There is not a physician shortage in the US

 

 

"The physician shortage as a significant driver of poor health outcomes is a red herring."

                                                                  -Corso et al


If anything, the poor state of affairs in American health has to do with too many doctors, not too few. Authors Corso, Dorrance, and LeRochelle make a good argument that simply blaming poor healthcare on the lack of primary care is insufficient (see their article in Military Medicine).

Specialists' Insist on More Care and Higher Prices

I agree with much of what this ENT doctor says. It is very brave and honest of him to own up to the responsibility we as physicians have for skyrocketing healthcare costs.  His solution, however, is overly simplistic and relies on more government funding and government regulation. An excess of these we can also see feeding healthcare cost spikes.

Click here or on picture for NYT article

The Service Dog

  

"Jesus knew that poverty and disease in themselves are not the hardest things for people to bear; the hardest to bear are the loneliness and the hopelessness that come with being sick or being poor."
                                                                              -Shusaku Endo, A Life of Jesus

We doctors often poke fun of the service dog. We see the dog-lovers, obsessed with their dogs, bring them around the hospital to visit the sick.  What can they do, really?  Get in the way, pee on the floor.  

In America, various programs offer a safety net, a help, a support, to the poor, the elderly, the sick.  As I walk into the hospital every day, I am thankful that the patients can be cared with a high standard with relatively minimal restrictions due to the cost of care.  More so since the Accountable Care Act, otherwise known as Obamacare.  

Yet Endo reminds me of what else I see daily:  chemicals and surgeries leave a large gap in care, and perhaps inadvertently contribute to it.  When the care came out of love and sacrifice in the face of need in the form of a family member, a volunteer caregiver, or a nun, that love and spiritual connection was obvious.  When the care comes with a paycheck as a carrot and the threat of liability as a stick, the love is not so obvious, and may be missing altogether. 
 
Thank God for the opportunities to serve those who are suffering.  For God still calls His people to love.  We should learn from the service dog.  Never tempted to suspend presence with the patient to mix a medication or do another x-ray, the service dog is unpretentious to the core. Perhaps if Jesus were here today, he would say: "if any would enter the kingdom of heaven, let him be like one of these service dogs."  Sit with the patient.  Do not try to cure them, leave that to someone else for a moment. Listen.  Empathize.  Lay hands on them in prayer and communion, not only to cut them open. They may not live longer because of this.  But perhaps they, and us, will become more human.

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.

Centrally Planned Healthcare

The lastest SGR Deal (click for article) sounds good, increasing doctor pay tied with quality.  However:

1.  Interventions from DC that purport to make doctors provide a higher quality of care by paying them extra for certain check-boxes and computer clicks are not effective.

2.  The doctor groups that are supporting these measures do not see, or choose not to see, the reality of #1

3.  The primary net results of these measures are:  more bureaucracy, increased cost for already overpriced medical care, more passing the buck on cost-control.

How Many Doctors Does It Take?

I had not realized that the Annals had posted my thoughts on this article a few years back, though only on the web site comments which probably did not get much read.  In any case, I think this is still relevant though perhaps too "insider" for many.

Click HERE to go to the article sample and my comment at the bottom.  Or just read my comments below.






Doctors as Bed Managers Inappropriate Use of Resources

Posted on March 7, 2009

Paul D Bunge

In the December 2 Annals, Howell et al present their case for "active bed management." In the intervention, they had hospitalists take turns doing twelve-hour shifts as bed manager, a position usually filled by a senior nurse (1). The bed manager typically coordinates the placement of the new patients from the emergency room and clinics onto the appropriate available ward. This person also tracks patients as they go in and out of the ICU and other units. The bed manager must keep track of all available beds, and negotiate as needed when beds, patients, and staff must be shuffled around to make room. Note that in the intervention, the hospitalists did not do any patient care while they filled this role.

