First Week on the Job

Taken from inside car (hence reflection)

The hospital at which I am working is about 30 minutes from where I live (that’s with traffic and bad roads, so I have no idea how far it really is). There is a hospital driver who picks us up every morning -us being a couple local doctors who are on the residency faculty, the program director, myself and any visitors. Septermber-October is a very pleasant time to be in K, so there will be a number of other visiting doctors. The car is small, and male and female passengers should not sit next to each other ideally. However, it is okay for me to sit next to another female or one of the other expatriot male (if necessary), but not a local male. So often, the two local male faculty members end up sharing the front passenger seat (not so comfortable). Anyway, I always have to ask where I should sit so I don't make a cultural faux pas.

The drive itself is interesting. Along the way, there is this bombed out palace and some burned out old Russian tanks. There are mountains on both sides, mostly brown and not too tall. Although one day this week it rained in the city, leaving the mountains with a light dusting of snow and clearing the air somewhat. It was actually quite pretty.

Once at the hospital, there are separate entrances for men and women. I head up to the female resident room where I can change into my white coat (I wear a black coat anytime I’m outside) and join the residents for morning report. This consists of a quick update on the patients in the hospital, those who were seen in the emergency room and any new admissions in the past 24 hours. Then one of the residents or faculty give a short presentation. After this, everyone disperses to their various duties.

I started out in OPD – outpatient department. This is basically a walk-in clinic for non-emergency health problems.  Since I can't speak the language, I worked with one of the male residents. At first I wasn't sure how to interact, but after a day or so, I realized it was okay to ask questions and felt more comfortable conversing with him about various topics. The residents have been great about translating my questions to patients and including me in the history as well as the assessment and plan. Also, I wasn't sure if it would be appropriate to examine the male patients, but apparently there really isn't a problem doing a basic physical exam (heart, lungs, abdomen, extremities, ears, nose, throat...). I do think some of the female patients were relieved to have a female doctor present. 

Actually, I have been surprised at how open many of the women patients have been with male doctors. Some women come with male family members who do most of the talking, but some come alone. I suppose if I weren’t there, they would be seeing a male doctor alone, which I thought would be culturally inappropriate. Apparently there are women who refuse to see a male doctor. But so far I have not seen any problems with this. On the OB ward, the male residents only step in when necessary but often try to maintain the privacy of the patients.

I’m still trying to get to know the residents and faculty. I was really pleased on my third day when one of the female residents made an effort to include me in an emergency appendectomy and then pretty much took me under her wing to make me feel comfortable. I hope to get to know her and the other female residents better over the next weeks. They all have interesting stories to tell I’m sure.

This is now my sixth day (Friday and Saturday are the weekend days) and I have had some great experiences. Besides the appendectomy (which was open, not laparascopic), I've helped with two vaginal deliveries, newborn exams and resuscitation, lots of gyn exams, insertion of an IUD, and a circumcision of a 2-year-old. The latter was a new experience; I've only ever circumcised newborns. Circumcising a wide-awake toddler under just local anesthesia was something! Occasionally, when outpatient clinic is quiet, I wander into the ultrasound suite and get to watch and do abdominal and pelvic sonos. Most have been normal, though we did pick up one acute appendicitis. I can't say I've seen anything unusual or terribly different in terms of the medical problems or general approach to patients, except that it is more routine to cut episiotomies here and I have seen the midwives using fundal pressure to facilitate delivery. Oh, and they do not have amniotomy hooks (to rupture membranes); instead they use needles. (I would definitely be more worried about injuring mom or baby with a needle, but I guess they are used to it.)

I am humbled at how eager everyone is to include me and give me learning opportunities. It is a teaching hospital, and the faculty and even residents all like to teach. So far I have received tips and hands-on teaching in anesthesiology, surgery, ultrasound, OB. I guess I wasn’t sure how much I would be allowed to do, but I am being treated just like one of their residents, which is great. It is also humbling to see how much I still have to learn. The residents here are much more experienced and comfortable with surgery than I am, and they all learn to do ultrasounds – these are great skills to have for someone working in a rural district hospital in a resource-poor country. 

