --by Max Ehrmann (1927)

quitters sometimes do win

The sun is once again shining, after months of darkness. I quit the first real job I've ever had. The etiologies were varied and complicated and many. It wasn't an easy decision. My gut had been telling me to quit since the day I started, but my head was reminding me I wasn't a quitter and I had worked exceedingly hard to put myself in this position. Many people would die to be where I was.

I was running along the Cherry Creek one evening when I finally let myself quit. I felt as though an elephant had been lifted off my shoulders. I could once again run fast and free. Many people have called me stupid. These are the people who choose security over passion; the people who are content with mediocrity, who are afraid of uncertainty and change. I am not.

I quit, if for no other reason, than on principle alone. I don't believe people should be treated the way a surgical intern is and continuing to submit myself to their torture methods is only condoning the process and allowing it to perpetuate. Cheers to happiness, health, freedom and sunshine. I'm back.

intern absurdity

I went to four years of medical school to tell people when they can eat. It's not rocket science. I'll even let you in on the secret so you don't have to go through the four years of hell, ahm I mean school, and $180,000 debt part. If a patient is farting and pooping it means his or her guts have woken up enough after surgery so that he or she can eat, hopefully without puking. That's it.

I am essentially a glorified secretary in a long white coat with MD on my name tag. I wander the hospital halls like a zombie, making phone calls, answering pages, writing notes, typing orders, dictating discharge summaries. I'm not really sure why they call it medicine because it's really only about 2.7% medicine, 97.3% crap. And I'm not so into the crap. I want to actually have to think. I want to apply the physiology I learned in school. I want to see it in action. I want to see that I've made a difference in someone's life. Thus far I have been so sleep-deprived and depressed that I don't think I've seen anything.

For those of you considering a medical career, consider this your fair warning...it's not what everyone on the outside thinks.

identity theft

I've been waiting my entire life to fit in and now that I finally do, I'm not so sure I like it. I can no longer tell someone I ran the Boston and expect them to look at me like I'm some sort of god, or better yet, say "what's that?" Instead I get, "Oh, what year? Yeah, that was my 11th Boston. The weather really sucked that year, didn't it? Hey, I'm doing this 50-mile trail run race this weekend...interested?" I no longer get looks of awe and "are you crazy" when I tell someone I went mountain biking for two hours in a hail storm yesterday. Instead I get, "Yeah, yesterday, I did this 12 hour adventure race and then, after grabbing a quick bite to eat, went out and rode for 3 hours in the moonlight with a few of my buddies."

On my way home after a long hike in Rocky Mountain National Park with my cousins yesterday, I decided to stop in Boulder to see if I could still sign up for the Bolder Boulder, a 10K running road race on Memorial Day and the largest of its kind in the nation. As I drove around town for 20 minutes looking for a place to park (which I never found), I was appalled at what I saw: 10 year-olds riding $2000 miniature road bikes to the candy store; every third car with a bike on the roof; beautifully sculpted bodies walking down the street in their chacos; people riding bikes everywhere you turn--serious racers out for their training rides, commuters, dads pulling their kids in buggies... Hey, wait a minute...that's my gig. You can't do that. The more I saw, the angrier I got and I finally had to leave without signing up for the race. Let them have their stupid race. I don't need 40,000 Sarah clones to run with. I can run my own 6.2 miles wherever I want.

I am officially, no longer, crazy Sarah. I am now completely ordinary, below average Sarah. Congratulations. You got what you wanted.

loss for words

I made it home. And I am already depressed.

Today was my first day back in the hospital and I am convinced that there is something seriously wrong with the way we practice medicine here. I never saw it before. I guess because that's all I ever knew. It took me over two hours to wade through the patient assigned to me's charts (yes, multiple--there's the nurses paper chart, the other paper chart, the computer program where you can access all the labs, x-rays, etc, the computer program where you can access the patient's past medical records that have been scanned in, the computer program where you can print a progress note for the patient and yet a different computer program where you can print the changeover sheet.) The patient is taking no fewer than 20 different medications and 10 additional prn (as needed) meds. She has been taken care of by probably 20 different doctors and at least as many different nurses. She has pneumonia and acute respiratory distress syndrome and congestive heart failure and chronic obstructive pulmonary disease and morbid obesity and obstructive sleep apnea and hypertension and acid reflux and pseudotumor and osteoarthritis and a brain aneurysm and bipolar disorder and chronic lower back pain and cellulitis of her right calf and a few other things not worth mentioning. A fancy machine is breathing for her and she is now developing bed sores. She has a tube in her nose that goes down to her stomach so she can receive liquified nasty tasting calories. Her potassium was a little low yesterday so we put some extra potassium in her feeds today. We give her a little of this, go up a little on the dosage of that, and continuing tweaking until she is just "perfect." We will continue to tweak her to perfection until she dies, likely right here in her ICU bed.