I am not surprised at the result reported: The patients moved around the hospital more efficiently. The time that the patient remained waiting in the ER was shortened (a quality and hospital efficiency goal). The major problem with this intervention is not the result, but the cost: Whatever the possible short-term cost savings to the hospital and short-term benefit to patient comfort, the overall cost to the health care system must be factored in, which is essentially the huge cost of pulling 1/4 of the hospitalist staff out of direct patient care.

I am afraid that I must regard this intervention as both unethical and ridiculous. Unethical because "pressure from administration" lead to inappropriately removing doctors from patient care to achieve a financially-motivated efficiency goal. It is the doctor's responsibility to call foul when the administrator crosses a line and refuses the patient appropriate care. Yet in this intervention, the patients were left to the mid-level providers and others while the doctor was making phone calls.
This intervention is ridiculous in that it is already a waste that so much senior nursing time goes to administrative duties, including the role of bed manager. Are we to have the doctors do this job that would more appropriately be performed by a clerk? When the movement of patients around the hospital is dysfunctional, that is a leadership problem, not a clinical problem.

This article is an unfortunate illustration of some very important points:

1. We have strayed far away from our job, our profession, our calling: patient care. We have left it to a few weary, brave soles who we now call "primary care managers." The rest of us, with no apparent limit, gather specialty or hospitalist status, and make as clean a break as we can from the whole mess. Shame on us! And shame on us for blaming others (the government, the economy, the payment system).

2. We need to question the current band-wagon thinking that there is a shortage of physicians in this country. When our highest levels of medical learning can advocate using doctors as bed managers, we may actually have the opposite problem: an illness of too much. (see Shannon Brownlee's article for a look at this topic: http://www.theatlantic.com/doc/200712/health-care )

3. Common sense needs to find its way back into the hospital. In the days of Oryx measures and JCAHO rules and sub-rules, the doctors of the world must be the ones to bring some wisdom to the table to question quality measures that may actually decrease quality, the multiplication of pointless paperwork, and other like challenges.

Once as a young physician on the way to work, I stopped my car at the scene of an accident. I told the ambulance crew my credentials and asked if they needed my help. One wise EMT told me quite simply: "sir, it probably would be more helpful if you made your way to the hospital where you are needed and see the patients there. We can handle this part." I did just that. Perhaps more of us should do the same.

References
1. Eric Howell, Edward Bessman, Steven Kravet, Ken Kolodner, Robert Marshall, and Scott Wright Active Bed Management by Hospitalists and Emergency Department Throughput Ann Intern Med 2008; 149: 804-810

The Packing List

Fanny pack 

No longer stylish, but useful nonetheless.  When you quickly need bandages, a light, or gloves. Supplies are not as readily available as in a US hospital. For work in the triage tent or the ER.  We bought two fanny packs at REI, an outdoor store, before the trip.  One was way too big, so I’ll take it back after, unused.  My EMT niece and I shared the other one, trading off when the other came on shift.  Beth is my niece’s name; she wants to go to medical school.  I told her she needed Emergency Medical Technician (EMT) training if she wanted to go to Haiti with me.  So she did the class last summer.  Her nurse aunt and I guided her through IV practice on the relatives after family dinners.  Now she is pretty good.

Bandages and Chucks

Donated by Caroline from church.  Her husband was supposed to live longer, to need more home health.  But he left this world and the medical supplies were still fresh.   “Chucks?” the translator in Haiti said.  Like “Chuck Norris?”  “Yes, same Chuck” I laughed.  Refers to a large absorbent sheet with plastic on one side.  So useful when blood is dripping down.  To catch the life before it hits the floor.  Less messy.  Less dangerous than the splashing red.  For us, not for the patient.  For him it is less dangerous if he keeps his blood inside his veins where it belongs.

