My Friday morning started as
usual, sitting on my porch reading over coffee, catching up on the latest in
the US presidential primaries. It had been a busy but great couple of weeks of
teaching and learning, to be capped off with the Medicine team leading Journal
Club at 8 a.m. So I set off a bit earlier to ensure I was at the board room on
time. As I walked onto the hospital grounds, I noticed two of my three medical
officer interns (who were supposed to be presenting) were standing outside the medical
ward. I figured that was a bad sign. I asked why they were not preparing for
the start of Journal Club and they informed me the third intern would present
for us while they took care of two unstable patients.
I sat down in the board
room and before the first Powerpoint slide I got a call on my little Nokia. “Dr.
Travis, please come, we have a code in the male ward.”
The interns were running a
code, doing chest compressions on a very sick patient. He had Diabetes that was
poorly controlled. Well, it was not controlled at all – he had never taken his
medication. He had now been admitted with extremely high blood sugars and a
foot in which he had lost sensation giving rise to a deep wound causing a
severe system-wide infection. The code went a little over 30 minutes with a few
rounds of adrenaline, potassium, bag-valve-mask ventilation to help the patient
breathe, and intravenous fluids running into both arms. His random blood
glucose was now just above the normal range. We had finally controlled his
sugar, but his anticipated amputation had not occurred soon enough. He passed
away and we de-briefed on how we performed in the code.
Valuable lessons can
usually be learned after a poor outcome. But that outcome has to be identified
before one can know the sequence of events that led to the teachable moment. A
frustration when working in a low-resource setting is that we many times do not
end up with a firm diagnosis. Autopsies are extremely rare (I have not heard of
one done in the last three months). Laboratory investigations can be
unreliable. So, without a definitive answer, we are left to clinical patterns
and team deliberations to decide the lessons learned, or what was missed, following
a difficult case.
“This ward is so discouraging.”
One of my favorite senior nurses was down after another death.
We returned for the finale
of Journal Club, where the entire room discussed the (largely detrimental) useof steroids in HIV-associated Cryptococcal meningitis. As our team left, we
reviewed the previous call night and our plan for rounds that morning. We arrived
back onto the male ward and the same nurse notified us that our previous
patient’s neighbor had passed. The patient in the bed right next the patient we
coded had died while we were out at Journal Club, and because of his poor prognosis
due to metastatic prostate cancer, there were no plans for resuscitation.
Rough start to this
Friday!
One early traumatic death.
One expected, seemingly peaceful death.
--
Teaching is not easy. It
requires patience and organization. Preparing a quality lecture takes time.
Arriving at a plan for any clinical scenario takes guiding a young physician
without taking the reigns. This is one skill I have been taking time to develop
while here, and it is an effort that has given me a renewed respect for teacher
friends and my professor father.
Two weeks ago I gave a
lecture on depression. With infectious threats under better control,
non-communicable diseases are on the rise. Mental health issues are commonly
underlying forces driving patient behavior and many times they manifest in
physical signs. Perhaps our diabetic was not compliant because he did not
believe he had the disease or did not understand the diagnosis or was down
about managing a chronic illness for which he could not afford the long-term
treatment.
The recent announcement ofincreasing suicide rates in the US alongside recent writings of the stigmaassociated with mental health issues in Kenya, in addition to my experience in
managing chronic depression and anxiety among other diagnoses, made me think it
was an appropriate and timely topic to discuss with the residents. Poorly
controlled mental health diagnoses lead to poor compliance with treatment
regimens, decreased productivity at work, increased absenteeism, and an overall
lower quality of life. No matter the label you put on the patient, there are
always psychological issues that could be better addressed to improve their
lives. But our society and our employers sometimes ignore their importance. One
need to look no further than daily current events such as the Germanwings pilotwho flew a plane directly into the ground or the multiple shootings across the
US each month to realize one major thing: we are not adequately addressing
mental health issues worldwide.
Teaching about depression
in an area that does not typically focus on mental health issues gives rise to
interesting discussion. The overall goal is to simply have the residents be
aware of mental issues surrounding each case so that discussions with the
patient and their families may address some potential barriers to care beyond
the hospital.
--
In the US at least, we do
not value teachers near as much as we should. American society rewards certain
types of business and entertainment, but fails to invest in some of the most critical
vocations or professions. And our healthcare system fails to direct resources
towards issues sometimes difficult to address, such as mental health.
So many people say how
important mental health or primary care is, and they say how important teachers
are, but words do not incentivize
sharp students to become and remain teachers and they do not pay off the
massive educational debt of primary care physicians or psychiatrists and they
do not form the necessary teams to manage the ignored despair that affects
almost everyone, worldwide, on a daily basis.
--
This morning before leaving a patient’s room on the private ward, he asked us to sign the Guest Book. “Like a hotel?!,” I asked confused. He was blind, due to poor diabetic control, and this teacher (more educated than our average patient) wanted to be sure he had a log of those health workers who had cared for him. What an excellent idea, I thought, as the three of us signed before exiting.
Well said, Travis!! I think part of the problem, at least in the U.S., is we all try to project how we have it together -- and any vulnerability is seen as a sign of weakness. (When in fact, it seems to me, vulnerability is what helps us towards empathy with others.) And this near-universal facade of strong mental health means that everyone (I exaggerate) goes home and thinks he or she is the only one suffering! My psychologist says that the research shows that some mental health patterns -- for instance the tendency to see the world as a warm, comforting place versus seeing it as a cold, threatening place -- are established VERY early, with childhood trauma of any sort tending to steer one down the "cold, threatening" path. The best answer I've found is to try to hang out with smart, caring, usually upbeat people who are honest with themselves, and with me, about their emotional selves. You know, people like you!! I love you. Dad.
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