Is There A Doctor In the Room?

 (practicing in the days of Ebola)

This Article is Published in a shorter version in The Olympian.  Click here to read that version.

A longer (more raw?) version is below:


“Is There a Doctor in The Room?”  The question was asked by the chief surgical resident soon after he entered the trauma bay, full of confidence and clearly in charge in the midst of chaos.  He asked it after he had been informed that the nurses had been trying in vain to get an IV.  He knew the answer already.  Several intern doctors and medical students (like myself) were trying to help: getting our gloves on, wondering what to do next.  Afraid of death, which was obviously knocking, but excited at the same time to be where the action was.  We all questioned what he was getting at.  What did he want?  Did he not know?  Was this a trick question?  Was he trying to teach us something?

After the appropriate pause for effect, but not so long as to delay anything, and while putting on his own gloves, the chief explained,  “If there were a doctor in the room, he or she would have been getting a cut-down.”  Of course!  A venous cut-down.  We all secretly kicked ourselves for not already reaching for the minor surgical kit.  We could get IV access.  We had been trained in how to “cut down” through the skin to a superficial vein and grab it, get an IV in it and tie it up so it would not come out.  That way we knew we could get some fluid in.  I grabbed the kit and the chief and I did my first cut-down.

I think today it is time again to ask this question:  “Is there a doctor in the room?”   The today I am talking about is the day of Ebola.  The disease on the headlines.  This fearsome outbreak that has killed thousands in Africa and has reared its ugly head here in America as well.   There are newspapers.  There are lawyers.  There are many people scared out of their wits.  But the question is,  “Is there a doctor in the room?"

If there were a doctor in the room, he would go and treat the patient.  He would stop looking around and even though he had never seen such a patient before in his life.  He would dig into his brain and remember his training and come up with a logical, determined, and reasonable plan to do something about the problem.  He would do it, even if it made him shake in his boots.  He would do something even if his friends did nothing.  He would do something even if there were risks.

If there were a doctor in the room, she would volunteer to go to Africa and help treat the epidemic at the source.  Some have gone.  But recruiting doctors for this job has been very difficult.  Many working at the Ebola Treatment Centers are on their second or third rotation.  When the President of the United States put out a call for doctors to rise up and go, there was a surprising silence.  Aid organizations have the money and the logistics personnel, but few doctors.  

Is there a doctor in the room?

If there were a doctor in the room, she would stand up for reason and science and compassion for those returning from overseas.  Instead, we have a fight between governors and lawyers as the people panic in the street.  Doctors trained in the current era of  “guidelines” and “protocols” cannot function without them.  So they bow to whoever comes up with the plan that carries the least amount of risk, no matter the harm it may do in the end, even in the fight against this disease.  A doctor, knowing history and literature and people, not merely science, would explain to the people that no life is without risk.  A doctor would help bring people to balance, realizing that those who insist on an absolute risk-free life need therapy.  She would realize that to send people overseas means they will come back and need support and help, and they themselves will be a risk.

Is there a doctor in the room?

If there were a doctor in the room, he would put his suit on to see the Ebola patient.  He would know from lessons learned from prior outbreaks that a full body suit is required, with every inch of skin covered.  If there were a doctor in the room, he would do his best to find out who had treated Ebola patients before him, and he would realize it was the Africans and the Aid workers.  He would contact them and read their reports and see what they did.  He would not stop at full body covering. Until there was a clear reason to change strategies, he would do exactly what they do in Africa:  not let the Ebola patients into the hospital, treat them in a separate facility or tent, give them good supportive treatment with IV fluids, use chlorine based decontamination, send them to specialized centers for care.

So the question remains in the air, as it did those years ago.  That day of the gunshot and the blood.  The question that made all of us very uncomfortable, but at the same time gave all of us a flag to carry and a rallying point:  “Is there a doctor in the room?”

Epidemic of Medical Care

Dr Welch in his NY Times article points out that screening for thyroid cancer leads to more diagnosis but not likely better treatment or better care, but likely harms. 

I think it is very interesting as I think about these questions:

1.  What does a country look like that has too few doctors?  I was recently in Liberia, where the WHO registered 51 doctors for the country of over 4 million persons.  Several of those have died of Ebola.  I worked with facilities in Monrovia, where patients are cared for, babies delivered, simple treatments done by nurses mostly.  Research has shown that having a medical attendant for a delivery dramatically reduces maternal deaths. 