Yes, patients in Africa die too. But not like that.

Are we really doing what's best for our patients? Doing "no harm?" Somehow I don't think so.

oh, africa

Africa is kind of like medical school in that it is nearly impossible to describe to anyone who hasn't experienced it. After you've been here for a while, you eventually go from saying why, why, why to why not? Why wouldn't there be a man chasing a goat that is darting back and forth in the street, on your way to work? Why wouldn't there be a live chicken in the front seat of your taxi? Why wouldn't there be a man selling perfume out of a crate on the back of his bicycle at the hospital? Why wouldn't the bovie stop working in the middle of a mastectomy or flies be landing on the sterile field? Why wouldn't there be a viper in Dr. Daniel's house last night, "attacking my son"? (His wife killed it because he is afraid of snakes. Oh, by the way, I live right next to him in a duplex sort of thing. Good thing they have antivenom here at the hospital.) Why wouldn't our landrover get stuck in deep sand and we all have to get out and push for 50 meters? After a while, it somehow all just starts to become normal. You fall into the rhythm of craziness, and just have to say "Oh, Africa" and continue on with your day.

d-day

I wake up at 5:30 (T minus twelve and a half hours) to go for a run. The sunrise is hazy and the most distant mountains are obscured by dust in the air, but I can already tell it's going to be a hot day. The village is just waking up. Women are going to the well to pump water. The occasional child or chicken scurries across the road. My legs feel like lead, as they have for the past two weeks. I chalk it up to being anemic since I haven't had meat in 6 weeks and cut myself some slack.

I make myself a cup of instant coffee (I have been forced to become less of a coffee snob since coming here--it's instant or nothing) and head over to the hospital at 7:30 (10.5 hours to go).

This morning I get to go to Mora with Myra, the Canadian who, along with Dr. Ellen, built this hospital from nothing 18 years ago and who is the keeper of the money fridge (ie: accountant and administrator). In Mora, I buy some guava (new fruit of the week) at the market and get some quality people watching in, while she makes stops at the button store and the tailor. I'm convinced there is no better place in the world to people watch. I think I could have sat there all day without ever getting bored. Everyone and everything just seem more alive and vibrant here. I don't know how else to describe it.

When we get back to the hospital, I scrub in on a prostatectomy, sans the Davinci of course.

5:45 pm (T minus 15 minutes) I have been waiting for this moment for almost forever it seems. I'm sitting in Dr. Ellen's hot office staring at her computer screen, anxiously clicking refresh over and over again while my 270 classmates have gathered en mass several thousand miles away at this very same moment, our uncertain futures about to be decided for us.

General Surgery, U. of Colorado, Denver. Silence.........................................................................
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Damn. .......................................................................................................................................................
Colorado was 4th on my rank list but I somehow wasn't expecting it. Well, I guess if I can manage to elude the 37.5% attrition rate and enjoy the 300 days of sunshine a year, it might actually be okay. And there are mountains and biking and hiking and climbing and skiing galore. And the staff I interviewed with there were incredible. And it's not Indiana. And maybe, okay, it might just be alright. It might just be where I was meant to go after all. I trust that someone is looking out for me and my future.

So I send a few emails and make a few phone calls, shut down the computer, cover it with plastic, two towels and a sheet to fend off the dust, and while my classmates are all out drinking and celebrating together, I walk home in the moonlight alone. Somewhat anticlimactic if you ask me.

Ahh..........Colorado..........What color will I paint my walls?

Everyone--please let me know where you're going next year! I'm sad I missed out on all the excitement back home.

you know you're homesick when...

-You try to make cookies in a skillet over a gas stove.

-You bust out the make-up you had been wondering why you brought, and wear it to work just because it makes you feel more like at home.

-You fry yam cubes in cotton oil, top with tomatoes and pretend you're eating french fries and ketchup.

-You borrow a quality single speed Skylark for the day and pretend the huge springs under your seat are actually your rear suspension.

-You sing out loud to yourself because you haven't heard music in five weeks. The last song I listened to before I left home was Snow Patrol's "shut your eyes and think of somewhere, somewhere cold and caked in snow...", which now helps me make it through the days of 105F heat and sleepless, sweaty nights with no AC and no fan, only a wet shirt and frozen water bottle between my legs.

Several hours after doing laundry (and by laundry I mean washing every piece of clothing by hand, in a bucket, with blue powder that people here call soap but I'm not convinced actually cleans anything, and hanging my clothes on a clothesline in the bathroom), I find that several hundred mosquitoes have invaded the bathroom and I empty half a bottle of deet in the toilet, sink and air to scare them away enough that I can use it.