Today I gave a talk on pediatric developmental milestones to the residents. I used a participatory activity borrowed from my residency program and included chocolate for incentive. It was fun and I think well-received. And hopefully it gave the residents a chance to get to know me a little better.

Okay, this was a really long blog. So I will stop and save more stories for next time.

First Impressions

View from street en route to work

My first impression of K is that it is dry and dusty. The surrounding mountains blend in with the brown landscape and brownish air. (I’m not sure if the air is brown from pollution or dust, probably both.)  Like so many other parts of the world I’ve been, in traffic is crazy with no obvious rule or reason: cars, trucks, people on foot and on bikes, herds of sheep – all trying to make their way along or across the roads with no signals. Most of the roads are in poor condition. If once asphalted, they now are potholed and dusty. So travel anywhere takes a lot longer than it would at home. 

View from my roof

Of course, as a woman, I immediately noticed all of the women in blue burqas or long black coats, some completely covered except for their eyes, others wearing scarves that show their faces. Even the young school girls have long black robes and white head coverings. Though I’ve seen plenty of pictures and knew what to expect, it is different to experience it in real life.  I have not yet gotten used to wearing a scarf over my head, and still haven’t figured out how to keep it from slipping off. Fortunately, there are places I can take it off - inside the guesthouse or in the female residents’ room at the hospital. It is nice to see my colleagues face to face, though it is amazing how much personality can be expressed with just the eyes. In some ways, I appreciate the safety of anonymity that comes with covering up; in fact, I wish I could wear a burqa just so I wouldn’t stand out as a foreigner.  On the street, even wearing my black coat and scarf, keeping my head down and avoiding eye contact, I feel vulnerable. 

View from my roof

In general, I still feel very uncertain about how to act and interact here. As a western female, I am considered a “third gender.” Supposedly I have more freedom to interact with both western and local men than the local women do. With my fellow expatriots, I can relate more or less as I would to men back home.  And I should be able to talk to my local male colleagues at the hospital more or less as equals. But I don’t quite feel comfortable yet. It is hard to be constantly aware of my expressions, gestures, tone of voice, eye contact, body language, head covering, etc. Do I greet everyone I pass in the hospital? How friendly should I be? Since I don’t speak the language, it’s hard to do much more than say hello anyway. At least with the women, I know I can be more relaxed, so I’m focusing on that for now.

Getting Here

I know you are all eagerly awaiting exciting blog posts from "K" (no specifics for security purposes). There is plenty to tell, and I promise to tell it bit by bit. So bear with me - one story/experience at a time.

Despite having lists upon lists to organize my preparation for international travel, my last few weeks of getting ready were pretty much chaotic.  Being on in-patient adult medicine service (my busiest rotation) made it a bit more challenging. The week before I left, I was on the night shift. In a way, that actually made things easier, since I could use the daytime hours to run errands (at the expense of sleep). It had the added benefit of helping me shift time zones with less trouble. In addition to getting packed, I had to finish discharge summaries, dictations, clinic notes and other work-related tasks to make sure I didn't leave any patients hanging.

I’m so grateful for my parents, who drove up to Wichita on the Thursday before I left to help me get ready. They ran all sorts of errands, bought last minute items, and kept me calm and well-fed. On Friday night, some dear friends hosted a gathering for prayer and blessing to send me off. So by the time I got on the plane, I was feeling as ready as I could be – at peace and encouraged.

On a side note, unfortunately, I think I wore my parents out. My father ended up in the hospital with pneumonia the day after he left Wichita. They didn’t even make it back to Houston but were stopping to see my sister and her family in Dallas on the way.  Though I know they would prefer to be home, I’m so glad they have had family support throughout this ordeal. I can’t help feeling somewhat responsible, since I may have overworked them getting ready to go. But I think Dad is on the mend, and I’m so grateful for the ability to talk face to face with them over the internet despite the thousands of miles that separate us right now.

