Hospitals, Presidential Campaigns and Other Things Badly in Need of Repair

Once again CRH is splashed across the media – and right on schedule, it was about this time last year that the neonatal scandal surfaced. This time the papers are focused on the gradual loss of hospital services – clinics, the lab and pharmacy are operating at less than 50% capacity with no proposed timeline for the return of function.

The primary issue is one of air quality, with administrators pointing fingers at the Radiology department for “Xray fumes” that have leaked all over the first three floors of the hospital due to “faulty ventilation”. The problem is being rectified slowly, and “experts from PAHO” have been called in, six months after the fact. Remember in April when the lab was down? Turns out it was an early manifestation of the same problem.

However the root of the problem is simple – the entire system of public health has been left to struggle along for too many years without the necessary financial attention.

The problems at Cornwall are the result of an aging infrastructure that has not been given the repairs and maintenance it needs to be functional. When you have a CT machine that works 40-50% of the time because it is old and routine maintenance is not up to scratch, that’s just a symptom of the disease.

This isn’t new though. Last year the Gleaner ran an article about how under-resourced the health facilities are in the Western Region. Minister of Health Christopher Tufton was quoted in the newspaper as saying:

“Frankly, it is an indication again that the infrastructure of the public health system in Jamaica is plodding because of limited capital investment in the sector over time, expanding population, much greater demand and usage, and all of that combined has made the system ripe for reform,”

Health reform is desperately needed, and its going to take a lot more than just three experts from PAHO.

Meanwhile in Foreign…

I’m going to admit something that’s a little unusual for a middle class Jamaican – I’ve never actually been to the United States of America. Not Disneyland, or New York or California. Not even a visit to Canada. North American soil has never had the pleasure of meeting my feet.

And with the way the US election is going, I may never ever get there. On the background of worsening racial friction and ingrained unrelenting sexism, the presidential campaign is breaking the glass ceiling and rock bottom at the same time (quote stolen from Twitter).

What I find crazy is how many people do not actively hate Donald Trump. People I work with, people I consider intellectuals, (these are also people with no ballot to cast of course) are not as convinced as I am to vote for anyone except Trump. Usually I can consider alternate points of view with aplomb – I have no issues working with or talking to people who’s ideas are different from my own. But this political debate has absolutely polarized me. I don’t care about his policies or his economics – he is too horrible a creature to become the next POTUS.

Of course Hilary isn’t a saint – no politician is. But she has experience and the common sense not to piss off and alienate large groups of people (in public). And as a nation which is often cast in America’s shadow, that’s really about as much as we can ask for.

Unless (hopefully) Obama decides to stay permanently in office.

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Day in the Life of a Paediatric Intern

This post originally titled, Waving the White Flag. (It’s Kleenex).

Where to start with Paediatrics? The current headlining scandal? The mind-numbing, soul-crushing duties? The prickly staff? The demanding work days? How about all of it, all at once, the way it is in real life. Nothing about this rotation happens in an orderly fashion. One time our senior registrar scolded us for not completing discharge summaries on time, saying “they are just as much a priority as dealing with procedures for patients on the ward and from clinic and giving medications”. If it’s one thing Paeds has taught me, it’s that everything can be a priority, all at the same time.

But all this non-stop action has succeeded in murdering my already feeble immune system so that I am now sick. With the flu. Probably. Or tuberculosis. Probably (not). If you know anything about me, it should be that I do not handle illness well. I handle it like a boy, really. Which is probably sexist to say but we all know it’s true. Boys are complete babies when they get sick. And so am I. I curl up in the foetal position and demand soup in a voice that sounds like death colded over*. I am utterly useless at anything involving physical, mental or emotional energy and I sometimes fantasise about using telekinesis instead of getting up to retrieve my phone from the counter five feet away.

Going to work today was entirely out of the question, so I used my leftover energy to feel guilty about calling in sick. I know what a Paediatric work day is like. I also know that I have duty tomorrow and I had to make the decision to take today off so that I could have some reserve of energy with which to survive that 36 hour beat.

This is what a Paediatric work day is like for me:

Starts at 8AM (unlike Surgery which would start at 6:30-7 because the earlier you arrive, the earlier you leave. On paeds you leave late no matter what). At 8AM you see patients on the ward until ward rounds start at about 9:30.