Cliff Bars

From Costco.  Very useful when hunger hits and rice and beans won’t come for several hours.  My wife bought two boxes for us before the trip.  I can’t stand going into Costco after a trip to Haiti.  Gives me nausea, even more than usual.  I take it out on the oversized cart--kicking it in the parking lot.  Why can’t someone even put it where it says “put carts here?”  How many suction machines could be purchased with one cart-load of junk food from Costco anyway?  Could have used another suction machine in the triage tent.  That patient, someone’s mother, hanging on by a thread.  Maybe if I had had another suction machine she would have lived.  Instead I rolled her over as the brown liquid no longer was vomited but ran out of her lifeless form, onto the floor, scattering the EMT’s like ants.  How much of that was from internal bleeding?  I will never know.  Autopsy is an unavailable luxury.  Need to move on to the next patient. 

Headlamp  

From Walgreens.  $12 on my visa.  Should have gotten two.  Or three.  So useful for guiding the needle while suturing lacerations.  Hard to see the needle sometimes at night, or during the day, when the curtains are closed to keep it cool.  I use the headlamp to crown a Haitian medical student so she can learn suturing.  Then for the trauma surgeon since I couldn’t stop a hand from bleeding.  Into a bucket this time.  Too much blood for even Chuck Norris.  A deep bleeder, since the knife had gone all the way through. “Tendons OK, though,” said the orthopedics doc.  Maybe he should have bought a headlamp, too.  On another case, he lost track of the needle long enough to poke his finger.  Wasn’t a big hole, but he looked down and there was a bit of his life oozing out in little red bump.  Only one drop, but enough to tell him the risk, bring the fear.  The patient with HIV, not on meds.  One in 300 chance of getting the disease himself.  He wandered a bit after the surgery.  What should he do?  What of his wife and kids back home?  He mentioned it to me and I whisked him off for “PEP.”  No, not a talk, but a month-long mound of HIV pills called “Post Exposure Prophylaxis.”  Reduces your risk of getting HIV from your needle stick. They have five days for you here, and you can pick up the rest when you get home.  Take some nausea meds, you’ll need them.  It’s the same approach we take in the U.S. with HIV needle sticks. 

Baby wipes

I don’t use them, but my niece does.  Some days when she can’t bear the cold grungy shower.  I am not afraid of the cold shower.  I find it refreshing actually, though painful.  You feel new after, not just clean.  But the violence of that cold water is not enough; more than just sweat gathers on me in Haiti.  And it seems I don’t deserve a hot shower.  How could I be pampered when down the hallway death approaches due to lack of adequate washing?  Where the water itself has brought death by cholera instead of the life and cleansing it is supposed to bring.

Glasses

I don’t really need them most of the time.  I can see 20/20 with one eye, at least after Lasik surgery, complements of the government, before I got out the Navy a few years ago.  But they help to read the x-rays, and God knows there’s no radiologist looking at them.  Except now there are some volunteers out of Duke helping out reading the CT scans.  That helps, except when I disagree with the read.  Hard to get a hold of them after.  Will have to leave that to the next team.  There is a European girl with several months of belly pains who comes for an ultrasound.  I talk her into a CT scan.  She can afford it and she needs it.  The radiologist from Duke says her adrenal gland has a tumor.  Let’s get her a copy of the CT; she will need that when she has a follow up in Canada.  They can compare.  See if it grows like a cancer or stays quiet, an unseen blemish of no consequence.  We hope.  I see fear in her eyes, and I do my best to speak to it.  Speak to God of it.  She has worked hard for the people of Haiti.

Pens

I always bring a whole box.  As a doctor, the last thing I need to worry about is whether I have a pen in my pocket or not.  So I don’t care if I leave them here and there around the hospital, even in the States.  If someone needs one, I hand it over.  Though at the same time I always bug the med student if he is unprepared.  They need to grow their anxiety a little sometimes.  Can’t be a good doc without some anxiety.  Didn’t know the pens would be so busy this time on a certain form:  the Haitian death certificate.  We write in English, trying to understand the form in French.  Getting the name right is easier this time, due to the printed intake form from the hospital’s new computer system.  In the Sates, I get the forms back months later:  what sort of cancer was it?  What stage?  Was it treated?  Usually I can figure out the answers to these questions by looking back through the chart.  But in Haiti the cause of death is more often a guess.  And the box of pens does nothing to make it clearer.  Nor can it hold off the power of death.  The trauma surgeon tried to take it in stride with a joke:  just fill out the death certificates when they arrive, he said, and save our time later.  The black humor of his trade; shared with soldiers, morgue workers, and the like.  I try that kind of humor some, but that shield for me is incomplete.   What gets through gathers in the pit of my gut somewhere and gnaws.