2.  What does a country look like that has too many doctors? This is where Dr Welch and the Lown Institute and the Dartmouth research helps us to understand that so much of our medical care is actually hurting us because of over-medicalization, over-treatment, over-testing, and certainly overspending on healthcare in America. 

In both situations--Liberia and the USA--one thing that strikes me is how invisible this issue seems in the regular everyday life of the people and the thinking of the medical workers.  The Liberian government, even today in the days of the Ebola crisis, still will ponder over your application for a medical license.   Providers wonder if a volunteer doctor will be unfair competition.  As if there was not an absolute desperate need.  And in America, new medical schools are still opening, with a call for more doctors in a "national shortage."  The fish does not notice the water she swims in.

And so it takes certain people, with a special vision, to help the rest to understand that realities of the medical establishment perhaps are different than we think. 

Holes

“Am I leading a rebellion, that you have come out with swords and clubs to capture me?”

This is what Jesus said in Mark 14. He knew what was going to happen: in fact he had just explained it several times to his disciples both during supper and later in the garden of Gethsemane. He knew the disciples would all desert him: he had just been arguing that point with the Peter, who angrily thought he would be better than that. So the question is: why did Jesus ask this question? Surely he was not looking for an answer. In addition, he knew that in asking it, it would not change the course of events: he would still be captured, tried unfairly, and tortured to death by crucifixion.

One reason I think that Jesus asked this question was simply his emotional response to the situation. The injustice, the absurdity, the irony. As if he was overthrowing a government, or he was a master criminal. After all of his efforts put in to teaching these very people. After all the miracles, all of the work, all of the sacrifice, was this the result? A night time secret arrest by a bunch of thugs? Surely Jesus must have been upset at this, even if he knew it was to happen. Sad, lonely, even confused if that could be possible. No wonder he asked this question: is this really what is happening? Are you really going through with this? Et tu Brutus?

Are we who follow Christ to expect no confusion, no being forsaken, no betrayal in walking the pathway He walked? Do we expect no existential crisis when the world in its insecurity and vanity turns its back on us? No, more than turns its back on us: actually seeks us out to capture us, as if we were a danger and not a help. A threat and not a hope. A bringer of chaos and not what we are in reality: the hands and feet of Christ in the world. Remember that His hands and feet have holes in them. If we are his hands and feet, are we not to have gaping holes?

We will run away. We are more like Peter than like Christ. The crisis is too much, and we like all of the disciples bend under the pressure. But the life of Christ depends on Christ, is fulfilled by Christ, and is sustained by Christ. With Christ, the laws of mathematics are put aside and 1-1=1. When we fall, he does not. When the rooster crows, we cry; but even then Jesus is not finished with us. It is then he dies for us. It is then that his body sustains and His blood washes.

We have our questions, just as did Jesus. Like the holes in Jesus hands, there are pieces missing, things we cannot explain. Even moral and religious matters that gnaw at us and weaken us, draining out our life strength. But Christ is with us. He is our strength. Let us serve Him with all of our selves, holes and all. Be like unto Christ and wear those holes without shame.

Kill Off The Zombies

This opinion piece from CNN is talking about the Ebola Crisis:

"It raises an interesting legal and moral question, one any fan of the zombie genre has wondered about: If one of our citizens is living but fatally infected, and will harm others if allowed to live out their doomed life, does the state's broad authority include authority to terminate the infected? At what point would we be comfortable with that? In the zombie movies, it's a no-brainer: generally, as soon as the group knows someone's infected, execution follows. And it's not always humane. Don't think we're above that in the real world. If the life of one threatens millions, does the state's police power authorize the pre-emptive taking of that one life?"


This un-useful extremist theorizing plays on fears and nightmares, but does show an important underlying error that is not uncommon in Western society.  That is, that Ethics is only about maximizing.  A modern person, devoid of underlying transcendental philosophical foundations, can only work with legal concepts such as personal rights and freedoms when considering ethical dilemmas.  So it becomes a matter for the lawyers and the accountants to add up the particular points on one side and the other and see who has more at the end:  more lives, more freedoms.  At the same time, the modern person knows that this cannot possibly be all there is.  But fearing that this line of reasoning will lead to something embarrassing such as a belief in God, she suppresses it.  