Ward rounds end at about 11AM when you start the day’s procedures which include taking blood, collecting urine samples and sending patients for investigations (like xrays etc). This is for patients admitted on the ward, as well as patients here for the day for a review or patients sent up from clinic.

All intravenous medications are administered by the interns, on a strict schedule. Medication also has to be ordered daily from the pharmacy because they don’t send up more than one day’s supply. This means writing up several charts and getting your senior house officers (SHOs) to sign them because your signatures carry no weight.

Then there is other paperwork like writing discharge summaries and prescriptions for the patients leaving. And there is following up of lab results, mostly cultures from microbiology, that require one of you to go into the lab for about an hour to write down results from the 3-4 books that serve as records.

All this takes you until well into the afternoon and suddenly it’s 3PM and you haven’t stopped for lunch. You just gave the 2PM medication but you can’t eat yet because this baby needs an intravenous access (a ‘drip’) and another baby just got admitted from Accident and Emergency (A&E) needing blood and urine cultures.

There are three of you working but it doesn’t seem like enough. The SHOs will ask “Are you the only one doing procedures? Where’s Dr. So-and-So?” and you will calmly explain that Dr. So-and-So is giving medication while Dr. What’s-Her-Face is in A&E seeing referrals and there’s no one left to help you and they will press their lips together and give you a look which you’re pretty sure does NOT mean “That sounds rough, I’ll help you” and instead means “Well. You’re just gonna have to get your shit together” and you move on with your day. Breathe and move forward should be the mantra of Paediatrics.

After you finish procedures, following up the regular lab results for the samples you took off in the day can take you beyond 4PM because some result always comes back abnormal and needs to be acted on. I don’t like to leave that kind of work on the duty intern because duties are rough enough without adding work that’s carried over from in the day. So I never end up leaving before 6PM and usually leave around 8PM.

I’m not going to get into my eating habits because my aunt reads this blog and would probably have a conniption but suffice to say I would not turn down the offer of a live in chef. Or maid. Or professional masseuse. Or all three in one so I’d only have one monthly fee. Am I setting the bar too high?

Fuck it. The bar was high before I even got here. This whole time I’ve been trying to brush it with my fingers, on tiptoe, stretching furiously toward some untouchable standard. Today I got to rest my aching body/mind/soul for a teensy bit. Tomorrow it’s back to the rack.

Flecti non frangi.

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(*Because death warmed over sounds a little too pleasant. Like Death already got soup and a blankie and now he’s pleased as punch. Although I have been told that my sick voice sounds very sultry so maybe my voice actually is warmed over).

Of Scandals and Sheer Bloody-mindedness

For several weeks late last year the hashtag ‘deadbabyscandal’ was splashed all over social media. At the time I was studiously avoiding any news or public opinion on the topic because I was working in the midst of the neonatal department at one of the hospitals involved. I was already getting a lot of emotional backlash at work from my superiors (it having trickled down from the public) – I didn’t need it firsthand.

The first time I looked up any information at all on this topic was when one of my fellow intern/blogger (barefootmeds, she’s awesome. Go say hi) asked for details, which I will share here. Newspaper articles, because now that I work for the government I’m legally obligated to keep their secrets (or some shit like that).

This is how it started: Four Months, Eight Babies Dead.

And then it got worse: Another Baby Dies at Cornwall Regional.

And then someone said something they shouldn’t have: Ferguson Sorry for ‘Not Real Babies’ Comment.

And it only continued to escalate: Backlash Over Dead Baby Scandal because babies and conspiracy theories are a social minefield.

Here is a handy timeline of the hospitals’ responses.

To which I have only the following to add (as a soldier working on the front-line, whose opinion the crowd back home rarely ever wants to hear).

  1. The death of a baby is and will always be a tragedy. It is a horrible, horrible thing.
  2. An approach that was more solution oriented rather than blame oriented would have been infinitely preferable – and this was the approach taken by our Head of Dept and other consultants. Contrast the approach taken by politicians.
  3. Outbreaks happen a lot, especially in critical care areas, and largely because we have an imperfect system that is overburdened and understaffed.