 

The trip here was quite long. 14-plus hours to Dubai (got lots of sleep and watched three movies!), not to mention several hours of lay-overs.  The Dubai airport was quite interesting. I listened to the Muslim call to prayer while sipping coffee in the airport Starbucks. Then I had to take a taxi to change terminals for the final flight.  Everything went smoothly though, and it was to have a travel companion who is also staying at the guesthouse here in K. Everyone at the guesthouse, who all work for the same organization, has been very helpful and welcoming, and I already feel at home (at least in the guesthouse).  More to come...

Count down 13 days

13 days until I leave for my international rotation. There's still a lot to do, and I'm tempted to get overwhelmed with the details. But then I think, I'm only going for 4 weeks. I can do without a lot of things for 4 weeks. Plus, I'm going to be in a big city, so I should be able to get the essentials.

The only hitch is that I am on the adult medicine inpatient service this month, which is probably my busiest rotation. Generally I work from 6 AM (more like 5:30 since I like getting there early) till about 6 or 7 PM every day. This coming weekend the third-year residents are covering everything as the 1st and 2nd-years are on a retreat for 5 days. So basically I don't have any days off until I leave. Oh, and I am on the night shift the week I leave so that should be fun. At least I won't have to worry as much about jet-lag and shifting time zones!

Actually, I've had a great month so far on medicine - interesting cases, great patients, great attendings, great teammates. I haven't been on adult medicine for several months, and I'd forgotten how mentally stimulating it is - the challenge of figuring out what's going on with the patient and how to balance all the systems that are out of whack - heart, lungs, kidneys...  It's always rewarding to "fix" someone and send them home in better shape. For example, I recently had a patient who came in completely out of it due to liver failure. She was unresponsive, completely disoriented when she did wake up, and her all of her labs were abnormal. By the time she went home, she was awake, oriented, back to her baseline. I had the chance to talk to her and her family about her liver failure and what it would mean for her down the road. She is very motivated to stay "sober" (the cause of all of her problems is alcoholism) and I believe she will. We talked about the importance of having help - namely asking for God's grace every day. I got to pray for her before she left the hospital.

Of course, you can't fix everyone. I had another patient with a drug abuse problem that got him kicked out of his living situation. Unfortunately, he's in denial and won't admit the extent of his drug problem. How can you help someone who doesn't think they need help?

Sound like I'm running a psych/drug addiction ward?  Maybe. But I've had lots of other cases too:  pancreatitis, diabetes, UTI, a huge thyroid goiter filling the patient's whole right chest, pneumonia, ruptured ovarian cyst, chest pain...some of them text book cases, others not so easy to figure out. Every day I discharge one or two patients and get a couple of new ones. There's always a more to learn - keeps it interesting.

Please continue to pray for me as I prepare to head overseas. Pray that I will not become caught up in the details but be able to focus on the big picture - the opportunity to serve and learn in a different country and culture. Pray that I will be able to give my patients here the compassion and care they deserve in the next two weeks despite having a lot to do to get ready to go.  And please pray that God will use this experience to guide my next steps in life. I have a couple of job interviews when I get back, and I want to choose the best path to whatever it is that God wants to do with my life. Proverbs 3:5-6 assures me that the Lord will direct my steps if I acknowledge him and trust in him.

Have a blessed week!

Third Year of Residency

I guess it's time to post again - it's only been eight months! I am now a third year resident which means I should know all there is about family medicine, right?  Hah! What it really means is that I now realize that I will NEVER know it all and will spend the rest of my life learning and depending on God to help me help my patients!

Marion Historical Museum

Marion Hospital

Right now I am writing to you from Marion, Kansas, where I am "moonlighting" - working as a small town doc in the emergency room of a rural hospital. I'm here from 6 PM Friday to 6 AM Monday to take care of anything that walks (or rolls) in the door. So far I have seen three patients, none of them truly urgent - a sports concussion, a foot injury and poison ivy. I do have to be prepared to stabilize very sick or injured patients, so it's a lot of responsibility (and a bit scary still). Mostly, I enjoy meeting the folks in the community, putting my medical knowledge and skills to the test, and gaining confidence.

