Physician, Heal Thyself

A Mother’s Tears: Lessons from the Dying

2010-06-03T19:16:00.001-04:00

I am standing at the nurses’ desk watching the cardiac monitor on the patient in room 32 slowly become more and more unstable. The patient’s family members have decided to change the patient’s status to CMO (comfort measures only), which means the goal of care is no longer to recover, but to keep the patient as comfortable as possible. The patient has essentially no chance of recovery and has been on a heroic amount of life support to sustain him, and the family wants the suffering to end for both the patient and themselves, and all care-givers agree that this is an appropriate course of action. A few minutes earlier, the nurse discontinued the vasopressor infusions (powerful medications to maintain blood pressure and heart function), and now the patient has become hypotensive (low blood pressure). As the family gathers around the loved one to say their final goodbyes, the nurse and I keep an eye on the cardiac monitor outside the room. I study the progression: The heart rate becomes fast, then abnormally slow, then the morphology of the waveform starts to change and become more and more unstable until the patient is clearly in cardiac arrest, and then…asystole (no electrical cardiac activity). I take a deep breath, and walk into the room of the patient that is crowded with tearful family members saying goodbye. I do a brief examination as a formality, look at the clock on the wall, and pronounce with finality: “time of death: 10:18pm.” Even the strongest family members who have held their composure burst into sobs, and I quietly express my sympathy and excuse myself to let the family mourn for a few moments without interruption.

***

The experience above is one I have come to know very well since beginning my critical care fellowship this past summer. Before this year, I have had patients expire, but never have I spent so much time with dying patients and their loved ones, as when I came to work full time in the ICU. Someone asked me recently what I had learned during my year spent in the ICU. I told them, that I have refined and expanded my knowledge about the management of critical illness. I have become proficient at supporting the sickest patients in the hospital, and though I still have more to learn, caring for people with life-threatening problems eventually becomes routine. On rounds, we discuss the care of people who are very near death, and one might think emotions run high, but largely, this is very calm and methodical work. The younger doctors report on the status of the patient, and then give their assessment and plan of action to help the patient. The attending either nods in approval, or points out where the resident may be wrong or could improve the plan. I usually stand by and try to keep the troops cheerful, and occasionally offer some bit of insight that I may have.

It actually sounds easy, but there are many aspects of working in the ICU that still challenge me. Perhaps the most difficult job is communicating and building consensus with all the stakeholders: the nurses, the surgeons, the consultants, nutritionists, physical therapists, and most importantly the patients and their families. While many frown at this part of the job, I find it challenging, and this was perhaps the most important part of my education this past year. In particular, the complex communication that is required when patients are dying is crucial, because these cases are the ones where consensus can be very difficult to reach.

You might think that it’s the families that have a hard time letting go of their loved ones when they are near death, but actually families usually surprise me. Even though, they hope for their loved one to survive and recover, they usually can sense when the person is suffering needlessly. After all, the families know that patient better than the nurses and doctors ever could, and often are the ones to initiate conversations like “I don’t think he would want any of this done to him”. I find that the families usually have the patient’s best interest in mind, and they are usually willing to let go of the patient when they think it is the right thing. Family problems occasionally arise when two people in the family who don’t get along use the sickness as an opportunity to try to hurt one another by being resistant to what the other family member wants for their loved one. I find this kind of behavior rare though, and people are usually able to rise above their differences when their loved one lay so close to death. Some families are fortunate to have a physician or nurse in the family who really understands the clinical situation, but most don’t. For the most part, families depend on the professional care-givers to help them know when things are hopeless.

Communicating with families and explaining a poor prognosis in a sensitive manner is difficult, but usually it is not the hardest part of end-of-life decision-making and communication. The real challenge is reaching consensus with the clinicians. Every health care provider involved in caring for the patient may have a different idea of when the “line has been crossed”, and care has become futile and less than compassionate. The main three groups of clinical stakeholders involved in this determination are the ICU nurses, the ICU doctors, and the surgeons or the doctors who have admitted their patient to the ICU hoping that we can get them through their post-traumatic or post-operative critical illness. Usually the nurses are the first to question whether our efforts are going too far. The ICU physicians are usually somewhere in the middle, and the surgeons are often the last to be willing to accept that the patient does not have a chance at a meaningful recovery. Then within each of these groups is even still greater individual variability. How health care providers view end-of-life decision-making is largely based on values of the individual that are very personal. There are surgeons who NEVER want to make the patients “comfort measures only”, and there are those who are very reasonable. Then there are nurses who never give up hope that their patients can recover, and some who want to discuss code-status and goals of care within minutes of the patient’s arrival to the unit. Trying to come to a unified way to present the family with what we really believe is best for the patient can be nearly impossible with so much variability, but if all parties are open to discussion, then at least there is the potential for consensus. The family usually needs some guidance from the clinicians and it is much easier for the family to make decisions if they get a consistent, unified update on how their loved one is doing…versus conflicting reports about the prognosis. When we are able to provide this clear guidance, it makes a difficult and painful situation for the family a little easier to endure. Of course, nothing can completely dull the pain of having to make decisions for a dying loved one, but when we sensitively communicate our expertise to the patient families, we can minimize that pain and suffering for the family.

***

Part of being a physician requires dealing with other peoples suffering on a daily basis. In particular for a trauma surgeon and critical care physician, there will be daily exposure to the pain of my patients and the grief of my patients’ family members. Watching other people suffer is not easy. Most health care professionals have to develop some amount of detachment from their work to maintain their own personal sanity. I see this often in first responders (police, paramedics, firefighters), who witness so many gruesome sights, that they cannot internalize all of the tragedy, because they would be an emotional wreck. In the hospital however, health care professionals are often caring for patients for weeks and maybe even months, and one cannot help but get somewhat emotionally invested in many of our patients…and I think that is a good thing. In our ICU, I notice that among the doctors, nurses, and other staff, there are different levels of empathy for the suffering of our patients. Some are more quick to become emotionally invested in a patient than others, but all of us (to some degree) try to guard our hearts from getting caught up in the emotional turmoil of a dying patient…if we can avoid it. This is apparent in the care-givers of patients who come in with an exceedingly bad prognosis, like the severely head injured trauma patient who is near brain death on arrival. While we do our jobs as well as we can to try to save these patients, it would be foolish for us to invest ourselves emotionally into a patient that we are almost certain to lose. And while we may say the appropriate things to the family during this difficult time, we are not truly sharing their grief and internalizing their pain…once again…if we can avoid it.

Personally…I feel like I have seen a lot of suffering in my time as a physician. In addition to the heartbreak of seeing people die at Massachusetts General Hospital, a world class medical institution, I have seen some unimaginable things in other parts of the world like post-earthquake Port-au-Prince where the entire city lay in utter ruins and the streets smelled of death. Or like Dadaab, the Somali refugee camp in Eastern Kenya where more than a quarter million people live a miserable existence with almost no hope to change their circumstances.

Having seen so much suffering, one can start to believe that one is“tough” so to speak and can handle the relatively routine suffering and grief that one encounters daily when working in an ICU. While I always try to be sensitive to the families who are suffering and losing a loved one, I usually maintain some emotional distance, which helps me be as objective as possible in medical decision making, and as explained before is protective in the case of patients who have little chance of survival.

I remember one patient in particular. She was approximately 25 years old with a devastating head injury after a motor vehicle accident. We admitted her, and did our best to control the pressure and swelling on her brain, but after a couple of days, it became apparent that we were losing the battle, and we held a family meeting to update the family on how poor the prognosis was. By this time, I had learned all of the correct language to use, and how to explain things gently, but also clearly and honestly, so families can make the most informed decision. The entire time, I had managed to stay in perfect control of my own emotions, as this girl’s mother was going through kleenex after kleenex. The family decided to make the patient CMO (comfort measures only) and withdraw her life support. This was a hard decision, but because our experienced team of doctors, nurses, and social workers had explained everything with such professionalism and sensitivity, the meeting had gone about as well as one could imagine…so much so that something surprising happened. The girl’s mother stood up and demanded to hug each an every one of us for our efforts in caring for her daughter. This was a little unusual, but of course we obliged her given the circumstances. I stood up with open arms, and she embraced me very deeply, and continued to sob into my arms. As I held her and she cried, I felt her warm wet tears roll down her cheek onto my neck. But the tears were not just warm, they were hot…I mean they burned. All of the sudden I was overcome with the magnitude of what grief she was experiencing to be losing a daughter. It was as if those tears transferred some of her suffering to me. And sure enough, my eyes became wet with tears too. There I was thinking I had seen it all, and I could handle stuff like this with distant compassion, but there is something powerful in the human touch, and as this mother’s tears dampened my collar, I realized that no amount of previously witnessed tragedy made this any less of a bitter pill to swallow. A parent losing a child is utterly awful, and one is never too “tough” to experience the pathos of something so universally dreaded.

I am thankful to this patient and mother, and the many other families of patients that taught me so much about what being a doctor really means. The day before my graduation ceremony from my ICU fellowship, I gave bad news to another mother about her sick 21 year-old daughter who I had just operated on. She began to cry uncontrollably, and I did the only thing I know to do which was to hold her and try to support her as she suffered through the waves of grief that were coming over her. This time I was not surprised when some of her pain seemed to grip my heart as well. Even after an entire year of encountering loss, my heart remains tender enough to experience some of the hurt when I see my patients and their loved one suffer. I am thankful for that. And I am thankful for every mother, father, sister, brother, son, and daughter who lost someone in our ICU, because their pain remains my motivation for wanting to do a good job. I am thankful for the lessons these dying patients and their families taught me about not just pathophysiology, but also about the difficulties of end-of-life decision making. I am thankful for the world-class education I received from the nurses, doctors, and social workers in our SICU about how to communicate with families. And finally, I am thankful for those mother’s tears that taught me that even when suffering cannot be alleviated, it can be shared.

Thanks for the lessons,

chad

“Sharing is sometimes more demanding than giving.”

~Mary Catherine Bateson

Enduring the Worst

2010-02-04T23:43:00.004-05:00

On Wednesday, January 20, 2010 in the early morning hours, I was sleeping on a mat on the floor in the main room of an apartment in Port-Au Prince. I had arrived the previous night after a long day of travelling from Boston to Haiti, with several stops along the way. I knew I needed my sleep for the work that waited for me the next day to care for patients, so I had been intent on getting some much needed rest. Unfortunately, sleep had alluded me most of the night, due to the humidity, mosquitoes, and a noisy dog that someone had tied next to the apartment, but after hours of tossing and turning, I was finally enjoying a few moments of actual sleep when just at dawn, I experienced an unusual wake up call…another earthquake.

Actually, it was a 6.0 aftershock and was the first strong aftershock to occur since the day of the 7.0 main shock about a week prior. To me, it felt like I was on a boat or an airplane with some turbulence, but in actuality, I was indoors. The aftershock was short-lived (maybe 5 seconds), but everyone in the apartment was soon wide awake wondering what might be next.

Kez, the nurse who lives in the apartment and had been in the first earthquake, told the rest of us (who had just arrived the night before), that it was the strongest aftershock she had felt since the quake. I remained on the floor where I had been asleep, while the others were swirling about with nervous activity. It may have appeared that I was just sleepy and unwilling to start my day, but in actuality I was paralyzed with uncertainty.

Up until that moment, I had been single-minded regarding the mission trip. Thousands of people were suffering, and my skills as a surgeon had the potential to do enormous good in the post-earthquake relief efforts. The decision for me to go was actually very easy. I could certainly put up with some difficult living conditions for a short time, when the potential to help was so great. I had not really considered that my own life might be in peril. But the magnitude of the aftershock had suddenly made it clear that I was in a lot more danger than I had previously believed. My mind began racing: What if the “big one” still has not happened yet? What if a building collapses on me? What if I become one of the many statistics here in Haiti? Was this a big mistake to come here so soon after the earthquake?

***

I had a wide range of emotions that I experienced while I was in Haiti. While I am not proud to say so, one of the emotions that I grappled with was fear. It does not sound very courageous or strong to say that I experienced crippling anxiety during my trip, but I have to admit that it was quite overwhelming at times. After that first morning’s aftershock, there continued to be tremors here and there. Usually, there would be a substantial aftershock at night just as I was trying to lay down and sleep. The earth would suddenly shake for a few seconds, and I would spend the next 6 hours wide awake with my heart racing, wondering if I was going to see the next day. Even if I fell asleep, I had bad dreams. To be honest, it was one of the most difficult things I have ever endured.

But I did endure, and they say those things that don’t kill us make us stronger, and I believe that my fears did just that. By the end of my trip in Haiti, I was able to sleep through the night (somewhat, because I had become exhausted), but also because I eventually realized that my well-being is in God’s hands, and that no amount of worry could really protect me. I had to remember that the same God who had kept me safe from accident and disease for the last 35 years could certainly keep me safe in Haiti. After all, “who can add a single hour to one’s life by worrying?” (Mat 6:27)

I also re-learned a lesson that I had learned long ago about dealing with difficult situations. One of the best ways to alleviate anxiety, loss, and other painful emotions is to serve other people. To some, this seems counter-intuitive…to think that the way to deal with our own discomfort is to try to alleviate someone else’s. But in actuality, when it comes to emotional turmoil, I believe it is the best medicine. As I have said before in this blog: We are all designed to serve one another…to love one another. When we fulfill that purpose, we build up the emotional reserve to handle our own disappointment, anxieties, and fears… Even if you don’t buy that theory, busying oneself in the service of other people is at least a distraction to get one’s mind of their problems, and unlike other distractions (e.g. drinking), the side effects are beneficial.