I'm tired of being the celebrity in town. I'm tired of people staring and staring... and staring. Maybe they're just curious, but where I come from that's impolite. I miss being able to run down the street and not have people stop what they're doing and come out of their houses to stare. I miss being able to sit in a coffee shop and read with twenty other people and still be alone. I miss the order, organization, precision and timeliness of the U.S. operating room. I miss feeling clean. I miss my garbage disposal and my jeans and tank tops and my yoga class and my $1500 bikes and my grocery store and my Starbucks and my air conditioning and my car (or the abstract idea of my car since I don't actually own one) and even my cell phone.

As much as I hate to admit it, I realize I have become yet another victim reliant on the many conveniences of the western world. I may not spend hours a day watching TV or surfing the internet, but I'm just as guilty as those who do.

"women's" day my ass

Today is international women's day, apparently. I don't think it exists back home or at least I had never heard of it, but ironically, here in Cameroon, where women have essentially no rights or freedoms, it is made to be a huge day, celebrated with festivities all week long and concluding today with a parade and evening gala. Women spend weeks getting ready for this day, making dresses out of special 2008 Women's Day fabric, which they wear for the parade.

I never thought of myself as an extreme feminist, but here I probably seem like one to most people. I have almost gotten into several fights over such issues and am surprised at how angry I can get. A few examples...

--I am generally the only female in the OR; the rest of the staff are male, and they have tried, on multiple occasions, to make me sit down during long cases, shoving a stool at me and repeatedly yelling at me to sit. No one else is sitting. I feel like it is because I am a female and they don't think I can handle standing for six hours. I blatantly refuse and kick the stool away. I am (or will be) a surgeon and surgeons stand. I will stand.
--After Chrissy and Jessie left for the U.S., one of the male nurses told me I should walk home from work with one of the female nurses so I didn't have to walk the two blocks by myself (in contrast to Douala, Kolofata is a very safe village). Thanks, but no thanks.
--A Cameroonian journalist was trying to argue that Hilary Clinton cannot be president because her husband was already president and they are the same person. Wives have to agree with their husbands on everything and are not free to have their own ideas. I wanted to punch him in the face so bad...
--No one can understand why I'm not married with five kids already.

Most women here don't go to school and never learn French (they only speak their tribal language). Boys and young men play soccer, while women stay in and cook for them when they're finished. Polygamy is common and accepted. When I ask why one woman couldn't have multiple husbands, I just seem to get puzzled looks. "There are just more girls than boys here." Right. I could go on and on, but basically women here are slaves to their husbands.

And so as I sat and watched the parade go by today, I couldn't help but wonder how long, if ever, it will be before a woman will be able to play soccer or run or drive her own motorcycle or not get married if she doesn't want to or go to medical school or wear pants or argue with her husband and not be punished for it or just be able to have her own ideas, and concluded that this day was faux and all the work put into making their beautiful dresses was just in vain.

waza

3-1-08
We were graciously granted a day and a half off work to visit Waza National Park, which is about one and a half hours north of Kolofata. Our driver picked us up at the hospital yesterday afternoon and we were off.

Dr. Ellen had told us that going so close to the Chad border means "big men with big guns" will sometimes stop your car, "but they won't hurt you as long as you give them all of your stuff." Great. So I packed my bag, fully prepared to surrender it and all of its contents if need be. I only brought four of my malaria capsules--a few extra in case we were stranded for a few days, but not my whole stash or I'd be screwed later; no passport, driver's license or credit card (they don't work anywhere anyways)--just the minimum amount of cash needed and a photocopy of my passport. I replayed over and over in my head how I would quickly remove the memory card from my camera and hide it in my bra when we were pulled over. Turns out we weren't stopped by any big men with big guns so I got to keep all my stuff.

We stayed at the Waza "hotel" last night and got up before dawn so we could get into the park before it got too hot and all the animals went into hiding. At the park entrance there is a sign stating all the park rules including "vehicles must stay on the road at all times" and "do not get out of your vehicle, especially near waterholes." We hired our guide, paid the extra $5 each to bring in our cameras, and were wished "bon chance" as we drove into the park.

We saw tons of antelope, gazelle, vultures and even a hyena (our driver said he hadn't seen one in four years). Then we spotted the elephant poop. Our guide got out and stood on the roof of our 4x4 and spotted a small herd of elephants on the horizon. After he mumbled something to the driver in French, we turned off the road and started driving through tall brush over seriously uneven terrain towards the elephants. I mean this would have been the ideal car commercial for one of our many improperly-used American SUVs, actually at home in the environment it was made to live in. After bumping along for a half hour, the driver stopped and our guide said "we will now continue on foot." So we got out of the car and started walking towards the elephants. It was almost surreal. We got less than 100 meters away from them before we stopped because "the first elephant will charge if you get too close." On the way out of the park we saw some giraffes and ostriches and another herd of elephants. Pretty awesome.