In June, my father and I took a group to Bolivia for our annual mission trip. We saw over 250 patients during the week, worked at the girls' orphanage and helped to build a special education and rehabilitation center that will also serve as a daycare center for health workers' children.  My patients were mostly adults with diabetes, but I did see some interesting - and sad -cases. One man had just had a heart attack and needed a cardiac catheterization. However, the cost is really prohibitive in Bolivia, and I am not sure about the outcome. He was on medical management, but I am sure even the recommended medications are very expensive for the average Bolivian.  Another patient was in remission for ovarian cancer. She had to travel to Santa Cruz every 6 months for tests - CT scans, bone scans, blood work. You can imagine how expensive all of that is. She had already spent all of her money and taken out loans to pay for her initial surgery and chemotherapy. I wish I could have helped them more, but I was able to pray for them. I did diagnose one woman with diabetes. She was very upset initially. However, I gave her a lot of education and encouragement regarding diet and exercise, and she attended a diabetes education class while I was there. Hopefully, it was caught early enough that she can make some lifestyle changes to avoid some of the long-term complications of diabetes. Unfortunately, there are limited medications available to treat the disease in Bolivia. Insulin is very expensive and somewhat dangerous to use without good glucose monitoring. And almost noone has a personal glucometer; test strips must be outrageously costly there. How could you know how much insulin to use without frequent testing?

On September 22, I will be heading to  the Middle East for a one-month rotation at a small hospital and residency program. It will be a unique opportunity to learn about Muslim culture, the health issues and medical system in this part of the world, in particular women's health.  I will also get a first-hand glimpse of what it's like to run a residency training program and teach residents. Please pray for safety, a great learning experience, and clear direction about whether or not this is something I want to do long-term. I'll be blogging while I'm there, so stay tuned....

Almost done with Medicine!

The adult medicine service at the hospital is our most challening rotation. The hours are long, the patients are really sick, and the cases are usually pretty complicated. But I guess that's what makes it fun - I get to use my brain to figure things out, and my best people skills. I didn't always think it was fun, but this year as my confidence has grown, so has my enjoyment of medicine. Of course, I won't be sorry for the month to be over. On to new things! The rest of the year should be a piece of cake since this is my last medicine month this year. I've gotten all the hard rotations out of the way.

I got to go home for a weekend too -that was fantastic! It was so great to just hang out with friends and family and to visit my church back home. I'll be home for Christmas too, but only for 4 days. Can't wait to see everyone again!

Aaahh. Family!

The highlight of this month was seeing my niece and nephews, especially my newest nephew. There's nothing like family to remind you what's important and eternal in life. I am blessed to have two sisters who share my faith in Jesus and want to raise their children to know God and follow him. My niece is especially sweet and has such a tender heart to please the Lord and love her brothers.


I enjoyed spoiling her by taking her for ice cream (it took her over half an hour to finish a cone!!) and buying her Halloween costume. Doesn't she make the cutest witch you've ever seen?



She got to meet Christopher Columbus at a special event, but she was a little shy. Apparently a man dressed in strange 15th century garb was a bit scary for her. So I took her for ice cream and we watched the people walking by. She's really into "I Spy" right now. I got to play for hours while she licked her cotton candy cone.


Here's the two older ones giving me a concert. The middle nephew is all boy. He doesn't sit still - likes to be on the move, making noise, running, jumping, going up and down stairs . . . and up and down . . . and up and down...


And here's the newest guy. You have to admit he's adorable! I couldn't put him down!


I don't know when I'll get a chance to visit again. Thankfully, I will see them all at Christmas. It will be rushed and crazy, and I'll be competing for their attention with Grandma and Grandpa. But I'll settle for whatever I can get. They grow up so fast!