During the daytime, staying busy was easier. There were patients to assess, operations to perform, medial supplies to sort, drinking water to filter, etc. When I had work to keep myself occupied and busy, I was able to focus on those tasks and my fears moved to the back of my mind. Additionally, the sense of accomplishment seemed to justify the risk I was exposing myself to. Most importantly, seeing how much others were suffering or had already suffered made my own problems seem small in comparison. So many people had lost loved ones, homes, and their health, and needed someone to help them through this difficult time. Seeing the hope that they maintained gave me the resolve to face my own anxiety about my well-being.

I won’t say that I was able to totally master my fears, because I did not. In fact they often got the best of me at night when things were dark and strangely quiet, but I can say that I did not become a slave to my fears. I did not allow them to control me, and prevent me from doing what I had come to do. I was able to endure my anxiety, and ironically it only demonstrated how strong I could be. Being fearless is not strength…facing fear is strength.

Interestingly, when I got the email from my boss saying that I had to return to Boston as soon as possible, I was very conflicted. On the one had, I was relieved that I would soon be returning to the “safety” of the US, but I was guilty that I felt this relief. I knew that many surgeons were arriving and could continue the work (if anything, by the time I left Haiti, their had become too many doctors, and not enough other staff), but I still felt some shame that part of me was so happy to be leaving the stressful circumstances of post-earthquake Haiti.

This week, my hospital conducted a meeting with all of the hospital employees who had returned from Haiti…sort of an informal debriefing. I quickly found that I was not alone in feeling torn about being back in the Boston. Many expressed similar conflicted feelings of relief and guilt. Most desired to return, and felt that the work they had done in Haiti was so much more important than the work they were doing in the States. The other theme of the meeting however was to discuss anxiety and resources to deal with the after-effects of being in such a stressful environment. Several psychiatrists and therapists talked to us to talk to us about the “acute stress response”, and how feelings of anxiety, or for some, feelings of numbness were normal after a traumatic experience, and that the symptoms would likely improve, but if they did not, there were resources to get help. To me it was therapeutic just to hear other people talk about their feelings, and know that I was not alone in how difficult it was to cope with the experiences of the mission trip.

Looking back on the trip, I have no regrets that I went to Haiti when I did. There are certainly still some bad experiences and images that are burned into my mind that I will carry for a long time. But more deeply etched into my heart than the difficult moments, are the amazing moments. The sincere appreciation of the Haitians in the neigborhoods for trying to help. The small victories like alleviating someone’s pain or fixing their physical problem. The sense of accomplishment and teamwork of caring for patients with doctors and nurses from all over the world. And these moments were especially amazing, because they had happened under so much distress.

I too wish to return to Haiti to continue with relief efforts. I am hopeful that some time this spring will be available for that second mission. I suspect things will be calmer by then, and the stressors more predictable by that time, but even if they are not, I have learned that one can endure the most uncomfortable of feelings for a worthwhile reason…and Haiti is definitely worth the while.

Enduringly yours,

chad

“Bear and endure: This sorrow will one day prove to be for your good”

~Ovid

So Much Things to Say

2010-01-25T17:48:00.011-05:00

I am on board the Mississippi National Guard, C-17 Military transport jet travelling back to Florida after what was probably the most stressful week of my life. Amidst the stress, it was also perhaps the most amazing week of my life too. As I sit among about 100 passengers, many relief workers such as myself, and the rest are Haitian refugees, I am having difficulty processing everything I just experienced. I saw destruction and death like I had never seen it before, but I also saw resilience and hope unlike I had ever known. At times, I felt overwhelming anxiety and fear, but there were moments of total peace and serenity between the horrific sights and sounds. I’m sure it will take some weeks to really wrap my mind around what I have just seen in Haiti, so expect more posts in the coming days. I have so much that I want to say about my experiences, but I cannot even put it into context to begin to write. One thing is certain though...what I saw in Haiti has changed me, and I will never be the same again. For now, I just want to post the few photos I was able to take (as electricity and opportunities to charge my camera battery were rare). I will leave out the gruesome ones out of respect for the dead and injured.

Forever changed,

chad

“We learn geology the morning after the earthquake.”

~Ralph Waldo Emerson

The charter plane we took from Fort Lauderdale

Me with Patricia of American Airlines and Vanessa of Angel Missions Haiti prior to departure

Beautiful are the feet...

Vanessa and I settle in for the flight in the cabin of the airplane

We had a 15 minute layover in the tiny Bahamas island airport on the way to Haiti

Structural Damage to St Joseph's Home and Vanessa's place (Where we stayed at night)

Me pumping cistern water through the filter for drinking later on

One of the many tent cities that had sprung up all over the city:

We made rounds here, mostly looking at wounds and other minor medical problems

Earthquake Damage

Earthquake Damage:

I know you have seen pictures of the damage on CNN already, but what these photos cannot capture is the extensive and pervasive destruction the earthquake left. Buildings looked like this EVERYWHERE, some entire blocks just gone. And what you can't see is that as you would walk by these buildings, you could smell rotting bodies still trapped inside. CNN has focused on people pulled from the rubble, but this has been only 100 or so people. When you look around, what you really see is how much death this earthquake caused.

Nos Petits Freres et Soeurs (Our Little Brothers and Sisters) Haiti Hospital

This pediatric hospital had been temporarily converted to a general hospital, and we were able do the most surgery here. Mostly I did wound debridement, burn care, and amputations.

Courtyard of the Little Hospital

Patients overflowed from the hospital's wards into the grounds in tents and make-shift wards

I think this was a consent form, but my french is rusty...

Even people with homes that were standing were reluctant to sleep in doors fearing more aftershocks, and many were sleeping outside on the streets.

This was suppose to be the new Angel Missions Surgi-Center, but most of the new surgical equipment was on the 3rd floor stuck under that collapsed ceiling.

I rumaged around the first two floors to find enough supplies to help with the clinic/infirmary that Joanne eventually set up at the site

I had to leave earlier than planned due to some unforseen repercussins of me leaving Boston so suddenly. This is the military C-17 jet that took us home (A little faster than on the way in)

This is the Mississippi Air National Guard C-17 transporter. Previously, I have not been a fan of Mississippi, but my feelings changed drastically today.

Boarding the plane at Port Au Prince airport

Something interesting happened when we boarded. Most of the relief workers elected to sit on the floor, and gave the seats to Haitian refugees. It was a spontaneous, but beautiful moment.

Me and another surgeon from San Diego ready to fly home

Beautiful are the feet...okay maybe smelly are the feet after wearing these boots for close to a week

Arrival in Orlando around sunset: God Bless America!

A Knock At Midnight

2010-01-19T00:45:00.001-05:00

It’s close to midnight on January 18, 2010, and today is Martin Luther King, Jr. day. Every year at this time, many Americans commemorate one of the greatest sons this nation has ever born. While many think of King as a champion of civil rights for black Americans, most who have studied his life and his words, know that he was a champion of the poor and oppressed. And while black Americans enjoy substantially more civil liberty than they did when King began his famous work in the bus boycott in Montgomery, Alabama in 1955, the world is still filled with stifling oppression, especially of the poor. King’s words still echo in the hearts and minds of Americans today, because they are still relevant. I am reminded of King’s acceptance of the Nobel Peace Prize when he noted that all of man’s technological achievement had not allowed him to overcome racial injustice, poverty, and war: “We have learned to fly the air like birds and swim the sea like fish, but we have not learned the simple art of living together as brothers.”

And tonight, as the clock nears midnight and I am awake with such heavy thoughts in my mind, I wonder what Dr. King would think about our progress were he alive in 2010 on what would have been his 81st birthday. I think if Dr. King was still alive, his heart would remain heavy with anguish about the disproportionate suffering of the poor throughout the world. In particular, I think he would be deeply troubled by the devastation in Haiti, the poorest country in the Western Hemisphere shaken to its foundation by last week’s earthquake. I think Dr. King would weep knowing that so many more people were dying, because it is a poor country.

***

Natural disasters cannot be reliably predicted. Mother nature is far too powerful a force for man to ever hope to contain her, or predict her most catastrophic moods. But what can be reliably predicted, is who will suffer the most, when natural disasters occur…it will inevitably be the disenfranchised…the poor, the young, the old, the weak, etc. These are people who live at the margins of society, and their marginalization becomes their decimation, when disaster strikes. Haiti is an incredibly poor nation with very little infrastructure…bad roads, unreliable utilities, and terrible sanitation. In a place like Haiti that is scraping by, on the margin if you will, the results of a natural disaster are amplified and the suffering is always so much worse and prolonged than it would be if the same circumstances occurred in a more affluent setting. Sometimes the devastation merely highlights what terrible and precarious circumstances people have been living in. Almost a week has passed, and so far the biggest challenge has been getting supplies and personnel to the small country. The news reports have been awful, but finally some doors appear to be opening to allow more relief workers into the area.

As a surgeon with a desire to go and help the critically injured, it has been frustrating for me to hear how much suffering is taking place in Haiti. I have put my name on the list of doctors and nurses from my hospital who are willing to go, but the last 5 days, all I have heard is more and more push backs in the time to deployment. Meanwhile, broken bodies that are in need of someone with some general expertise of how to put them back together again lie everywhere. Who will help them?

Well a few hours ago, I got word from an organization that has several temporary operating rooms up and running. The organization says they have lots of medical supplies going to Haiti, but are in dire need of medical personnel to staff these facilities. The problem is that they leave from Florida tomorrow, and in order to get on the plane I will need to leave Boston in a few hours…not much time to prepare.
So now the hour is midnight, and I have to decide if I want to go into the fray. Little can be guaranteed about the trip, but one thing is certain…if we continue to wait, more people will die. The opportunity to help rarely comes with convenient circumstances. It sometimes comes at strange hours, and it sometimes comes with risks. Just like the proverbial knock on the door at midnight, the opportunity to help can be very inconvenient and anxiety-provoking.
But here I sit at my computer in Boston at 12:04am, and the knock on the door of my heart is too loud to ignore. I am perfectly equipped to save lives in Haiti, and any opportunity to do so must be taken. It is possible that I may not even be able to get to Haiti. It is possible that I may not be able to get to the operating rooms. It is possible that it may be too late to intervene and help those who need it. But what is impossible is for love to ever be in vain. If all I can do is cry with a mother about her dead child, the trip will not have been in vain.

Dr. Martin Luther King, Jr. preached a sermon called “The Knock At Midnight.” I leave you with this excerpt from the ending of this speech.
chad

Centuries ago Jeremiah raised a question, "Is there no balm in Gilead? Is there no physician there?" He raised it because he saw the good people suffering so often and the evil people prospering. Centuries later our slave foreparents came along. And they too saw the injustices of life, and had nothing to look forward to morning after morning but the rawhide whip of the overseer, long rows of cotton in the sizzling heat. But they did an amazing thing. They looked back across the centuries and they took Jeremiah’s question mark and straightened it into an exclamation point. And they could sing, "There is a balm in Gilead to make the wounded whole. There is a balm in Gilead to heal the sin-sick soul." And there is another stanza that I like so well: "Sometimes I feel discouraged."
And I don’t mind telling you this morning that sometimes I feel discouraged. I felt discouraged in Chicago. As I move through Mississippi and Georgia and Alabama, I feel discouraged. Living every day under the threat of death, I feel discouraged sometimes. Living every day under extensive criticisms, even from Negroes, I feel discouraged sometimes. Yes, sometimes I feel discouraged and feel my work’s in vain. But then the holy spirit revives my soul again. "There is a balm in Gilead to make the wounded whole. There is a balm in Gilead to heal the sin-sick soul." God bless you.

Delivered at Mount Pisgah Missionary Baptist Church, Chicago, Illinois, on 27 August 1967.

Made to Serve: Lessons Learned in Kenya

2009-06-11T14:52:00.001-04:00

It’s early June in Boston, and it’s one of those years in New England, where summer seems to be having a difficult time arriving. It is cold and rainy today, more like an April day should be. I sit in an apartment in Beacon Hill, one of the most affluent neighborhoods in Boston, and I look out of the window, where I see busy Bostonians hustling about on their way to work looking quite harried. There seems to be no joy on anyone’s face even though they all live in this wonderful community of abundance. It causes me to pause and wonder why we are in such a hurry, and so focused on our problems, when over all there is so much to be thankful and hopeful for. I start to day dream about the wonderful community I have just left. Kijabe was not free of problems…in fact there was an ever present climate of need and lack in this small town, especially during the drought when people were hungry. But despite the problems, there was so much joy in the residents of Kijabe. People were thankful for the smallest things, and most wore a countenance of hope across their faces, even when they were facing obstacles. There was always a spirit of collaboration, and no one was allowed to suffer alone, even if the only help that could be given was an encouraging word or a willing ear. A smile broke across my face as I began to think of my friends who I had just left in Kijabe. My heart warmed as I thought of our moments of shared laughter and tears. Then suddenly, my deep thoughts are interrupted by the sounds of the loud garbage truck coming down the street to remove the trash, and as I am startled back into reality, it hits me that I am not in Kenya anymore.