It is a sad truth of our society that change is only galvanized by conflict. That the things which are broken are never addressed until something terrible happens, and even then we can expect a patchwork job at best.

The nine day wonder that this tragedy was paraded as has created some minor changes, yes, but the over-extended structure of our health care system still stands poised to collapse under the pressure. As our politicians preen and pontificate in preparation for the upcoming elections, this tragedy becomes nothing more than mud to be flung and then swept under the rug. When will we forget the curry goat/Red Stripe and the dancehall gatherings masquerading as political rallies and remember what really matters?

The same people who pile up in the Accident and Emergency Department demanding shorter waiting times and more bed space from the hospital staff (who have no say in the matter) neglect to hold accountable the people with the power to actually effect change. On election day they do the same thing they have always done; at the rallies they cheer and stomp and revere, ask no hard questions, make no demands. They they get shot or get sick and they get upset at us in the public system for not having the drugs they need in stock, for not having the right equipment to save their lives.

Jamaican people are the ones swatting violently at the mosquito while sinking knee-deep, waist-deep, neck-deep in quicksand. But don’ worry, mosquito soon stop bite you.

Coming in Live through Your Stethoscope

I like to think my shenanigans on the blog are useful to other people, that it’s not just Jamaican-accented self-gratifying chatter amidst all the other self-gratifying chatter that clogs up the internet. So in the same vein as my posts on medical school and UWI, I’m transitioning into something a little more adult. Still PG-13. Well, depends. Some internship stories are pretty out there.

Mic test.

Internship will probably be the worst year of your medical career. Scratch that. It will be the worst year of your medical career, unless further down the line you end up with a horrible boss who treats you like an incompetent intern. That would probably be worse.

But it’s also supposed to be the most liberal year of your career. The level of responsibility is much higher than medical school (for obvious reasons) but much lower than it will be once you get fully registered as a doctor. Internship is the test the waters year. Dip your toes in all the specialties and a few sub-specialties. See what you like and what you don’t. Free time is limited because you’re first call and therefore can never leave the hospital, but just like med school – doctors work hard and party harder. And sleep even less.

Between the working and the partying (notice how no one cares about the sleeping) it’s important to learn as much as you can. There are aspects of patient management that only become apparent once you start working. Add to your skill set and exposure – minor amputations, sutures, chest tubes, thoracocentesis, paracentesis and neonatal resuscitation (among others) are all the forte of the medical intern. If you show interest, people are almost always willing to teach (because some people are dicks, and there’s nothing you can do about that) and there’s a lot to learn.

While you’re busy learning, take everything with a grain of salt. Always, always be cognizant of the complacency of third world medicine, and the fact that sometimes the things we routinely do are not the internationally acceptable things. Double check your management with evidence-based guidelines (and be up to date), Youtube your procedures to see how it’s being done in more resource-rich centres. Keep your standards high, even if you don’t live up to them.

One inescapable downside to intern year is that people will be mean. People will be mean and cranky and at some points downright bitchy. They will take their frustrations out on you; you will end up being blamed for the incompetence (and sometimes sheer slacking off) of other people. Patients will yell and cuss. Staff will grumble and talk about you behind your back. Work environments (as I have discovered) are rarely if ever rose gardens. And even if it smells pretty, there are usually thorns.

So, keep the faith. Remember why you started doing medicine in the first place. If that doesn’t work, remember that you won’t be at the bottom of the food chain forever. If that doesn’t work, remember that at least you have a job that pays more than most in this country. And even though sometimes I feel the urge to be just as mean back to them, I have found time and time again that it pays to be nice (even if you have to fake it til you make it). Also that having friends in every department is pretty much the only way to get things done for your patients in an overwhelmed, understaffed system (as I have mentioned before).

 In my last seven months, I’ve developed some words to live by to help me keep my sanity.

Don’t be a hero, is what I learnt from Paediatrics.

Surgery taught me that responsibility is informing your seniors.

And on Internal Medicine, I am learning that you catch more flies with honey than with vinegar.

Somewhere in these ramblings, I hope you find a truth you can apply to your own internship. Or maybe it’s enough to know you’re not in the struggle alone.

All of Only Halfway There

What’s the hardest thing you’ve ever had to do? Physically, emotionally or mentally. Have you ever stretched yourself to the absolute limit?