Sun block

My white skin is an extra chore, but something I can afford.  Trying to prevent a painful burn and slow the lines that are forming from various adventures.  Skin cancer risk doesn’t bother me.  I can’t fathom having it, though I have treated enough of it on others.  I bring for a week more than I can use in a month.  The excess margin our culture carries around.  Too much sun block above the eyes and it runs down in the mid-day heat and burns my eyes.  

Books

I never have much time to read during my week of work at the hospital in Haiti.  When I am off shift, there are interesting people to talk to, quite the adventurers that volunteer their time.  Some quite wacky, maybe they can’t function in America.  Unfortunately the third world gives them default leader-status, at least at first.  But most are admirable, self-giving, and illustrations of a Covey Highly-Effective book.  The airplane ride, though, gives me reading time.  It is a long way from Seattle to Miami, and layovers to make the flight cheaper are also prime reading spots.  I bring a devotional to read in the early hours before I start work.  Crucial to forming spiritual energy that rapidly depletes during the long, draining days.  My book Authentic Faith by Gary Thomas says  “Our attitude toward God is defined by our actions toward the less fortunate.”  I share a passage with one of the nurses as she feels compassion fatigue:  “As you begin to reach out to the hurting, it’s important to check your sentimentality at the door.  In reality, it’s something we need to do with our eyes fully open.”  On the plane I read a less encouraging book: When Healthcare Hurts, by Greg Seager.  After that, one realizes that there is even more hard work to be done here:  Balancing helping and giving with critical and scientific analysis.

Batteries

Didn’t need to use them.  The new headlamp lasted the whole week.  And I hardly used my otoscope this time: between the pediatrician helping me in the ER and just randomness I think, there were not too many ears to look at.  Probably should have left the C batteries in Haiti for the laryngoscopes.  It is difficult to keep the laryngoscopes ready for the next emergency.  This kind of code needs an Intensive Care Unit (ICU).  This hospital has one, an ICU that works.  The ICU is a major step up in complexity and cost in the third world.  It takes many batteries, along with working ventilators, trained ICU nurses, loads of equipment with a working supply chain, and many, many other things.  Though it doesn’t have all of the bells and whistles (and extra redundancy) of a high acuity hospital in the U.S., this oddly partnered hospital in Haiti has walked up this difficult step and is sustaining.  Probably has taken much more investment in time and money and training than anyone would have anticipated.  Someone should write a paper about it, I ponder.  Not me I hope; musing is more my line.  I put the batteries back in the garage when I get home.  A room that holds 2 cars and the boxes and bikes and lawn care stuff of an American family.  Seems wrong, like the Costco cart.  If this room were carried to Haiti, it could be another ward full of patients.   I could have accepted another person to the hospital.  Could have saved a life.  Lives for toys it seems.  Lord, have mercy on me. 

Deodorant

Seems rather pointless to put it on only once in the morning.  Like using a teaspoon to drain the ocean when I am on duty in Haiti.  Maybe it helps more when I am out of clothing and what has aired out on the bunk bed is going into service for another round.  Smelling good is another luxury.  When my wife and another niece pick us up from the airport, they are not shy to encourage us to visit the shower when we get home.  Walking around Miami in veteran Haiti underwear and then flying just did not produce an appealing fragrance for them.  Perhaps we should have sprayed on some perfume from the duty-free shops.  