***

Last September, I left Boston with great anxiety about what would happen to me in Africa. In my spirit, I knew I was doing the right thing, but it is difficult to silence the doubtful voices in ones head, when one endeavors to walk by faith. My mind was racing with a thousand “what-ifs”: “What if I get sick?” What if I am not well trained enough to be a surgeon in Africa?” “What if I run out of money?” “What if I am lonely?” I thought of all the things that could go wrong, and I just could not see how I was going to have a productive, safe, peaceful trip. My mind would just accelerate with worries until finally, I would just take a deep breath and pray that everything would work out.

Well…600 operations, 1500 clinic visits, and 300 inpatients later, I am happy to report that it was a wonderful trip. I really had no major problems. Financially, I did not have to go into debt to complete the trip. I did not get seriously ill, and my PPD is even still negative. I was able to thrive professionally, and most importantly teach many trainees and students which is probably the most crucial activity to helping change the quality of health care in Africa over the long term. And I was never lonely…I made so many wonderful friends, and even though I was 10,000 miles away from home, I never felt like I was any further away from my family than when I am in Boston.

And now as I look back on the entire experience, I can say that I learned some very valuable lessons about life:

We will never regret any decision to serve others.

We often regret decisions we make in life. Sometimes those regrets are because we make decisions out of wrong motives. For me, I still regret a decision I made over 15 years ago. The decision eventually hurt several people, myself included. And when I think back to what motivated me to make the decision, it was very selfish. On the other hand, I cannot think of one time that I made a decision to do something for someone else, selflessly, that I regret. I am not suggesting that nothing bad happens to us when we attempt to serve…actually, we can be used or taken advantage of when we try to help others, but even if our efforts to help are taken advantage of, we will not regret trying to help. We may have to alter our approach or even abandon our work all together, but there is no shame or guilt in that. Regrets only come when we do something and we should have known better.

What we do is not as important as how we do it.

When I moved to Africa, I was pre-occupied with the possibility of clinical scenarios that might overwhelm my skills and knowledge. I thought that the most important thing for a doctor (especially a surgeon) is to know what to do…especially in an emergency. But in actuality, knowing what to do is of less importance than knowing how to show respect for colleagues and care for patients. A surgeon can be technically very skillful, but rude and condescending to co-workers or distant and unavailable to their patients, and that surgeon will be ineffective. On the contrary, a good doctor leads by example first and foremost. Other doctors can be consulted if one does not know what to do, but we cannot regain the opportunity to inspire our colleagues or make our patients feel important, and this is key to being an effective physician, or an effective anything for that matter. Albert Schweitzer, the famous African missionary, once said “Example is not the most important thing in influencing others…it’s the only thing.”

Our financial problems are not as bad as we may think.

I used to believe that I had financial problems. I used to believe that if I could just get a couple financial breaks, my life would be good. I thought driving and old car, and not owning a home made me financially disadvantaged. Living and working among the truly poor made me realize how wealthy I am. Living in rural Africa has helped me to simplify my life and learn the value of a dollar (or a shilling at least). Even now, as I re-enter life in Boston, I realize what I really need to be happy and healthy, and I have more than enough financial resources to meet those modest needs. Plato said it well: “the greatest wealth is to live content with little.”

The collateral damage of love is more love.

Often times, my attempts to help patients while I was in Africa failed to achieve the desired outcome. Even with my best efforts, some patients died. And even with the patients I was able to help, there was always such a long list of people who I could not help. People with incurable disease, or problems beyond my expertise to help. Sometimes, I felt so impotent to make a difference, but what I learned was that even when my attempts to do good fell short of the immediate goal, the effort often had some unexpected benefit. A co-worker might have been inspired by my dedication to a patient, even though the patient died. Or a family member was able to renconcile with their loved ones, in the time we were able to delay the progress of their incurable disease. There are so many unseen blessings that come when we serve. So even when it seems that our service is in vain, it is not. I believe that love is infectious this way, and can spread beyond the direct act of love we attempt to commit. Love does not die…it multiplies.

The cure for a broken heart is to love.

Mahatmas Ghandi said “the best way to find yourself, is to lose yourself in the service of others.” I understand this now. We often say to ourselves that we are going to get involved in some charitable activity or community service project as soon as we get our own lives straightened out. Many of us are focused on our own pain and problems, and we don’t think we have anything else to give away. But ironically, one of the best ways to deal with our own hurt, is to serve someone else. We were created to love one another…it should be our primary occupation. And when we “lose ourselves” in the occupation of serving others, our problems are able to come into proper perspective. It turns out that we don’t have to be perfect to love other people, but loving other people will serve to perfect us.

I am thankful for the many lessons I learned in Africa. My life was so enriched by this mission trip. It’s a cliché to say that it was a “life-changing” experience, but that is exactly what happened to me. I have been transformed. I look the same on the outside, but my heart is alive in a way it never was before. And now, as I look to the future, I know what I need to do to continue to enjoy this peace, joy, and fulfillment…even in America. I have to continue to serve. Perhaps I will not always be able to serve overseas, but I can have a servant’s heart no matter where I am and what I am doing.

We were all made to serve. The golden rule that is common to almost all religious faiths is “to do to others as you would want done to you”. But it’s not simply something we should do, because it enhances the lives of those around us. When we follow this simple rule, we are doing what we were designed to do…and when we do what we were designed to do, we experience fulfillment of our purpose…we feel complete…we know peace. And what is most beautiful about this truth is that this wonderful way to live is accessible to anyone…not just doctors, or educated people, or the rich. Each and every person has the capacity to love and serve someone in their life.

I’m not suggesting that a life of service is always easy. It can come with sacrifice, suffering, and in some cases even death. But I can tell you from my own experience that those sacrifices that I had to make to work in Africa were well worth it. I have no regrets, and I look forward to returning to Africa knowing that there are risks involved. I would rather endure suffering on my own terms as a servant than to live a “safe” life, but not fulfill my purpose. And I am not suggesting that we rush foolishly into dangerous situations in the name of doing good. We have to exercise wisdom in our efforts to serve, but at some point we may have to put ourselves at some risk to meet the needs of others. And of course, we cannot all move to a developing nation or a refugee camp…most of us have to serve at home. But we can all find ways to serve effectively, whether it be raising money for good causes, mentoring someone in our community, or even paying a visit to a lonely elderly family member. It is not really important how we serve, but just that when we see a need that we have the ability to meet, that instead of turning a blind eye to the problem, that we be willing to give of ourselves to meet that need. That is where our own personal fulfillment lies…being willing to put ourselves someplace we don’t have to be…or give something away we could have happily kept…or fixing something that was not our responsibility to fix. It’s what we were designed to do, and when we do it, the blessings are immeasurable.

***

As I have sat here in this Beacon Hill apartment thinking an writing, the sun has found a little crease in the clouds, and squeezed through for a moment of sunshine. The weather in Kijabe was very similar. Often, days that started off looking like they were going to be damp and dark would transform into gorgeous days with the sun streaming down over the beautiful valley below the town. As my mind wanders back to those days in Kijabe, I realize why I was so happy there. I was in a continuous state of service. I have never been so eager to go to work in the morning, and even a late night consult was an excuse to breathe the clean crisp air and look at the multitude of stars in the beautiful African sky as I walked to the hospital. It never felt like work…it just felt right. My body was tired, and I got frustrated at times, but those were always fleeting moments. The overwhelming feeling I had most of the time was serenity. It’s ironic, because there was so much happening around me, and so many demands on my time, and so many problems that seemed insurmountable, but all the while I was content. I felt at home in Africa…I knew I was right where I was suppose to be. It’s a feeling I pray everyone get to experience in their lifetime.

Peacefully yours,

chad

“I don’t know what your destiny will be, but one thing I know: the only ones among you who will be really happy are those who will have sought and found how to serve.”

~Albert Schweitzer

Case Report #8: The Patient You Never Forget (Case Reports from Kijabe Hospital)

2009-05-02T13:55:00.002-04:00

Warning: This post is one of a series that describes a patient (case) that I have taken care of in Kijabe hospital, and it may contain graphic descriptions or photos of medical pathology written primarily for clinicians. For my non-clinical readers, use discretion before reading, and please excuse the medical jargon.

Occasionally, a patient walks into your clinic, and right away you get a feeling that it is going to be more than the usual patient doctor relationship. Even before taking a history and physical, there is something deeper that stirs within you, and tells you that you are going to have a profound impact on this patient or this patient is going to have a profound impact on you or both. You just know that this is a patient you will never forget. In the case of JW, I felt an immediate connection to her and her family, but the effect we had on one another was not what I expected.

***

JW is a 20 year old woman who came to see me in clinic with her parents. The parents were very worried and concerned, and seemed desperate to find someone who could help their daughter. She had been vomiting, losing weight, and battling multiple pneumonias over the last year. Initially everyone assumed she had TB and likely HIV as that is the most common cause of weight loss and respiratory complaints in a young woman in East Africa. However, after all her tests came back negative, and she was not responding to TB therapy, someone decided to investigate further. They had recently gone to a hospital where a barium swallow and upper GI endoscopy revealed that she had achalasia with mega-esophagus.

Achalasia is a condition where the lower esophageal sphincter will not relax, and it causes the patient to store food in the esophagus until they vomit. It usually has an onset during adolescence or young adulthood, and the esophageal sphincteric hypertension grows worse until the patient can develops severe esophageal dilation (mega-esophagus), malnutrition, and aspiration. The repeated respiratory infections that JW had were from aspiration pneumonia and not from TB.

Once the diagnosis was made, she was referred to Kijabe hospital (where the family had been told there were surgeons who would take on her case). She essentially had end-stage achalasia, and while sometimes medical therapy is used to treat the hypertensive sphincter, her condition warranted a more aggressive treatment. I talked to the family and explained that I could operate to alleviate the obstructed distal esophagus and allow her to eat and hopefully gain weight. They consented to the surgery and since my operating theater schedule was booked for the next two weeks, I asked the head theater nurse to arrange to have a team on Friday night of that week to operate. As I talked to the family about what to expect, I noticed what good people they were. JW was very polite, but also anxious about her deteriorating health and pending surgery. I tried to encourage her, and told her how fat I was going to make her, and the skinny young woman smiled a smile that lit up the room. Her parents were also very polite. Her father in particular impressed me with his dedication and love for his daughter. He had been traveling all over Kenya trying to get her help, and was willing to make any sacrifice for her. He told me he had faith in me that I would help them, and I smiled a confident smile and said, I would do my best.

Friday came, and the operation went about as well as could be expected. I knew I had to get the operation right the first time, because she did not have the capacity to afford any post-operative complications. I went home that night after having operated from 8am until 9:30 pm (I started JW’s case after 7pm). I was tired, but I still had this special feeling about JW and her family. I just felt like our paths had been destined to connect. The first couple of post-operative days were a bit bumpy. Despite her rapid sequence induction in the operating room, she clearly had aspirated, and got a bit septic. However, she responded well to antibiotics, and by that Monday, she looked much better. Because of the pneumonia, I had waited to advance her diet, but I let her start sipping water on Monday, and then on Tuesday I let her drink liquids ad lib. Unfortunately, she had some vomiting at that point. The next few days, she was unable to drink very much, and her abdomen became distended. Then over the next weekend, she began having fevers and peritonitis.

I was devastated, I had such high hopes that she was going to do well. I consulted a couple of thoracic surgeons by email back at home about what to do next. And I took her back to the operating room where I found a leak from the distal esophagus and about 2 liters of fluid in her peritoneum. I washed her out, fixed the hole, and buttressed the repair with serosa from what I made into a 360 degree fundoplication. I left drains and a jejunostomy tube for nutrition. She subsequently got very sick and had to be transferred to the “ICU”. She had developed bed sores, anasarca, and sepsis. Over the next 2 weeks, JW was nursed meticulously by the ICU staff (as I demanded when rounding on her 2-3 times every day.) She slowly began to make progress, and started to look like she would soon be ready for the floor. She had been through a lot, and was still far from being able to go home, but her bright disposition had returned. When I would make my round she would flash that smile, and it would keep me encouraged for the rest of my day. I thought to myself, this is why I had such a special feeling about her. Because I was going to have to go through this extensive hospital course to get her better. By this time her father and I had also become pretty close. I talked to him everyday to give him an update either in person or by phone when he had to return home to work. His dedication had been incredible. He had spent every moment either at the hospital or at work. We discussed everything that had happened, and believed that God had merely wanted to test our faith by allowing JW to get so sick.