So, modern thinker, listen up:  you do not have to limit your mind and heart in this way.  Allow your reason to explore this area.  Is this an adequate way to look at the complexity of the world, the value of life, the beauty of creation?  Is the reason you cannot answer this question evidence of a spiritual reality?  In your heart you know that there will be a reckoning one day.  There must be a power, a source of ethics that is more than what the statisticians can calculate.

In the mean time, do not let fear and anxiety lead your heart and mind.  The Ebola crisis can be fought and is being fought by brave men and women, primarily African, on the ground in West Africa.  If you want to help, send some money to one of the NGO's.  Or volunteer yourself if you are in the medical field or logistics.  But don't just get attention for yourself by useless articles promoting more fear.

A Very Long Question from Augustine

For although we can never sufficiently give thanks to Him, that we are, that we live, that we behold heaven and earth, that we have mind and reason by which to seek after Him who made all these things, nevertheless, what hearts, what number of tongues, shall affirm that they are sufficient to render thanks to Him for this, that He hath not wholly departed from us, laden and overwhelmed with sins, averse to the contemplation of His light, and blinded by the love of darkness, that is, of iniquity, but hath sent to us His own Word, who is His only Son, that by His birth and suffering for us in the flesh, which He assumed, we might know how much God valued man and that by that unique sacrifice we might be purified from all our sins and that, love being shed abroad in our hearts by His Spirit, we might, having surmounted all difficulties, come into eternal rest, and the ineffable sweetness of the contemplation of Himself?

                                                    -Augustine, the City of God

An Example

Love of God

Is but a phrase

For He invisible

Talk is cheap

When sounds of praise

Are boiled in selfishness

The Son of God

Came to the Earth

With His life's example

With tender eye

And listening ear

He spoke in parable:

One looked away

While singing hymns

the injured left to die

Another feasted

In his house

A beggar starved outside

So to show

His own command

Jesus took a bowl

And foot by foot

And toe by toe

He washed his servants all

A Lamp

In one of the places in Melbourne, I visited an old man, whom nobody ever knew that he existed, and I saw his room, in a terrible state, and I wanted to clean his house, his room, and he kept on saying "I'm all right".  But I didn't say a word.  In  the end he allowed me.  There in that room was a beautiful lamp which had been covered with dirt for many years.  I asked him: "why do you not light the lamp?" - "For whom?" he said.   "No one comes for me, I don't need the lamp."  And I asked him: "Will you light the lamp if the Sisters come to see you?  He said, "Yes, if I hear a human voice, I will do it."  And the other day, he sent me word: "Tell my friend the light she has lighted in my life is still burning."  This is the people that we must know.  This is Jesus yesterday and today and tomorrow, and you and I must know who they are.
                                                                                -Mother Teresa

Red Wrath of Ebola

In the depths of poverty, in the heat and the sweat of Western Africa, is the world of red.  Unique red dirt exposed by two great turners of the soil—the African termite raising great mounds of the crimson stuff, and people, clearing the rain forest to show the red clay previously hidden by lush and full vegetation.  The green stands ready to take it back over in an instant when untended. Formed of the clay, “road” is a seasonal term.  That which carries a vehicle in the dry season, swallows it in times of rain.  Houses of people, formed from the red clay into bricks, lose some of their deep color in the drying process as the sun shines mercilessly.   The hands of the farmer are red, constantly moving and forming this soil to make room for the crops.  Using the hand hoe is like spooning the ocean as she bends at the middle to reach dirt, a baby tied on her back.   Clothing is streaked and stained with the soil, mixing earth with the daring colors adopted in this part of the world.  Wearing something white is more like bringing out a canvas than a choice of fashion, for it is only a matter of time for the West African paintbrush to bring that permanent mark from the world of red.