Shoes with no holes

It feels like my feet are cooking in these shoes.  But flip-flops just will not do, with blood and needles and cholera.  The first time I wore these shoes here, I thought I would throw them away after.  With the bleach from the cholera tent and the ubiquitous dust from the earthquake rubble, they were not pretty.  But a shoe shine later in the Chicago airport and they were good as new.  Had them back three times since.  The first couple of times in Haiti I wondered why my legs were so swollen.  But my doctor buddy in the Navy explained heat edema to me, having had the same puzzle in Iraq.  A transient problem as the blood vessels dilate in the heat, probably worse with the salty Caribbean food and long days walking around the hospital grounds.  Beth added to her discomforts this edema and a significant reaction to the mosquito bites with quite a bit of pain.  I had to reassure her that, no she was not going to die or be disabled.  She got it.  Tears she had, but she kept them away from the patients.  During the work day, she kept a smile on her face.  That and management of chaos, skills of value ingrained in her over high school years of part time work by the McDonald’s corporation.  Who knew that Ronald would be so helpful in Haiti?

My Traveling Hat

I am very particular about my traveling hat.  This is my third over the years.  Brim bigger than the current fashionable Fedora.  Soft and wool made, so that unlike a cowboy hat, it can be crushed and bounces back to its original shape.  Helps protect my over-white facade, and makes me feel a little like Indiana Jones.  No whip though, and women don’t chase me.  I do enjoy the adventure part of these trips.  It is exciting to be there in the midst of the action.  Some are quite addicted to it, signing up for long stents with Doctors Without Borders or moving to places like Haiti full time.  I am taking it in doses.  Need to be careful not to overstep my bounds.  To avoid doing medically overseas what I cannot do well.

Money

Small bills, they said.  For tips, for food, for souvenirs.  Needing more and more each trip.  As Haiti rebuilds, there are more things to do, more ways to spend your money.  The massive fields of post-earthquake tents are gone.  There are parks again, stores.  Back to urban sprawl.  When does post-earthquake camp change back to urban slum?  Perhaps in part defined by whose hands the money passes to and through.  The shop owner now, not the developer so much.  And still there is hunger.  Still orphans and knives and no margin.  An odd, odd thing, money.  Can cause so much damage and so much good.  A thing of faith and a thing of filth.

Passport

I always carry it on my person.  I don’t know really if that is safer than leaving it in the room.  Nothing seems to get stolen out of there.  And if someone came in with a knife and wanted my passport, I am sure I would part with it rather than part with an organ.  But I doubt that would happen, with our fenced area and our guards.  Our bunks are in the back hallway of the small hospital.  Formerly private rooms for patients back before the earthquake put things on top that were on the bottom and vice versa.  Many third world hospitals are like that:  a large open ward for the poor, and private rooms for those who can afford the rent.  It helps the hospital stay afloat.  Now they are just starting to reintroduce billing, a transition back to having the patients pay.  But it is only the open bay patients now; the private rooms are still filled with volunteers.  Hard to say what is better for the health care system and the patients: not paying or paying.  But those decisions are, appropriately, in the hands of those who don’t need a passport to live here.  Of course the passport for me is the final thing on my list.  Gets me on the plane out, back to the U.S.  Don’t even need a ticket any more really:  it is an idea rather than a piece of paper, accessed by the passport.  Who you are, or who the government and the bank define you to be.  Another book of faith.  Not as solid eternally, but it helps for now.  Means to an end I hope.  The many stamps in my passport reflecting a love: for the world, for cultures, for people, for life. 

“Please don’t send me to City Hospital, I will certainly die if you do.”  It was probably the most complicated statement this quiet woman had made to me since I first saw her in the Emergency Room three days before.  She said it with her usual very subdued and meek manner, looking away, with a face full of sadness.  What was it that drained her spirit?  Fear of death?  A general forlornness pounded in by years of poverty followed by earthquake?  A worry for her unborn child, four months in her womb?  This I could not say, but I was moved.  However, with recommendations from local providers and administration, I requested she be sent.

Three days prior, she had been brought to the emergency room, the triage doctor quite accurately predicting a large amount of fluid around the lung.  After drainage, she was discharged with antibiotics, and fear that she had tuberculosis.  The next day she was back with even more fluid and required oxygen to breath.  Today we had drained the fluid for the third time, and again suspected TB.  Because initial tests were negative, we could not treat her under our hospital’s TB program, and thus the need to transfer her to another hospital, with its expanded resources.