Then I came in one Sunday (about 2 weeks after the second operation) and JW did not look like herself. She was a bit confused and had a fever. I hoped it was just another mucus plug and lung collapse as she had had before, but the x-ray was okay, and over the next 48 hours, her fevers got worse and her abdominal pain worsened. Then on Tuesday morning, I came in to find her feeding tube had fallen out. She was as sick as ever, so I took her back to the operating room for the third time. I found purulent fluid in the abdomen, but could not be certain if it was old tube feeds, or from an ongoing leak. The repair appeared intact (or at least stuck down), and the fluid was in the lower right abdomen. I washed her out, left more drains, and replaced the feeding tube. We took her back to the ICU, and I prayed that she would get better.

Over the next 4 days, she walked a fine line of mild sepsis, but made good urine and maintained her blood pressure despite some low grade fever. Friday, May 1, 2009 is a Kenyan Holiday (Labor Day), but it was also JW’s 21^st birthday, and she appeared to me as if she was starting to make progress again. I ran into her father as I finished rounds, we both believed that the “test” was finally ending and that JW was going to get well and be able to go home. We remained optimistic as ever, and I still had that special feeling about JW. It had been 28 days since I originally operated on her, and it had in deed been a trial of emotional ups and downs. I had never had a patient come to mean so much to me. She had become like my sister. I would round on her sometimes in the evening and not even look at the flow sheets (unheard of for a surgeon). I was just visiting my family. As I left the hospital, I could see why I had that special feeling when I first met JW. I had never invested so much of myself in a patient, and she had brought the best out of me as a doctor.

***

At 2:05am early Saturday morning, just hours after JW’s birthday had ended, my pager went off. I was on call, so I lazily dialed the number waiting to hear what trauma patient was awaiting me in the hospital. But instead, it was the ICU doctor on call. He was calling to tell me that JW had just died. He said she just became very unstable over 20 minutes, then her pupils became fixed and dilated followed by ventricular fibrillation and then asystole shortly thereafter. I could not believe it…How? She was looking well. How could she decompensate so fast. While I lay stunned in the dark in my apartment, the ICU doc told me he was looking for the phone number to contact the family, but I told him I would call the father. I did not want him to hear it from anybody but me. I think this was the hardest number I have ever dialed. He answered, and knew something was wrong from the hour of the phone call. I confirmed his worst fear. At first he said nothing, clearly shocked , and then I could hear the agony in his voice as he choked back sobs and said: “we did all we can do, we must accept God’s will” and then he hung up. I lay there for most of the rest of the morning seeing JW’s lovely smile in my mind, and not being able to believe she was gone. She was such a good person. Her parade of dedicated friends and family confirmed that. I kept thinking of the pain her father was going through (infinitely worse than what I was coping with). And then the overwhelming guilt came over me. JW would still be here if a better surgeon had been in clinic that day. I felt so small and worthless. I knew I had done my best, but my best is so inadequate. I’m a 34 year old surgeon less than 1 year out from residency. I let this woman down. I let this family down.

By the time the sun came up, I was able to let go of the guilt. Even though I am young, I know I am a good surgeon, and I know complications will happen to everyone. I know I had given everything within me to help JW, and there is no shame in that…even with the adverse outcome.

As I walked through the hospital gate, I saw JW’s family gathered in the courtyard in the morning hours. As is typical for Kenyans, the father was totally composed by this time. He thanked me for my efforts, and would not let me express any apologies or sorrow. His faith is strong, because in just a few hours after learning that his precious daughter was gone, he could say that it was God’s will. He was thankful for the time he had with her, and he had no anger toward me. While the father was strong, JW’s mother was still shaken. She is a quiet dignified woman who had never said anything to me other than “habari” (how are you), and nzuri (I’m fine), but now she sobbed and cried with emotion she had never showed before. I guess, I had not really grieved myself, because as I tried to say some words of encouragement to the family, tears begin to fill my eyes and my voice broke down. JW’s father told me, “I have lost a daughter, but you have lost a sister.” He was right, and I needed to grieve too. I pulled myself together to make rounds, putting forth my usual smile and laughter for rounds, but after I came back home…I finally let go and cried. I miss her. She came to mean so much to me in such a short time. Making her better mattered more to me than anything. And now, I sit here broken-hearted, with tears still rolling down my face trying to write this blog entry. My heart hurts, and I wonder why God would allow the one patient who I have cared for more than any other before to die? What is the meaning in that? I thought this bond that developed between me and this family was going to end in joy and celebration. I would always remember the patient who I saved, and they never forget the doctor who helped them, but instead we are etched into each others memories through loss and pain.

It is almost midnight in Kenya as I write this, and it is certainly the darkest moment I have ever had as a doctor. And while weeping may endure for a night, I know that joy will come in the morning. And in the midst of the darkness, I am thankful. Even though, I hurt right now, I know that I am blessed. I am blessed to have a job that matters to me and other people. I am blessed to be working in a setting where I am needed. I am blessed to have come to Africa and learned to care for patients more than I ever did before. I am blessed to have gotten to know JW and her family. I am blessed for being able to care for her in her last days in this world. I am blessed, because in those last days I saw her smile. And I am blessed not only for having a special patient that I cared for, but for having a sister that I loved.

Rest in Peace Jacinta.

I will never forget you.

chad

"I have found the paradox, that if you love until it hurts, there can be no more hurt, only more love."

~Mother Teresa

Case Report #7: A surgeon cuts, but a doctor listens (Case Reports from Kijabe Hospital)

2009-04-26T17:37:00.006-04:00

Here in Kijabe Hospital, there is a large variety of patients and problems that show up in my clinic. Many of the cases are routine, like old men with urinary retention and BPH, young women with goiters, and hernias, hernias, hernias. Sometimes it gets a bit boring, and there is a temptation to emotionally disengage and just work on autopilot. But just about every week, someone comes into my clinic with a very unusual problem. A problem that I would never think a general surgeon should be assessing, but there aren’t that many doctors around here so sometimes, people are just seeking your opinion even when the problem does not appear surgical, but is “unsual”.

Often, the diagnosis is not that difficult to make, it just requires that someone actually listen to the patient. In Kenya (like America), clinicians often focus on the easily obtainable data: labs, reports, and previous notes, and don’t talk to patients, because of time constraints. I always do my best to not fall into this trap, and I think I have made a few diagnoses that had been missed by others simply because I took the time to hear what the patient was saying. GS is an example of a patient with a problem that had been undiagnosed for years despite his complaints, because no one had really listened to him.

***

GS is a 16 year old boy who presented to Kijabe hospital complaining of abdominal pain for FOUR years. According to the chart, he had been seeing doctors most of his life for various vague complaints. His past medical history was notable for having bilateral undescended testicles. The chart also noted that he had a low transverse incision on his abdomen that was thought to have been from an exploratory surgery to find the testes. The chart said the patient was non-tender, with no nausea, vomiting, or unusual bowel habits, but that he just had low abdominal pain. He had labs including a complete blood count and liver functions that were normal and an ultrasound showing a normal gall bladder and no hydronephrosis/hydroureter. After this work-up, someone sent him to me, thinking that I might want to explore him. But most general surgeons hearing this case would be uninterested. No signs of obstruction, inflammation, or even focal tenderness rarely adds up to a problem that is correctable with surgery.

Part of me wanted to toss the chart aside, and tell him to follow up with the internists or family medicine doctors, but I decided to be faithful to my training, and take a history myself and examine the patient.

I asked the patient about his symptoms and he confirmed most of what was in the chart. He had a normal appetite, no weight loss, no vomiting, no diarrhea, no fevers, no dysuria, or any other complaints besides four years of abdominal pain. I thought maybe the previous operation had been the source of the trouble, but he had no documentation about the surgery, and could only tell me that it preceded his pain by some years. Then, I asked him to describe the characteristics of the pain, and suddenly the clinical picture changed. He said that he had been having pain in his lower abdomen every month for 4 days since he was 12 years old. He said the pain came and went like clockwork every month. Should sound familiar, especially to my female readers.

I quickly had him lie on the exam table. His abdomen was in deed non tender, and soft…totally normal, but when I examined his genitals, I noticed his penis was bit small for a 16 year-old. I confirmed that he had no testicles as the chart had said, but I took a close look at his scrotum. He really had no scrotum. Instead at the base of his penis, he had what appeared to be large labia. He also had a slight hypospadias (a urethral opening on the ventral penile shaft instead of the tip of the glans). I stepped back to assess the patient again. He had a soft voice, was short in stature (shorter than his mother), and he had some mild gynecomastia.

After actually listening to his complaints, his physical findings made perfect sense. He had been having pain for 4 days every month since he was 12 because he has a UTERUS. His pain was worsened by the fact that he was not able to pass blood, because his “vagina” has no real entroitus…kind of like having a really thick hymen. Now the group of disorders that can cause these types of presentations are beyond my general medical knowledge (ambiguous genitalia, pseudohemaphroditism, true hermaphroditism, mosaicism, etc), but fortunately me making the general diagnosis was all that was required. Kijabe hospital has a group of pediatric surgeons who are much better equipped to counsel this patient on what should be done. Now if his condition had been diagnosed as a baby, there would have been an option to try to make him into a girl (he essentially has a vagina with a hypertrophic clitoris), but he had been raised as a boy for 16 years, so psychologically, debulking his “penis” may not be a good idea, and I was happy that Dr. Heuric was willing to take this case on for me. However, I did need to explain the diagnosis to the “boy” before I could refer him, and that was a delicate conversation to say the least. As I explained to him and his mother, I told the him that he was not “cursed” and that God did not make a mistake…to not let anyone make him feel like he was less than human. I told him that outside of Kijabe, he would be ridiculed, but the doctors here understand that it is a medical condition that can be treated. I told him that we were happy to care for him, and excited that we could do something about his pain. I shook his hand, and made sure he knew that we cared for him, and did not judge him for his condition.

Two weeks later, I popped my head in the operating room to observe his hysterectomy (as that was the plan that the pediatric surgeons and the patient decided was best). Knowing what to do with the gonads is a little tricky. Without frozen sections, we cannot be sure if they are testicles or ovaries, so they pediatric surgeons biopsied them and left them in, in case they are testicles. (One gonad appeared to have an epididymis associated with it.) He may need yet more surgery, but I was happy to see that his problem had been taken seriously, and he was being treated to the best of our ability.

Intra-op photo I took of uterus and gonads

In hindsight, I am very grateful that I was able to participate in his care. I felt ashamed that I was initially upset about the referral, and reminded that patients are sent to me because they have a problem, and it’s not their fault if the problem does not fit neatly into one of our little specialty boxes. Each patient encounter is an opportunity to make an impact in someone’s life…sometimes a major impact, and I should never become detached from interviewing and examining patients. I am not just a surgeon who cuts whatever patient that is brought before me. I am a doctor, and doctoring requires that I listen to patients, and treat each one as a valuable individual, not another chart in the pile that is keeping me from escaping clinic. So I thank GS for restoring my perspective. I did not even do his operation, so I can’t say I was his surgeon…but I listened to him, and I cared for him so I was something much more important…I was his doctor.

Yours in relearning compassion,

chad

“Difficult as it is really to listen to someone in affliction, it is just as difficult for him to know that compassion is listening to him.”

~Simone Weil

Look into the Eyes of a Somali Refugee

2009-04-19T15:25:00.016-04:00

Currently, Somalia is in the thoughts and minds of many Americans. Of course, most Americans are thinking about the rescue of a ship captain and the thwarted plans of the Somali pirates who tried to take the Maersk Alabama hostage. But long before Somali piracy brought this East African nation to the forefront of the American consciousness, Somalia has been a troubled land.

Somalia has basically been in a state of civil war for over a generation. Many Americans remember that in 1992 and 1993, American forces (as part of a UN team) came to the aid of Somalis who were suffering from this civil war as famine had become widespread from the ongoing conflict. Initially these operations were successful, but eventually these peace-keeping/humanitarian forces came to be seen as a threat and the conflict between the Somali warlords and the UN forces became bloody, most famously in a raid in Mogadishu in October 1993 that led to 18 American casualties. (This part of the conflict was the basis for the 2001 movie, Black Hawk Down.) By 1995, the UN had largely abandoned peacekeeping efforts in Somalia, but not because order had been restored. In fact, the last 15 years have essentially been lawless with clan loyalties and regional authorities exercising most control while weak externally recognized central governments have been ineffective at maintaining any consistent national order.

***

In the setting of this civil war, a refugee camp opened up in the desert region of Kenya near the Somali border in a place known as Dadaab. The last 15 years have seen steady growth of the camps in Dadaab, and today Dadaab is probably the largest refugee camp site in the world in terms of population. At the beginning of 2008, approximately 160,000 refugees were in the camps, but new arrivals continue to pour in and just one year later, the number of refugees is above a quarter million. I recently had the opportunity to visit Dadaab on a brief 3 day medical mission trip. It was very eye opening to learn more about the suffering of the Somali people, and even more helpful to understand some of the situations that are currently facing Somalia such as Islamic fundamentalism and offshore piracy.