A new red stain has come to this world.  As if years of civil war, anarchy, and misrule were not enough to satisfy whatever demons delight in the separating of the blood from the body of the black man, a people who fear cruel leaders now find an even greater wrath: Ebola.  At first it was a mystery as the patients passed blood in their feverish fits and then died.  But many and assorted doctors from other lands have come in plastic suits and rubber gloves, to diagnose this disease, label the outbreak and collect data.  What has worked in the past they have implemented in hospitals and tents:  intake, isolation, support.  In former days, this demon has been content to destroy a few villages in a quick but containable horror.  Now it has found its way across families and cities and even borders.  Fear and ignorance have been its friend, as patients hide from help, fearing isolation, and useless bush treatments cause even more damage.  One cannot help but notice an adaptation--patterns that have been effective over thousands of years--the isolated village, fear of others, independent beliefs and superstitions.  The village that has been for the people a place in this world, not only of survival in the midst of old-world disease, but a fertile thriving of family, culture, art, and even science and medicine. 

The doctor is the foreigner to the scene.  Yet that doctor or nurse was born and raised in West Africa, speaks an unwritten tribal language with his heart and not just his mouth. He nonetheless carries with him the foreign, the unusual, the new approach, saying: “no, we do not want to go back to the village, not like this.  We will use the modern tools to fight this disease, and deliver our people.”  The doctors from the West come as well, assistants to these noble men and women of Africa—all bravely risking their lives as the plague rages on. 

The West Africans have changed, dramatically so in fact.  They have laid down their guns, have stopped spilling each others' blood.  They have courageously used the ballot following no longer the empty promises of the bloodthirsty.  And in this outbreak, they have largely followed the request of their leaders to stop meeting, suspend schools, change their greetings which are so important to them.  They have followed the instructions of the world's designated smart people.  And yet, the blood still flows.

What will happen next in this great drama? There was another epidemic virus ravaging Africa, more in the East:  HIV.  It took many years for changes to take place to bring medications and resources already in use in developed countries to the continent.  A few visionaries worked diligently to bring to reality what most people thought impossible or at least impractical:  effective HIV treatments in Africa.  Having the treatments available not only saved lives, it vastly improved the ability to educate people and impact populations.  Those who knew there was a treatment were now willing to discuss the problem, get tested, and listen to the education needed to interrupt the spread. 

In the case of Ebola, there are medications and vaccines available, though they need further testing.  The development funding came in part from the US military, which planned to protect its soldiers from the disease.  Will visionaries be able to coordinate with the military, the Centers for Disease Control (CDC), the World Health Organization (WHO), the companies with patents, the doctors on the ground, the researchers, and others, to make treatments available?  Or will there be only nods of “supportive care” when it comes to Africans, who have nearly no access to supportive care in the sense the term is used in the West, which includes blood products and an ICU.

The whole world is nervous, affected, ready to act.  Money is offered.  What is needed is creativity.  Obviously, with a disease that has broken the boundaries of our experience, we need new approaches that break the boundaries of tradition to bring it under control.  Not forsaking what has worked in the past, not lightening up on containment, education, supportive care.  But creatively seeking cure.  Finding out which weapons work best in this kind of battle.  What sanitation systems are needed.  How the family and village support systems can be a help instead of a hindrance.  How an ICU and a blood bank can be built and, more importantly, supported, in such a setting.  How money from outside can be channeled usefully into the already existing research Universities and other structures in West Africa.

God's wrath is red, like the West African soil.  And yet so is the life-giving blood He put into every one of us.  Perhaps in His Providence, God has allowed this time that people whose blood is red might come to help their brothers and sisters in the world of red.

How to Get Doctors to Small Towns?

The State of Missouri, using what has remained in State governance all of these years, the licensing of doctors, to make a very unusual ruling: allowing doctors without any residency training whatsoever to practice medicine (see article). This with the goal of providing medical care in rural areas.

This decision is short sighted and fraught with difficulties. It will serve to degrade quality and standards in the health care field. And yet it does illustrate the difficulty that the rural areas have in obtaining adequate health professionals in this country. And indirectly the failure of the medical education system to ensure the supply of doctors to rural America. This despite millions of dollars of loan repayments, various pilot projects, general guilt-tripping of students to goad them into primary care specialties, etc. Some fundamental changes must occur to reverse this trend and it is the responsibility of those in medical education and their f

und sources to ensure that this happens.