On our way home, we stopped at the bakery in Mora and bought some chocolate croissants and diet cokes. The vendor made sure we knew those drinks were for diabetics and thought it quite odd that we would buy pastries, bread and chocolate with sugar-free soda. I guess maybe she's right.

Mora is a village that's about a half hour motorcycle ride from Kolofata. They have a big market on Thursdays and Sundays. We took motos there last weekend (I tried not to think about the fact that I was helmetless and wearing sandals, and the frequent moto accident casualties we see at the hospital...), but couldn't find the bakery, so our chocolate croissants today were a special treat.

just another day gone by...

2-21-08

Internet access has been extremely limited--I appologize, so most of my stories will probably have to wait until I get home...

Today I did my first trauma case. A man was shot three times while trying to defend his cows--once in his leg, once through his chest and once into his abdomen, but without an exit wound. We sat on him for a day and a half until he developed an acute abdomen, hypovolemic shock and acidosis before we decided to take him to the OR. There's no such thing as a CT scan here. Once we decided to take him to the operating room "emergently", we waited around two more hours for a make-shift chest tube to boil. We removed a section of bowel that had been perforated by the bullet and closed him back up.

Surgery here is somewhat different than back home. Ketamine is the standard anesthetic and patients are not intubated. Sterile technique is attempted, but not always carried out well. During the operation, the patient was frequently semi-awake; he even tried to sit up and look at his guts spilling out of his abdomen at one point. He occasionally would spit blood across the room from his hemothorax. He started talking about yams. Near the end of the case, the electricity went out and we had to finish in the dark. It was a miracle he made it off the operating table alive.

The prime minister is coming in two days for the ribbon cutting ceremony at the hospital in Kolofata, 17 years after the hospital actually opened. He was supposed to have come many times before, but for one reason or another, the plans would always fall through. The concern this time is that there may be too much dust in the air for his plane to land in Maroua, where there is no radar at the airport. Everyone is super excited about the event and cleaning the hospital like crazy. All the staff get new white coats to wear. We have been designated official photographers for the day...if he actually shows up.

my first day in africa, alone

I arrived in Douala, the biggest city in Cameroon, one day earlier than Jessie and Chrissy, two family medicine residents also going to Kolofata. I waited for them in Douala so that we could make the journey up north to Kolofata together.

2.9.08
I generally tend to consider myself a strong, independent, courageous person, but I am not. I think I try to be for the sake of others and for the sake of my ego, but when I am stripped of everything I have ever known, my language, my culture, my rules, and I can no longer rely on past experiences to figure things out, I suddenly feel completely raw and alone and the furthest thing from brave.

Today I dared to venture outside the four walls of my seemingly safe, somewhat familiar hotel room, in search of a bank and atm. The hotel clerk warned me not to go too far because, well...she then lost her words and just kind of pointed up and down at me. I just nodded in understanding; yes, I know I don't look like everybody else.

My atm card didn't work, so I came back empty handed, but I was still proud of myself for wandering out into the jungle alone, even if it was only a block up the street.

anxious anticipation

I just bought 180 dollars worth of granola bars, toilet paper and deet, and I'm not even going camping, at least not in the normal sense.

When I signed up to go to Cameroon one year ago, the only thing my brain had room for was an overwhelming sense of excitement. I would not allow even an ounce of fear or doubt to seep inside. I was excited for the adventure, for the unknown, for the different. One month ago, I had a mental break down and decided for at least one day that I was no longer going. I didn't want to be robbed, raped or murdered. My two thousand dollar nonrefundable plane ticket wasn't worth my life. Now three days before I leave, I have entered this strange, calm, almost zen-like state of mind. The embassy still hasn't sent back my passport with my visa and I'm not even freaking out about it. Despite genuine efforts, I still don't speak French. I have no idea how I'm getting from Douala to Kolofata once I arrive. I got home from Montana later than expected after my car died in the middle of Iowa leaving me stranded, and my to-do list is down to my toes, but it's all good. Everything will work itself out; it always does. (kinda sounds like the stages one goes through when facing his or her own mortality...)

I have been told that nothing in Cameroon is predictable, and that being flexible and adventurous are essential survival skills for the unlikely visitor. Hopefully I prove to be adventurous enough to face the uncertainty, the unexpected and the great challenge that lie ahead. I am willing to predict, however, that this experience will likely change my life forever. Ready, set, go.