Me and my two colleagues from Kijabe Hospital took a small plane from the cool comfortable Nairobi airport, and landed on a lonely air strip in the sweltering desert of Eastern Kenya. Dadaab is not actually a refugee camp. It is a small town that serves as a base for the organizations that operate the camps. Outside Dadaab there are three camps (Ifo, Dagahaley, and Hagadera) with a fourth camp being planned in the near future. UNHCR (United Nations High Commission for Refugees) is primarily in charged of the camps, but they have several implementing partners (NGOs) that work with them, most notably CARE which implements food distribution, education, social services, water and sanitation programs.

The UN airplane on the desert airstrip in Dadaab

Another implementing partner that specializes in medical services in Dadaab is GTZ (Deutsche Gesellschaft fur Technische Zusammenarbeit or German Technical Corporation). GTZ was our host organization. GTZ provides medical staff for the camps. The three camps each have a doctor and medical facilities, but 3 doctors for more than 250,000 refugees (who have more health problems than most, because of what they have been through) is not nearly enough. GTZ also staffs a small health center in Dadaab that serves to care for refugees and also the local Kenyan community. Kijabe hospital has a relationship with GTZ, and they send us many patients who need inpatient care that is too complex for the camp's simple facilities. In addition, we routinely plan trips every 2 months to the camps to do screening for certain diseases that need specialized care. Usually a surgeon comes along on these trips and does surgery in the in the single operating room in the Dadaab town health center.

On this trip, I was this surgeon. They basically have a long back-log of patients that need surgery (that is doable in this setting) like hernias and lipoma excisions, and my job is to operate continuously from arrival to departure and try to do as many cases on the list as possible. While, I do not like being a technician who merely operates on patients who are brought in front of me, the circumstances dictate that more people can be helped in limited time this way. To be honest, it was a privilege to be able to participate in the surgical “assembly line” and while Dadaab is the dustiest, hottest, poorest place I have ever been, the operating room was an oasis of air conditioning and cleanliness in the midst of this austere outpost. There were still some unusual challenges to adjust to like flies landing all over the sterile field while I was operating and working with very little limited supplies and technology, but we managed to do quite a few substantial cases.

OR list for the day in Dadaab

While mostly, there were hernias, hydroceles, and lipomas, the cases were all quite challenging, because they were all big. (I was very happy I had brought some hernia mesh with me, because I operated on some giant scrotal hernias that would have been near impossible to fix without prosthetic materials.) One case was a 32 year-old man who supposedly had a groin hernia, but when I examined the patient, he only had one testicle. Upon exploring the groin lump that was suppose to be a hernia, I found his undescended testicle (which we removed because the vessels were too short to relocate it to the scrotum, and cryptorchidism is associated with increased risk of malignanacy).

Hernia repair in the beautiful Dadaab Health Center Operating Room

During the time when I was between operations while the room was being cleaned, they brought an endless parade of patients for me to see for surgical consultations. There was an array of ailments, many of which were problems from violence suffered in Somalia like complications from gunshot wounds or burns. It overwhelmed me to see what burden of untreated disease exist in the camps. The most memorable was a 12 year boy with soft hypervascular tumors growing from multiple parts of his skeleton including his skull. I had never seen anything like that in my life, and despite his condition clearly warranting medical attention, he had essentially received no care up to this point.

Boy with soft tumors on skull, right shoulder, and knees

Despite working continuously from breakfast until supper every day, there were always more patients to be seen when we had to return to the GTZ camp, and it left me wondering how many sick people remained in the camps that were simply being ignored due to the massive numbers of refugees.

The most relaxing part of the trip though was the evenings. We had dinner with our host who told us many of the overwhelming problems in the camps. To hear the stories of the numbers of people fleeing Somalia, and the amount of resources it would take to continue to support them in the camp is very discouraging. Somalia’s population is estimated at just under 10 million, and the largest city (Mogadishu) has about 3 million of those people, but if things continue to grow at the rate they have been for another 10 years, Dadaab will be the most populous “Somali” city on the map.

Also, another interesting thing about the evenings was visiting the NGO camps. Our trip happened to occur around March 17th, and we left the GTZ camp to go visit the UN camp that night for a little St. Patrick’s Day celebration. We drove by half a dozen NGO camps to the sprawling UN camp. Seeing how much money, personnel, and infrastructure are required just to “support the supporters” was overwhelming. The financial costs of supporting a refugee camp in the middle of the desert is mind boggling. To see how many resources are needed just to provide the most basic of services for this humanitarian crisis makes you realize the scope of the problem.

But for the entire trip, the most meaningful part for me was the time I got to interact with the refugees, in particular the patients I operated on who were kept in the health center over night, so I could check on them in the morning. I operated on several children and I got to see them with their parents. These were the most encouraging moments, because I had been able to fix the child’s problem surgically, and the parents were so grateful… While it was nice to see some patients get help, most of the Somalis I met had problems I could not fix. I was deeply troubled to see patient after patient (in particular the children) with terrible problems that desperately needed attention, but was beyond my scope to help. I would write on the small bit of paper they were using for a chart to refer the patient to some hospital or clinic, but in my heart I knew there were no resources or money to pay for such a referral.

All the while, the Somali refugees were very accepting of my inability to help them. It seemed they were accustomed to suffering. They had become used to people not being able to help them. They had no expectations or demands that their problems be fixed. When I would look into the faces of these patients, their expressions were so blank. It’s difficult to describe what you see when you look into someone’s eyes, but there was something subtle missing in their eyes, and I sensed it over and over again. There were no smiles, or frowns for that matter. Many Africans are stoic, but this was different. When I looked into their eyes, I could not see any hope…they were merely trying to survive, and to some degree I think many had even loss the desire to survive; they merely wanted to suffer less.

I don’t mean to depress you by writing these things, but I have to be honest. Life in a refugee camp is harsh and the hopelessness is pervasive, but there are moments when humanity can be restored…when you see a smile break across a child’s face or see a need met and the individual feels cared for. This happens too infrequently though. What is needed is so much more. More education, more health care, more services, and most importantly, an opportunity to escape the refugee camp for a better life.

***

I was not able to take many photos of the camps due to the operating schedule but these are some photos of Dadaab that I borrowed from others:

While no one will argue that refugee camps are a tragic reality of the modern world that demonstrate man’s inhumanity to man, what many don’t understand is how closely the circumstances of life in a refugee camp are related to life in the developed world. Somalia’s long lasting civil war is not merely the result of a nation not being able to get along. It is also the residual effect of colonialism, and the result of present external forces that maintain conditions that foster conflict, because they can be profitable. Where do all those weapons in Somalia come from? They are not made in Somalia. If large oil reserves are found in Somalia (as many believe there are), suddenly there will be a financial interest in stabilizing the nation (at least enough stability for Western industry to invest in Somalia), but until Somalia’s lawlessness led to the unforeseeable consequence of piracy costing hundreds of millions in international commercial trade revenue, the West had lost interest in stabilizing Somalia. Now millions are being spent in ineffective policing of the waters off the coast of Somalia, but if the international community had been more interested in the suffering of the Somali people since 1995, then perhaps this situation might have been avoided and Dadaab might have been closed by now. (Similarly, troubles in Afghanistan were largely ignored for years when the Taliban were running amok, but when that ignored suffering created an environment to train anti-Western terrorists, and the World Trade Center attacks occurred in 2001, the international community became suddenly interested in the suffering of Afghanistan.) Incidentally, Somalia is also struggling with an Islamic fundamentalist insurgency, and is considered one of the potential new training grounds for terrorists (the weapons are clearly there). Just this week, the Somali Parliament signed Sharia law into effect for the nation to appease the Islamic radicals. (Strict interpretation of Sharia law forbids schooling for girls, television, and music, among other things.) Somalia has slid into an anti-Western posture, while the international community was ignoring it. The international community cannot continue to ignore large populations of people who are suffering and not expect repercussions. Can you blame a young Somali from developing anti-Western feelings when he watches rich Western countries ignore his suffering, and even support it by profiting from Somali conflict?

So the reason I am posting this today is not just to write about my trip to a Somali refugee camp, but more to write about what is going on in Somalia today. Somalia is not a nation of thieves, pirates, and war-mongerers. Most Somalis want peace, and they want to support themselves through honest means, but after a generation of chaos, one might see how the sentiment toward piracy and anti-Western values might proliferate. What is required to prevent further sequelae of suffering is that Somalia be helped. And not helped out of selfish reasons. (Afghanistan was “helped”, but the primary motivation was hunting down terrorists and revenge, and now the situation in Afghanistan is dreadful.) People are not stupid, they know when they are being used. If the international community sends forces into to Somalia simply to secure the international waters outside Somalia, and then just build a couple of token schools, then nothing will change. The West needs to undo what years of colonialism and external political tampering have created. The West needs to truly serve Somalia. That means more money for education, schools, health care, infrastructure, and more Westerners to help implement the programs. Will this work? I am not sure, but I believe in the principle of sewing and reaping. If the international community sews seeds of good will into Somalia, I believe it will reap not only less suffering for Somalis, but good will back to the international community. There will be no need to police international waters outside Somalia if Somalis determine they are not going to tolerate their countrymen being a menace to the world at large. There will be no need to continue to support hundreds of thousands of Somalis in refugee camps. And there will be no need to hunt down anti-western terrorists from within the country.

Maybe I am naïve to believe that complex problems can be solved so easily by merely taking care of the most poor and oppressed people of the world. Maybe it’s foolish to believe that the hostility against Americans and Christians can be extinguished by acts of kindness, but I can tell you this for sure: I took care of the child of a Somali man in the Dadaab camp. Before I operated, the father looked cold and hopeless, but two days later, when I removed the bandage, and the child chuckled from the ticklish tape coming off, the father laughed too and looked into my eyes and said thank-you. In that moment, I saw a glimmer of hope in his eye that everything was going to be okay. So I know that an act of kindness has changed one heart, and that is there is at least one Somali who appreciates a Christian American doctor...because I could see it in his eyes.

Yours in hope,

chad

“To the people of poor nations, we pledge to work alongside you to make your farms flourish and let clean waters flow; to nourish starved bodies and feed hungry minds. And to those nations like ours that enjoy relative plenty, we say we can no longer afford indifference to suffering outside our borders; nor can we consume the world's resources without regard to effect. For the world has changed, and we must change with it.”

~Barack Obama, Presidential Inaugural Address

Case Report #6: Driving at Night Without Headlights (Case Reports from Kijabe Hospital)

2009-03-22T05:52:00.006-04:00

Warning: This post is one of a series that describes a patient (case) that I have taken care of in Kijabe hospital, and it may contain graphic descriptions or photos of medical pathology written primarily for clinicians. For my non-clinical readers, use discretion before reading, and please excuse the medical jargon.

One of the most difficult aspects of being a surgeon is taking care of trauma patients with closed head injuries. These are often healthy patients who have been in a severe accident of some sort or maybe they have been assaulted. Despite being previously well, the consequences of severe traumatic brain injury can be death or permanent disability, devastating outcomes for otherwise healthy individuals. One of the things that makes managing traumatic brain injury exceptionally frustrating is the difficulty in predicting who will do poorly. Prognosis is notoriously difficult and inaccurate at times…so much so that we usually tell family members “we will just have to see how he does”. Some unconscious patients will wake up and be totally normal, but some others that initially seem only mildly injured may decline suddenly and rapidly to brain death.
For acute trauma patients who present with an altered mental status (anything from mild confusion to profound coma) and evidence of head injury, the brain must be imaged promptly to determine the extent and type of injury after the patient’s airway, breathing, and circulation have been assessed and appropriately managed. In the developed world, this means a CT scan of the head which will tell the surgeon (neurosurgeon usually) whether there is extra-axial blood that needs to be drained (i.e. subdural and epidural hematomas). If there is no drainable hematoma, and the patient has a severely altered mental status, then he will be admitted to the ICU and have a pressure monitor place in his skull to help the ICU staff keep the intra-cranial pressures (ICP) appropriately under control.

While my clinical interest in trauma patients is higher than most general surgeons, I must admit that I have not enjoyed taking care of acute brain injuries here in Africa. In addition to the problems mentioned above, these patients are particular challenging because we don’t have a CT scanner at Kijabe Hospital. That means I have to make decisions about who to operate on without any imaging (except maybe a plain film of the skull, which is largely unhelpful). This is a little like driving a car at night without any headlights, because imaging is so central to managing closed head injury.
The usual approach is that anyone who presents with lateralizing signs (a unilateral blown pupil, hemiplegia, etc) goes to the operating room for decompression. Also anyone who has a documented drop in their Glascow Coma Scale (GCS) of more than 2 points (from their baseline score on arrival) goes to the OR for urgent burr holes as well, but this is a relative indication, and takes some judgement. If they don’t meet these criteria for surgery, we focus on preventing secondary brain injury (hypoxia, hypotension, elevated ICP), and they are managed accordingly. If they are stable, and make it through the night, (and have family members with money) we sometimes send them to Nairobi by ambulance for a head CT the following day, but by that time, imaging is rarely helpful.
My experience with managing acute severe closed head injury so far has been disappointing. To illustrate my frustrations, I present the following case.