This was my third week-long volunteer trip to Haiti.  Working with Project Medishare, where doctors and nurses fly in for a week or more to augment and assist the staff at Bernard Mevs hospital.  This project started as a massive tent hospital for surgeries after the catastrophic 2010 earthquake, with U.S. volunteers supplying the manpower.  The project evolved as required surgeries slowed down and local hospitals started to get up and running again.  At this point Medishare partnered with the Bernard Mevs hospital and packed up the tents.  Personnel from the U.S. and Canada still come and integrate as hospital staff, doctors, nurses, physical therapists, and others, with a constant local staff of translators and an extensive logistics and long-term component.  It is a very unique relationship.

It was not until after dark that the ride could be coordinated and the patient left Bernard Mevs.  An hour later I was in the emergency room again when the phone rang.  I answered it, fearing a French-speaking doctor was going to confuse and embarrass me in my rudimentary language skills still remotely in my brain from a childhood of French classes in the Canadian school system.  But it was Jerome, the night-time translator, who was at City Hospital with my patient.  “Dr Paul” he said, “they don’t have any oxygen at this hospital right now. I tried to remove the patient’s oxygen but she was very short of breath.”  No surprise, we had only today been able to get her off the oxygen mask and on to the nasal prongs.

But how could they not have oxygen?  This was supposed to be the place with more resources!  Well, though I had noted dramatic improvement in the infrastructure and the progress in earthquake recovery on this last trip (no tents or rubble in our drive from the airport, and signs of rebuilding and growth everywhere), certainly Haiti remained a challenging place to live.  And certainly a difficult place to be a pregnant patient with fluid around the lungs!

I had to think quickly and make a decision.  Our hospital beds were already filled.  I had been advised to transfer the patient.  But I did not have the heart to make her stay at City Hospital with no oxygen, and risk dying just from that!  So I told Jerome to bring her back.  Somehow we found a place for her and continued treatment.

The challenges of providing quality healthcare in Haiti are legion.  One of the most difficult things for me as the visiting doctor is trying to figure out what the standards are—as things are so different in Haiti than the U.S.  So many treatments are unavailable.  Newer and more expensive medications, more familiar to me, are out of reach.  Or often yes, there is some medication or procedure available – possibly at another hospital across town or if the family goes to a pharmacy for purchase. 

Another great difficulty in working in a medically needy setting is the reason one goes in the first place:  the need.  It is difficult to see people suffer and die, especially of something they would not die of back home.  But if you hope to save someone, you must go to the place where the problem is.  To give of your time, talents, and resources.  And that indeed can be draining.  Frankly, it is easier to help someone who really doesn’t need the help.  To doctor someone who can pay your mortgage, your car, and a boat besides.  And yet, a doctor doctors.  A helper helps.  And “blessed are the merciful,” said Jesus.

My patient improved with more antibiotics, and did not require any more fluid to be drained.  She managed to get off oxygen, and baby and mom were doing well when I left for home.  I hope the best for her, in her medical and other needs.

Overall, the Bernard Mevs hospital is doing well.  The Haitian doctors and nurses have grown in leaps and bounds in the practice high quality medicine, ICU care, and quality standards.  U.S. providers are needed less and less.  There is a CT scanner up and running now.  TB and HIV programs are reaching many.  A full array of clinics are open to outpatients.  And construction is underway on a needed expansion.  If you ask me, Project Medishare is a good organization to put some charity dollars into. There is still room for help:  in work, training, care, continued financial support for the many patients who cannot afford medical care.

God bless Haiti.  May those committed, hard-working people, seeking to bring their country up from despair, be rewarded with a bright future.  And may those with a lingering sorrow, my patient among them, find lasting comfort and rest.

-trip to Haiti, June 2012

-printed in the Olympian July 2012