What did you find? Did you break, or just bend? Did they crush you?

I bet you survived. Humans are like that. Determined as cockroaches.

My Paediatric experience will be unlike any of my batch-mates. We manned the special care nursery at a time of national crisis – babies were dying, health ministers were being impeached, the public was furious. We interns, the most junior staff, were the bulk of the paediatric department. To say we were screwed was an understatement. Every odd was stacked against us.

And yet.

We survived. Not just survived, thrived.

Of course, the first six weeks were the worst hell imaginable. I cried at work. Twice. I pushed IV medication and the lab staff and myself. I lost weight, I was anxious all the time. We all had chronic fatigue.

Then slowly and painfully, like a lizard shedding its skin (does that hurt? I feel like it should hurt), we metamorphosed, Kafka-style. Almost overnight we hardened, gained competence. The odds were still stacked, but we got better at playing them. The workload lightened. For doctors who were molded by an overpopulated nursery (thirty babies our first few weeks), taking care of eight newborns (plus or minus three) was child’s play. I moved from the desperate panic of ‘How will I survive this?!’ to the weary surprise of ‘I must have been stronger than I thought’.

Like all things do, my three months on Paediatric Medicine passed. January 4 I stumbled into the staff meeting bleary eyed and battle-worn but ready to take on whatever staff assignment they threw at me. Internal medicine was my new playing field. Game face, on.

 

Seasons of Surgery

Three months of my Surgery rotation are almost entirely behind me. Today I was on the ward jubilantly dancing to my own personal rendition of “Two and a Half Days Left” – if you haven’t heard it yet, don’t worry. It’s on my mixtape. Have a listen.

While a nurse wondered aloud whether I needed loading with Dilantin for my seizure-like activity, I blithely one-man-partied on.

This afternoon I had an epiphany: medicine is all about people.

But what about those five years of complicated biochemistry and endlessly detailed anatomy? Those reminders about evidence-based management and peer-reviewed research? All still relevant. But at the end of the day, what the delivery of health care is about is people.

Effective health care delivery means knowing what what people want.

We have to know what the patient expects from us. “to get better” is not a specific enough answer. It can mean keeping a limb or losing one. It can mean an IV line that never stops dripping, never mind that it’s only infusing normal saline. We have to know our patients.

Radiographers and radiologists are overworked. They know how we warp medical histories in our desperate attempt to get our patients’ done first, they know that sometimes we flat out lie. Yes, sometimes they send back really bad xrays and don’t bother to do the ultrasound for days because the porter only just now got sent for the patient, but getting angry has never solved any problems. They know we need their help, and we have to know when to pull back from all the pushing.

We have to know people.

Pharmacists are understaffed. They wield a lot of power behind their glass windows – second to laughter, medicines are the best medicine. They don’t have a lot of stock to work with either. Half the time, we’re out of this antibiotic or that painkiller. Now we have proton pump inhibitors, now we don’t. It’s like playing peek-a-boo only instead of a friendly face, what pops up is a stomach ulcer.

When we’re frustrated because the patient with a blood clot up the entire length of his leg hasn’t gotten his heparin because it wasn’t sent to the ward, it doesn’t do to yell. Yelling only makes pharmacists crawl behind their glass windows and give us a glass stare. I’m learning to bite back retorts and swallow anger because all it does is take me two steps back. Hopefully PPIs will be in stock by the time I get my stomach ulcer (which should be any day now).

We have to know people like porters. Have to know how to get them to work for you, instead of making them put you to work. Today, I got a patient down to the radiology department without having to accompany them personally for the first time. It was a red letter day, lemme tell you. It took me a dozen phone calls, endless cajoling and three months of saying hi and being friendly for it to happen. (In return, of course, I got a metric tonne of attitude, one “you owe me lunch, doc” and, AND, the results of my patient’s xray and ultrasound thankyouverymuch).

Working in a public hospital is about knowing how to tread around toes and egos, knowing how and who to bribe (always have candy) and knowing how to keep your head down and work hard. There’s a lot of humility and swallowing of pride and a little bit of knowing your limits. (there needs to be more knowing of limits).

It’s great to have someone you can learn from, even if that someone is sometimes yourself and your own mistakes because internship is one hell of a learning experience.