****

TS was a 58 year old male passenger in a motor vehicle collision. The patient was found to be unconscious at the scene, and was brought to Kijabe hospital at night by some good Samaritans. On arrival, he was hemodynamically stable and breathing spontaneously, but his GCS was 8 and on close examination he was found to have unequal pupils, with a “blown” pupil on the right. The patient was quickly moved to the operating theater where he was intubated. I confirmed the examination and prepared to drill burr holes.
After prepping and draping, I drilled holes on the ipsilateral side of the blown pupil first. I found no extradural blood, but on incising the dura, CSF spurted from the durotomy across the room at high pressure. This confirmed elevated ICP, but no hematoma was found on this side. I then turned my attention to the contralateral side, drilling more burr holes there. Again, no epidural or subdural blood was found, but only CSF (under slightly less pressure, since I had decompressed him a little on the other side). At this point, I was not sure what to do, I had found no blood, but there had clearly been elevated ICP’s. I talked to my colleagues who counseled against a craniectomy, but said perhaps a ventricular drain might prove to be helpful for ICP monitoring and even drainage. I tunneled a catheter under the scalp and through the burr hole into the anterior horn of the left ventricle. I then attached the drain to this low-tech cylindrical column/drainage system before closing the wounds and taking the patient to the ICU.
Over the next 12 hours, his ICP remained controllable without having to drain anymore CSF, but his mental status did not improve. He remained with a GCS of 6T, so after securing funding from the family, we packaged him up to go to Nairobi by ambulance for a head CT scan (a somewhat risky adventure for many reasons, the most obvious being traveling on Kenya’s dangerous roads with an intubated patient). The patient returned that afternoon with the CT scan, but it showed little to help us…some small contusions and evidence of edema was all that was seen. Surprisingly, we often get amazing radiographic studies from Nairobi including the 3-D reconstruction you see below, but we were still left with an unconscious patient with no real plan of how to help him.

Fancy 3-D rendering of head CT after burr holes and drain were placed

Over the next 7 days, we attempted to support TS hoping he would wake-up from his head injury. We fed him via an NGT, and even extubated him at one point when it appeared he could protect his airway, but without recovering consciousness, he slowly began to decline eventually developing complications including an aspiration pneumonia which he eventually succumbed to.

***

TS was just one example of the many patients with acute closed head injury that I have cared for since arriving in Kijabe. It’s very difficult to have patients come in alive, sometimes only mildly confused and only hours later be looking at fixed and dilated pupils. To be honest, my interventions and care seem to have little effect on the outcome.

Despite the discouraged tone of this post, I am very pleased that I have been allowed to participate in caring for these patients. It’s invaluable experience to get to do craniotomies, and that has helped me immensely in managing the sub-acute subdural/epidural hematomas (those patients have uniformly done quite well after having their brains decompressed). Also, I hope that one day, I am able to actually “save” an acute closed head injury patient with a correctable problem. And with all the practice I have had, I feel that I am well-prepared to do so, should such a patient present while I am on call.

And finally, while medicine is humbling at times, and we can often feel helpless in treating our patients with life threatening problems, the one thing I am learning at Kijabe Hospital, is that the care we attempt to give is often of great comfort to the family (to believe that “everything was done”).
The brothers and cousins of TS came to me after he had expired. They all shook my hand individually. They expressed their deepest gratitude to me for caring for him. And though their loved one had been taken from them suddenly, they were accepting.

In my mind, I was more hesitant to accept that death was the inevitable outcome, but I had done everything I knew how, and lost the patient despite my best efforts. In the minds of his family members however, TS had received world-class care from a stellar ICU team of health care providers… led by a first-rate “neuro”surgeon named Dr. Wilson. Humbling indeed.

Yours in reluctant acceptance,
chad

“Acceptance of what has happened is the first step to overcoming the consequences of any misfortune.”
~William James

Case #5: My Funny Valentine. (Case Reports from Kijabe Hospital)

2009-02-14T14:05:00.005-05:00

OR#5 also happens to be where I have all of my block time. Even in Africa, there is seniority, and since I am the newest surgeon here, I have the privileged of spending most of my time in OR#5… I didn’t know any better when I got the assignment, but now I realize why Dr. Bird (the head of surgery) has all of his block time in the cavernous cool comfortable OR#2.
But even though I am banished to OR#5 and walk around with totally sweat-soaked scrubs most days, I try not to complain. I am the least busy surgeon and I don’t do nearly as many “big cases” as my colleagues. But every now and then, I operate on a patient that is sick enough that they remove the velvet rope, and let me into OR#2. TW was one of those patients...

***

TW is a 60 year old woman with minimal past medical history. She presented on a Wednesday afternoon to the outpatient department of our hospital with complaints of abdominal pain and generally feeling unwell. Dr. Mwaka who is an excellent family practice registrar was one of the first physicians to see the patient. On exam, he noticed that she had a pulsatile abdominal mass.

As an aside for my non-clinical readers: A pulsatile mass in the abdomen of a patient having pain or unstable blood pressure is a surgical emergency. The patient likely has a ruptured abdominal aortic aneurysm (AAA). When one ruptures the main artery that carries blood to your legs, you can quickly exsanguinate. In medical school we learn that half of people who rupture a AAA at home will die before getting to a hospital, and of the half, that make it to the hospital, half of those will die. The ones who survive usually have a very difficult course with many complications such as renal failure.

Dr. Mwaka quickly checked the patient’s vital signs again (which had been nearly normal when she registered at the front desk), to find that she was only mildly tachycardic but had dropped her systolic blood pressure about 20 points since her arrival. Dr. Mwaka ordered the patient to have an IV placed and get some fluids on board and a blood sample to the blood bank, and then quickly made his way to the operating theater to find a surgeon. Since it was a Wednesday and all three general surgeons have block time on Wednesday, he was certain to find someone willing and able to care for the patient…at least you would think.

Dr. Mwaka looked into OR #2, and there was a patient who had just been anesthetized with the surgical registrar starting the case in cool comfort with classical music playing softly in the background. Dr. Bird had not even arrived yet. He looked into OR#3, but Dr. Davis was knee deep in a common bile duct exploration. Then he looked into OR#5. And there was a sweat-soaked Dr. Wilson struggling to get a thyroid goiter out of the lower neck/chest. He decided to pitch the case to the dehydrated surgeon:
“I have a lady in OPD that I think has a leaking AAA. She presented with complaints of abdominal pain, and has a pulsatile mass, with a drop in her blood pressure since arrival.”
When he told me about the case, I was skeptical… “What do you mean leaking?” “Did you really feel a pulsatile mass?” “Was there really a change in the blood pressure?” “Does she really have abdominal pain radiating to her back?” Then I tried to deflect. “What’s Dr. Davis and Dr. Bird doing?” No luck. “Well I have at least 30 more minutes here so can you give her some fluids, and put an ultrasound probe on her belly to confirm the diagnosis”, thinking to myself, ‘these guys freak out every time they can feel the abdominal aorta…she’s not gonna have a AAA.’

Well 30 minutes or so went by, and I finished the thyroid and pealed off my gown, and began to do the pinch-the-front-of-your-scrubs-off-of-your-chest-and-shake it- so-it-can-air-dry-maneuver that I have perfected when I remembered, 'Oh yeah...there’s some bogus consult in the outpatient department I have to go see'. So I sauntered out of the theater and began to make my way down to the outpatient department, when down the hall I see Dr. Myrick (the family practice consultant who supervises Dr. Mwaka) pushing this lady on a gurney toward the theater quite briskly.

Uh-oh…

Dr. Myrick informed me that the ultrasound had showed an 8 cm pulsatile mass where the aorta was suppose to be, and she had dropped her BP another 20 points.

Okay, I’m a believer now…

So I U-turned back to the theater with the patient and took her into the recovery room which doubles as our resuscitation area for sick patients. I alerted the theater staff that I wanted to do an emergency AAA repair, and then went to OR#2 to ask Dr. Bird where I could find some vascular grafts. He was just finishing his mastectomy, so he alerted Dr. Newton, the anesthesiologist who was working in his room, and we had a brief discussion.

What I did not know is that Kijabe had a terrible record with ruptured AAAs. Even though they had a vascular surgeon there up to a few months before I arrived, they had not had a patient survive and go home in recent memory (about 5 patients), and they had seriously thought about not doing any more ruptured AAA, because it utilized too many resources in our resource limited setting to justify little chance of saving the patient. Additionally, now there was no one who was “comfortable” with AAA repairs, so weather or not to operate certainly was a worthwhile discussion.

So we quickly reviewed the information, but agreed it was worthwhile to try. The next 15 minutes went by in a blur of running around to find the right vascular grafts, getting a central line into the patient, and getting blood ready. Of note, Dr. Jeremiah (the M.O. intern on Dr. Bird’s service) ran down to the blood bank not only to make sure they were preparing the blood but to donate as well. By this time, OR#2 was empty and cleaned, and Dr. Bird had volunteered his operating room. Also, Dr. Davis (the other general surgeon) had finished, so all 3 of us discussed who had the most experience with AAA repair as the patient was wheeled into the room. We all agreed that we had watched a fair bit of aortic surgery in training, but had limited experience doing more than retracting and sucking. Fortunately, I had actually done one in residency (thank’s Dr. Balcom at Salem Hospital). Dr. Davis had several other cases to finish in his operating room, so Dr. Bird and I decided to give it a go together.

So there I was in with the patient prepped from chest to thighs. I said a brief prayer as the soothing music played over the speakers, and I took a deep breath of cool OR#2 air into my lungs as we finally made our incision. When we got into the abdomen, we fortunately encountered no intra-peritoneal blood, but the retroperitoneal hematoma look formidable. We decided to get a supra-celiac clamp on first before opening the hematoma and trying to get a clamp on the infra-renal aorta. (We had already decided that if the aneurysm went above the renals that we would back out and not waste any blood products, because without hemodialysis, we would almost certainly not get her out of the hospital if we had to clamp above the renals for any significant period of time.) After placing the supra celiac clamp, we opened the hematoma, and while initially it appeared as if we did not have aortic control, we quickly were able to get the operative field dry enough (with the powerful OR#2 suction) to see and place an infra-renal aortic clamp. We removed the supra-celiac clamp, and from there everything went rather smoothly. We opened the aneurysm sac widely, oversewed a few bleeding lumbars, controlled the iliacs with foleys since there was not too much back bleeding, and sewed in our graft…proximally then distally. (The graft was actually a very nice 20 cm by 20 mm tube graft from Gore. We have a charitable relationship with a rep from Gore, and really appreciated the donated materials, since we can’t actually afford any Gore products.) After the graft was in, we had good femoral and pedal pulses, so we then closed the aneurysm sac and the abdomen and then took her to our “ICU”. Then we practiced our specialty at Kijabe Hospital…we prayed.

The graft sewn in proximally and distally within the sac

Over night, things did not look so good. She was very confused, made little urine, and her creatinine bumped up to above 3. She got another couple of units of blood that next day bringing the total up to 8, but miraculously, and I mean miraculously, she began to turn the corner. Her urine output picked up. Her blood counts stabilized, and her confusion improved. Over the next 2 weeks, I rounded on her painstakingly (just ask my intern). The patient and I had an unusual daily interaction. She always frowned when I came around. I assumed it was because I would push on her belly or do something else noxious, but she always looked like she was unhappy to see me, even if all I did was smile and say hello. I would try to find out what was wrong, but the language barrier was quite substantial as she spoke no English and even her Swahili was limited, and there were few individuals around who could understand her mother tongue. She complained about abdominal pain and poor appetite, but nothing could explain her apparent displeasure at the sight of me. I guess I am sensitive, because I wanted her to like me…after all she was my favorite patient. She was a living, breathing, walking miracle. But I never got anything other than rolling eyes, sighs, and frowns. Well like or dislike, she survived, and went home a little more than 2 weeks after she was admitted.

The week of Valentines Day, she came back to the hospital for her post-op visit. I opened my mouth to speak, and there she went frowning again, but she was looking well, so I just moved on. Fortunately, her daughter was with her who was able to translate clearly. She said she was doing okay, except her appetite was still not back to being totally normal. Then after the interview and examination, I just couldn’t let it go…I asked the daughter why she seemed so unhappy and didn’t seem to like me. The daughter explained that she hates not understanding what people are saying, and that my speaking English was particular distressful to her, because she wanted to understand me. So I had the daughter translate. I told her almost jokingly “I’m sorry for speaking English around you, and that I wish you liked me. She spoke to the daughter in a very sincere tone, and the daughter said, she says “it’s okay and that she does like you”. I was a little taken aback, and then I told the daughter to tell her, “I think you are a miracle patient and I want to have my picture taken with you, because you are so special, and are the first person to survive this operation in our hospital in a long time”. The daughter translated, and for the first time ever, I saw a little smile curl up at the corner of her face. She spoke to the daughter, an then she translated, “she would love to take a picture with you, but only if you give her a copy. She thinks you are a very special doctor, and says thank-you for saving her life”.