“Begin with the end in mind,” as Stephen Covey would say. What do we need to see? Doctors in rural areas need to be different than primary care in the city, where a multitude of specialists line up to compete for every possible disorder, especially every possible procedure. In fact, different rural areas need different things from their doctors: some may have a well-established OB practice and need primary care doc who can work in the ER. Some have ER docs and need some people who can do OB and ICU. Many need docs who can do psychiatry, since there is very little mental health support in much of rural America.

The current training system does not produce what the rural communities need. Residency has become more and more focused on producing sub-specialists. Primary care residencies such as Family Practice and Internal Medicine have become so heavy with top-down direction, that there is very little room for the innovation necessary to address the needs we are talking about. Endless streams of directions come from the central planners such as the Institute of Medicine, and the ACGME, ensuring that any possible change is nearly impossible.

In desperation, the State of Missouri has decided: this field in which training is done is too restrictive, and we are punching a hole in a fence. Maybe at least we will get some doctors out to our rural patients by doing this. I disagree with the specific decision, but I can certainly see the reasons for it. And if the organizations such as the IOM, ACGME, Medicare (holding the purse strings and thus basically guiding a lot of this), the American Board of Medical Examiners, and the specialty organizations tie the hands of the trainees and the trainers, then the states and the doctors and whoever can, will have to also help break down some of these fences, though hopefully in more strategic locations.

Some examples of things to try:

1. Pick out more procedures for the primary care to do that strategically expands the capability of the medical care provided in the rural setting: colonoscopy and echocardiogram interpretation are low hanging fruit, that could be incorporated into primary care training.

2. Form more residencies in rural medicine. Perhaps tailored to the specific community in need, and at the community level. In the age of the internet, a resident could train in the community he or she is to work in, with needed supplements of education and experience in larger centers and through teleconference.

3. Fusion of specialities: why make a “family practice” doctor and an “OB” doctor? Why not credential someone in those areas or subsections of areas that they need to do their job in their town? Board certification is a way of ensuring quality, but when it becomes impractical and stands in the way of patient care, it may be time to replace the process or the particular board, or both.

Darkness and Stumbling

“Those who walk during the day do not stumble because they see the light of this world. But those who walk at night stumble, because the light is not in them.” -Jesus (John 11)

The disciples were afraid of being killed, worried that Jesus would be jailed or killed, if they went back close to Jerusalem to visit Lazarus and his family. Jesus told them that the day has 12 hours, and one should walk during those hours, not at night. Once again, Jesus is pointing to another reality. A picture of something else. He speaks of light and not stumbling, and that makes sense to them and to us. A reasonable proverb. If you walk during the day, you do not trip; a very important thing in a time before electric lights and steel toed boots. But Jesus means that that there is a reality like the light. And there is a stumbling that is apart from hitting your toe on a rock.

What is this reality? The disciples are afraid of stumbling. They know there is darkness in Judea. But Jesus, as he has explained repeatedly, is in fact the light of the world. Where he goes there is no darkness. So it matters not whether there is war, or peace, or danger, or risk, or disease, or even death. All of those things are immediately tamed because they are like stumbling in the dark: when there is light, there is no stumbling.

In verse 16, Thomas finally gives in and says “let us go and die with him.” That is the best most of us can do in following Christ: resign ourselves to defeat, to death, to failure. We play the sad martyr and bring ourselves (with some self-righteousness thank you) to a giving up of security and success. But Jesus himself does not ask us to go this way. It is our insistence on holding to this world and closing our ears to Jesus' words that makes us joyless followers. Jesus himself says:

“Lazarus sleeps” - giving hope that he will rise again. A better picture for us of the reality that Jesus can see but we cannot. Jesus sees Lazarus, and all of us, rising again. We, never having seen anyone ever rise again, do not get that picture when the word “death” is mentioned.

“I am glad for your sakes I was not there, that you might believe.” Not that Jesus is a sadist but that Jesus, again, sees the end of things: a risen Lazarus, a woken Lazarus. A joy after the sorrow. A baby born after the pain. Faith birthed. The church begun.

Poem Space

A poem says
My language is not enough
I need more room
Let me dance my words
Even if I knock over a planter
Or some heirloom

Darings

Now, against the sacrilegious and impious darings of reason, we assert both that God knows all things before they come to pass, and that we do by our free will whatsoever we know and feel to be done by us only because we will it.

                                                                                     -Augustine (City of God)