Me and the ruptured AAA survivor Teresia in clinic

Well needless to say my heart melted at her kind words. Some people want to feel romantic love on Valentines Day, but this year I felt something much more powerful and enduring. I felt the sincere appreciation of a patient for doing my very best. So this year my Valentine is Teresia. She reminded me of why I love being a surgeon. She showed me that I could get through a difficult vascular operation despite my limited experience. She demonstrated that God can take my feeble attempts to treat, and work a healing miracle. And just when I was feeling unappreciated, she made me feel like the best doctor in the world. But most importantly…Teresia is my Valentine, because she got me into OR#2…if only for a few minutes.

Yours in feeling loved and appreciated,
chad

“Everyone wants to be appreciated, so if you appreciate someone, don’t keep it a secret”
~Mary K. Ash

Complications & Confidence

2009-02-12T14:11:00.000-05:00

You walk home from the hospital with your head hung low. Throughout the day, you tried to appear upbeat, but your colleagues could tell that you were troubled inside. You have had your first major complication as a surgeon. Your co-workers try to encourage you, but their words don’t comfort the pain of knowing that you have hurt someone. They assert that complications are part of being a surgeon. They tell you of similar complications they have had. They remind you that you were doing your best. But no matter what anyone says, the disappointment in oneself and the guilt of having a bad outcome burdens your heart like a weight on your chest. Even as you go about your day and try to put it out of your mind, the patient’s face suddenly flashes across your mind, and that hollow ache in your stomach returns… You are literally haunted by the patient you have hurt., and can’t help but feel unconfident and unworthy to be a physician…to the point of feeling ill.

This is the part of being a surgeon that Grey’s Anatomy doesn’t capture.

***

Moving to another continent to practice surgery has been a substantial stressor for me. But, I suppose that every surgeon who finishes training and takes on the role of attending surgeon (the physician ultimately responsible for the care of the patient), experiences some growing pains during their first year of being “in charge”. And while it is always difficult to navigate the first year of independent clinical work, my being in Africa has amplified the insecurities and anxiety associated with being a young surgeon. I practice very general surgery and operate all over the body. For instance, today I did a skin graft, a sapheonous vein stripping, a testicular varicocele ligation, an orchiectomy, a thyroidectomy, and an urgent groin exploration for an incarcerated inguinal hernia…and today was an easy day. I had at least done all these procedures during residency. Many days, I’m doing an operation that I have only read about, and sometimes for more urgent matters, the reading is taking place while the patient is going to sleep! I’m fortunate to have two amazing mentors/peers here in Kenya that offer me guidance and support, and I can’t imagine what it would have been like here without them, but ultimately I have to accept responsibility for patients’ outcomes…whatever they may be.

Even without complications, the week can be overwhelming. My clinic is overflowing with patients with difficult to treat problems, and I have limited diagnostic and therapeutic modalities to manage them. Much of the time, I am struggling to get a history through a series of multiple interpreters… the pt speaks Somali, the friend translates to Swahili, the nurse translates to English (although my Swahili is improving), and I wonder if the impression I get at the end of the translation is even close to what is really going on with the patient. Then my operative days are filled with challenging cases that depend on some piece of equipment or material that is broken or run out. Meanwhile, consults are coming from every direction. Then, I have to prepare for conference to teach the residents, and medical students. (Oh, by the way, can you give Grand Rounds next week, Chad). And to top it all off, more than every 3rd night, I am on call trying to manage surgical emergencies (trauma patients most often), and tramping into the hospital at the midnight hour.

But I can handle the clinical chaos, the endless to-do lists, and the long hours…that is no different than residency. What really disturbs my peace of mind are complications. I have had two particularly difficult complications to cope with since I have been here. Both were patients that had elective operations, and they subsequently died. (One patient had a neck mass that I explored and found a carotid body tumor, which I successfully dissected off the bifurcation, but the patient suffered a stroke from the manipulation of his internal carotid artery, and died 7 days later. The other patient had an early diagnosis of esophageal cancer, so I did an esophagectomy, and she initially did well, but she suffered an aspiration pneumonia and died 16 days post-op.) These two cases haunt me most, because they were patients who came to see me and were feeling okay, despite their problems. I booked them for elective surgery, admitted them a couple weeks later, but they never left the hospital. I don’t get nearly as bent out of shape when one of my trauma patients dies or when one of my patients with a ruptured aortic aneurysm dies post-operatively, because they had life threatening conditions, and would have died without my care undoubtedly. However, to have a patient come to clinic with a problem that is not immediately life-threatening, and you tell them, “I think I can help”, but instead you hasten their death…that is painful to accept.

I am sure I am not alone in my feelings. Every doctor has to learn how to deal with complications. When I was a resident, I saw how upset the attendings (especially the young ones) would get when their patients did poorly. A small minority of the more experienced surgeons had healthy attitudes about learning from complications, and were able to grow from the experience. But most doctors tend to fall into one of two categories: Those that blame themselves and those that blame others for their complications. Some physicianss blame themselves entirely which can be very counter-productive, especially if they become so paralyzed with fear that they hesitate to intervene in other patients’ management thinking they may hurt someone else. On the other extreme, a handful of doctors have difficulty accepting that they may have made a poor decision or an error. One particular attending I worked with almost always found a resident or nurse to blame for her patients’ bad outcomes, and I could see how that limited her growth as a doctor.

In actuality, complications are inevitable. One cannot always make the right decision. We must be willing to accept that at some point, we will prescribe a medication or make a decision to intervene that will hurt someone. Even if we make all the “right” decisions, patients still can have complications. And though this is discouraging on the surface, it is merely a reminder of who is ultimately in control of the outcome: whether a patient recovers is in God’s hands, not mine. I have seen patients receive poor care with life threatening problems, but miraculously recover…And I have seen others with seemingly treatable problems, and they don’t make it despite perfectly executed care. The truth is that we must do our best, but recognize that we cannot save every patient. As the Kijabe Hospital motto states: “we treat, God heals”.

***
Even though I know that I am human, and cannot expect all of my patients to be cured, I still struggle to recover emotionally from serious complications. I just feel guilty…like if I was better doctor, maybe things would have turned out differently. My confidence (which is usually quite high) is shot momentarily. I try not to be this way, but it is hard to silence your inner critic.

In the midst of guilt and feelings of inadequacy, the hardest thing for me to do is to face the family after one of my patients dies. This one particular case that I mentioned above was particularly upsetting. I knew that it would be heroic to try to cure her cancer in Kijabe hospital, but I booked the surgery with a strong feeling inside that everything was going to be okay. So when the patient died, I felt betrayed by my intuition, and it hurt me so bad. To make things worse, I had gotten quite close to the family during the hospitalization. But something interesting happened when I went to talk to the family…something that might only happen in Africa. I talked to the patient’s husband and sister, and explained that despite the patient recovering from the surgery initially, she aspirated, and developed a pneumonia, and her heart just was not strong enough to survive the lung infection. As I tried to explain what happened, and expressed my sorrow about how things ended, I got a little choked up, and the husband and sister ended up comforting me. They were so strong, and so accepting of her death. As I struggled to find the words to express my self, the husband put his hand on my shoulder and said in his best English, “Never you mind it, thank-you.” I am still in awe of that family, and how strong they were. I thank God for them, because that particular complication so early in my career might have been devastating to my confidence, but with their words, my faith was renewed in myself and the mission: to serve the people of this community as best as I can with my surgical skill...regardless of the outcome.

Grey’ Anatomy and other medical dramas sometimes depict surgeons as having impenetrable egos…That no amount of adversity can undermine their belief in their own abilities. In actuality, very few surgeons are this confident. The majority of us take it very personally when a patient dies, and we struggle to maintain our confidence and optimism in the midst of complications. Don’t get me wrong, by most standards we are all egotistical… but it is a healthy and necessary egoism for the job of cutting people open. But when that ego gets beaten and battered by a few bad outcomes, one can lose the desire to care for patients. I have had my brief moments when I did not want to be a surgeon anymore, but thankfully I have recovered my passion for surgery, and soon I am celebrating the miracle of a healing that I was able to participate in.
So tomorrow when I walk to the hospital, I will once again hold my head high in anticipation of what the day may hold. I’ll look forward to opportunities I may have to help my patients. I’ll be eager to get into the operating room and practice my craft. I will no doubt be confident that I am a gifted and talented physician with excellent surgical skill. And while complications will certainly occur sooner or later, I know that my job is merely to treat…and let God heal.

Yours in renewed confidence,
chad

“With realization of one’s own potential and self-confidence in one’s ability, one can build a better world.”
~Dali Lama

The Worst Form of Violence

2009-02-02T14:49:00.001-05:00

At the intersection of ignorance, poverty, and corruption is suffering…profound needless unimaginable suffering.

Perhaps the saddest thing I have seen in my time in Africa is the loss of life that occurs for no other reason than because no one puts any value on the poor. I have seen patients that have died as a result of clear gross medical negligence, but their poor families have no way to achieve justice.
There are Kenyans who are literally starving to death, but the government is more concerned with cultivating ways to enrich the wealthiest 1% of the nation than to figure out a way to feed the hungry.

But, what happened this past weekend up the road from my hospital is unconscionable. On Sunday, I saw a burn patient who was one of countless victims of a tragic explosion. He had 2nd and 3rd degree burns to 45 % of his body including burns to his legs that were so deep, I had to slice the burned skin (eschar) open to get blood flowing to his legs again (escharotomies). Taking care of burn patients is not unusual for a surgeon, but the accident that this young man had been in was entirely avoidable.

The day before, a tanker carrying fuel overturned on the highway. The particularly bad stretch of road often has truck accidents, and the incredibly poor people who live in the nearby villages usually come to the scene to take whatever product has been strewn about the highway, usually produce. When news spread that a tanker carrying petrol had overturned, people began coming from out of the nearby forest with containers to siphon fuel to sell. These people see these “opportunities” as God showing them mercy. They were actually climbing in to the overturned tanker to obtain fuel. Sounds crazy but poverty makes folks desperate, and an opportunity to obtain a few thousand shillings worth ($20 or so) of fuel was too good to pass up. Where were the police, you ask? Aren’t they suppose to cordon off a dangerous accident like this one until the appropriate hazmat team can arrive? That’s what they are suppose to do, but in this case, they were charging these poor people for the right to steal the fuel.
So hundreds of folks are showing up with containers to get the fuel, the police are taking bribes instead of keeping them back, when someone forgets to put out their cigarette…

So far the body count is about 120. They are still pulling bodies out of the nearby forest where the victims ran screaming in flames (but when your pants are covered in petrol, there is nowhere to hide). Those who managed to survive are overwhelming the local hospitals and we have already gotten a couple of patients in our small hospital (which does not have a burn unit). There will surely be more deaths.

The thought of hundreds of people in flames, having their flesh burned down to bone in agonizing pain sounds like a scene from war with incendiary bombs (nepalm) being unleashed on villagers, but this accident happened during peacetime to villagers who were celebrating their good fortune just moments before.
To an American, this scene sounds impossible: for people to risk their lives for a few dollars worth of fuel, but as I said: at the intersection of ignorance, poverty, and corruption is suffering...profound needless unimaginable suffering.

Trying to understand,
chad

“Poverty is the worst form of violence.”
~Mohandas Gandhi

More on this story

Case #4: Lord, Please Make It Stop Bleeding. (Case Reports from Kijabe Hospital)

2009-01-29T17:46:00.004-05:00

This is a case from November, only a couple of weeks after I took over my own surgical service.
While the perception on television is that the operating room is a stressful place to work, in reality, most surgery is quite routine, and there is only the occasional tense moment. However, every now and then, there is a case that really gets out of control and tests ones ability to cope with adversity…

***

“Hey, you wanna do a splenectomy for me?”

That was the question my colleague asked me in passing one day on a busy afternoon in the operating theater. The interesting thing about being “in practice” here in Kijabe, is that I didn’t have to wait long to get good cases. The other two surgeons are quite busy and willingly pass along interesting cases to me, and I am more than happy to take a few “general surgery” cases off their hands. So I did not think I was being set up when my colleague asked me to do a splenectomy for him (nor do I think he knew the case was going to be as difficult as it was), but this innocent request to do a splenectomy turned into one of the most challenging operative experiences of my young career.

JM is a 28 yo man with a diagnosis of hairy cell leukemia. While the appropriate treatment for his leukemia is chemotherapy, he had been having difficulty getting seen in the government hospital with his problem. We do not have chemotherapy in our rural hospital formulary, but we do often take care of cancer patients who might need a major operation. JM had developed splenomegaly (enlarged spleen), and the hematologic derangements that accompany this condition, namely profound thrombocytopenia (low platelets). Given his platelet level, the medical service thought a splenectomy might help stabilize him until he could get chemotherapy. Unfortunately, this would mean operating on a very large spleen with very few native platelets, (but we are able to give whole blood, and if it is less than seven days old, the platelets in the transfusion are still functional).

When I got to the operating room, and was able to palpate his abdomen and feel his spleen, I was impressed. His entire left abdomen down to the pelvis was spleen. The anterior aspect of the spleen stuck out though his otherwise small abdomen. I began to realize that his case might be more difficult than anticipated. However, I had only been an independent attending surgeon for a few weeks at this time, and believed I could get the spleen out safely by adhering to the principles I had learned about general surgery and doing a splenectomy during residency. After prepping, draping, and praying, I made an upper midline incision, and soon had access to the peritoneum. The spleen was bigger than any I had ever seen. I examined the abdomen, and pondered my approach.

There are two general approaches to doing a splenectomy. One is to divide the gastro-colic ligament and march along, dividing the short gastric vessels. This gives you access to the lesser sac, where you can try to find and ligate the splenic artery. The advantage to this technique is that you interrupt most of the blood supply to the spleen, and allow it to exsanguinate, making any subsequent dissection less bloody. Also, you are able to keep more of the blood in the patient instead of in the specimen. The disadvantage of this technique is that the splenic artery is often found way in a deep hole in the LUQ that is difficult to dissect safely. If an error is made, it is very difficult to control a large rent in a hilar vessel in a deep dark hole. The other approach is to mobilize the spleen from its attachments and deliver the spleen out of the abdomen thus pulling the hilum out of the abdomen, and into easy access for division. This is the typical approach for traumatic splenectomy and also what one might do if an iatrogenic injury caused one to have to do a rapid splenectomy to stop bleeding.

I decided that I would try to get control of the slpenic artery first, as often in these cases of splenomegaly, the hilum has been displaced downward, and the splenic artery becomes tortuous and displaced inferior and anterior out of the posterior LUQ, and is thus easy to ligate. I got access to the lesser sac, and soon realized that this would not be an easy proposition. I could palpate the splenic artery, but it was very far away, and had not been displaced into an accessible position to ligate. Furthermore, the sheer size of the spleen, had left little room in the abdomen to work, and retract to see vital structures. I was still not worried. I knew how to mobilize the spleen, so I thought I would try the second approach, and deliver it into the wound. That’s when trouble really began.

I was able to deliver the lower pole of the spleen partially out of the abdomen. I began taking down adhesions and attachments. Unfortunately, the capsule tore a bit and started to bleed. No problem, I thought. Just pack that area, and go somewhere new. I went to the superior aspect of the spleen to try to take down the spleno-phrenic attachments, but just retracting here, caused some heavy oozing. I thought that unusual, and tried to see what was going on. The medial upper pole of the spleen was densely adherent to the left lateral segment of the liver, and this new bleeding was from the torn liver capsule. Now I was starting to sweat. I packed this area, and went to the superior lateral aspect of the spleen. Once again, I made very little progress before getting into substantial bleeding. I packed this area, and decided that maybe I should return to the hilum, and try to find that splenic artery after all…wrong move, some delicate hilar veins tore, and unleashed the worst bleeding yet. I packed the hilum. Now if you are keeping count, the spleen was packed on every side at this point, and I had already lost more than 500 cc of blood (that did not seem to clot very well). I thought about backing out, but knew I would have to leave the packs in and come back the next day, which did not seem like a feasible solution especially since the packs were only slowing the bleeding .

Me trying to deliver the spleen out of the abdomen

A close-up view of the "beast"

I swallowed hard, and decided, I was going to have to just accept some heavy bleeding, and get that spleen mobilized. I warned the nurse anesthetist about what was coming so she could get some blood, and proceeded to mobilize the spleen. The next 10 minutes were the most uncomfortable I had ever felt in the operating room. I started by just sharply taking down the adhesions between the spleen and the left lateral segment of the liver. The bleeding was impressive! Next, I got the inferior aspect of the spleen totally mobilized from the colon and kidney. By this time, the blood loss was so brisk that I began to feel that I was certainly going to lose the patient. I still had the superior-lateral aspect of the spleen attached to the diaphragm and LUQ retroperitoneum. Close to a liter of blood had just poured out, and I began to feel defeated. Difficult cases don’t usually do this to me. I may become frustrated for a moment, but I always say to myself, “Come on! Focus…and fix the problem”. But the bleeding and the circumstances became so overwhelming, that I found myself losing hope that I could get the patient through the operation.

It was at that moment that I did something unusual for me. I usually pray before an operation as a matter of routine, but rarely do I pray during the case, at least not in earnest. But today, in that moment of hopelessness, I stopped for about 5 seconds, closed my eyes, and said, “I don’t think I can do this God. I need your help. Lord, please make it stop bleeding.”

I immediately became calm, I went back to work, and though it seemed that blood was just pouring out, I suddenly could feel a plane behind the spleen, and with a couple of bold cuts with the scissors, I managed to get the last part of the spleen free, and was able to deliver the spleen into the wound. Now I had the spleen on an easily controllable pedicle. I was able to quickly ligate the hilar vessels, and pass that sinister specimen off to the scrub tech. I then packed the LUQ, and systematically found all the small bleeders, and got complete hemostasis.

All totaled, the official stats were 2.5 Liters of blood loss, but I think it was closer to 4, and it was a rapid loss, especially for an elective case. I think I broke the Kijabe record for most packs (lap pads) used in a case: 65. (The final path report had the spleen at close to 5kg…which is 25 times the size of a normal healthy adult spleen.) As I closed the abdomen, and the patient stabilized with IV fluids and blood, I thanked God. The patient who I had thought was going to arrest on the table from hemorrhage, not only survived the operation, but he did well subsequently. The patient was sent to the “ICU” overnight, and did beautifully, and was eventually discharged to home on POD#6 with a referral for his chemo appointment in 3 weeks. Amazing.

Since that moment early in my time as an attending, I have found myself praying during an operation on numerous occasions. It’s possible to get overwhelmed during a difficult case, but I have learned that prayer reminds me who is ultimately in control, and allows me to operate during the most daunting of moments as if only a trickle of blood had been lost. Not to say that I don’t still sweat in the operating room (especially since I am operating in the tropics without any air-conditioning), because I still have difficult moments during surgery. But I realize that I am trained to do this, and all I can do is my best, and allow God to do the rest. Once I see it from that perspective, I am able to face even the most desperate situations calmly and effectively with my mind and heart knowing who is really in control.
And you know what? The outcome is usually okay.

Learning to be EVER dependent on Him,
chad

“Oh what peace we often forfeit, oh what needless pains we bear…All because we do not carry everything to God in prayer.”
~Joseph Scriven from the hymn: What A Friend We Have in Jesus

Home Invasion

2009-01-18T13:23:00.001-05:00

There has been a drought here in Kenya that many of you may have heard about. Kenya’s primary industries are tourism and agriculture, and both have been strained this year with the political unrest at the beginning of 2008 shutting down tourism, and then the drought that marked the end of the year. This combination of calamities has left many hungry, and this is a difficult year for the government to assist those who cannot eat with the lack of tourism revenue. The Kenyan government has recently asked for more than $400 million in aid to help feed its citizens. (I will withhold the political commentary for now on corrupt politicians continuing to take financial advantage of their political position, but simultaneously seeking outside aid to feed the nations poorest individuals.)

What is interesting are there are some surprising side effects that hard times (in particular a drought) can have on people. The missionaries here in Kijabe are relatively protected from these problems directly, as we are supported financially from abroad by and large. However, we have been counseled that our relatively safe community is more susceptible to crime during these hard economic times. Desperate times sometimes cause desperate actions.

I unfortunately experienced first hand how this drought can effect the harmonious balance of our community this afternoon. I was sitting in my bedroom, working on my computer, when I began to hear a bunch of noise and commotion. I thought perhaps some workers were moving some heavy furniture or appliance in the next door unit. But then I thought…today is Sunday, no one usually works on Sunday. That’s when I heard a very loud noise behind me. I got up, and opened the bedroom door and what I saw shocked me.
Three hungry thieves had snuck in through my window and were in my kitchen. I yelled at them to “get out of my house” which startled them, but I don’t think they spoke much English. Two of the robbers quickly scampered out of the window, but the third one was so frightened that he ran the wrong way and then got cornered in the living area.
Me and this guy clearly did not speak the same language, but it was obvious we had a problem. I just wanted him to leave, but he was so frightened that just stood in the corner of the apartment soiling himself. I guess it was not his fault that he felt trapped. I had closed all the windows and the doors to prevent his accomplices from returning, as I felt better dealing with one intruder versus three.
I decided to call for some back-up. I got on my mobile phone, and called some neighbors, and fortunately a medical student who lives downstairs was nearby. We came up with a plan. She would guard the door to make sure this fiend’s buddies did not return to help him, so I could concentrate on running him off. I left the door open with her just outside (armed with an umbrella just in case). I then went on the attack, but the little scared and hungry crook did not realize the door was open and ran for my bedroom instead leaving a trail of stool behind him. After 10 minutes, I finally got him to realize I was trying to run him off, and not catch him, so he ran out of the bed room and saw daylight at the door, before making a daring leap from my second floor balcony to a nearby tree.
I thanked the medical student for her help (she is from the same part of Texas as me, so she was quick to come to my aid when she realized I was being burglarized). I then set myself to the task of cleaning up the mess. There was poop all over the place not to mention the left over bits of fruit they had left behind (these guys were messy.)
I learned a valuable lesson today. When times are hard, you can’t be too careful about security. I don’t blame these guys for coming into my home. They were just hungry and this drought has clearly been a strain on them. I just know that it will be the last time I will keep my windows open with bananas on the countertop.

Yours in recovering from a monkey home invasion,
chad

The thief did not slow down to pose for this picture

PS: I hope this story made you laugh. It is a true story. I really did have 3 monkeys come in through my kitchen window and eat my bananas. And one of the little guys really did panic and run all over my apartment pooping and cowering in corners. It was just a little reminder that I live in rural Africa now…not downtown Boston. Anyway, I needed a little levity today, and chasing a monkey all over my apartment with a medical student guarding my front door with an umbrella was certainly funny. However, cleaning up monkey poop was not nearly as funny.

It taught me to be independent and never expect a handout and never wait for anybody to hand you anything in any aspect of my life.
~Jesse James

Everything Happens For A Reason

2009-01-14T10:21:00.002-05:00

I have not posted to my blog for a few weeks. I have not felt like writing much. It’s not that things here in Kenya don’t continue to amaze me. It’s just that I have been pre-occupied with news from Texas. For those of you that I have not been able to update about recent events, my cousin Robert (Robbie) Tolan was shot in the chest in his own driveway on New Year’s Eve by a Bellaire police officer who believed he was a car thief. He is still hospitalized in Houston, TX recovering from surgery to repair his lung (the bullet remains lodged in his liver).
When I fist heard the news by email from my Dad, I was in disbelief. Robbie is such a good kid, and I just could not picture it in my mind for some cop to feel that he was a threat. Then as the news settled in, I became very angry about the police officer who had shot him. My anger was mitigated by the fact that the shot was not lethal, and I was thankful that my cousin had survived this injury (and continues to recover). The bullet came so close to vital structures, and it could have easily been a much worse tragedy.
My anger evolved into cynicism about the situation. To be shot in front of your own home by police, on a mere suspicion of wrongdoing makes it hard to have faith in our law enforcement agencies and society in general.
The more complex issue of this being a white cop shooting a black resident in a predominantly white neighborhood is even more unsettling. It’s a painful reminder that while our country stands on the eve of a great moment in reconciling it’s ugly racist history with Barak Obama’s pending inauguration, we still have not resolved the institutionalized racism that continues to divide this nation. What do we tell Robbie’s little cousins who adore him? When little Dean asks his mommy why the police shot cousin Robbie, how does she explain it to him? We are suppose to teach little boys to trust and respect the police, but in 2009, many black families still feel the need to teach young black boys to fear the police, and with good reason.
And Robbie may recuperated physically, but there are also serious emotional and psychological injuries that will be much more difficult to repair. What is it going to be like for him to function in society now that he has been shot by a police officer for no reason. How will he react if he is ever pulled over by a policeman for a routine traffic stop. How is he going to return to a productive and optimistic approach to life after something like this?

Needless to say I have been pre-occupied with my cousin’s recovery, and it has been weighing on my mind. Every moment of calm I have had in between surgery and seeing patients, I have thought about what it was like for my cousin to take a bullet in the chest…What it was like for my aunt and uncle to see their son shot down in their front yard, and those anxious moments going to the hospital, and then waiting for him while he was in surgery. It twists my insides into a knot to think about what that was like for them.
And I am left disillusioned about America and our social progress. Skin color is still a primary determinant of how much freedom we really are allowed to enjoy.

***

In the midst of such a difficult time, I returned to the one thing that helps me understand the world and gain a positive perspective on life’s most bewildering moments: I prayed. Even though I profess myself to be a Christian, I often find myself forgetting to stop and pray during difficult moments. Instead, I try to “figure it out” on my own, but I can never generate any peace through my own efforts.
As I went to God with my feelings about the events, a scripture came to me immediately…it’s a scripture that comforts many Christians in difficult moments, but it is a hard scripture to accept at times. The scripture is Rom 8:28. “And we know that all things work together for good to those who love God.” This scripture is a reminder that nothing in this world is as random as it may seem. That even when it seems like misunderstanding and chaos is reigning, God is actually in control, and even the things that seem wrong are not happening beyond the reach of His omnipotent hands. It’s a reminder that God can bring about good through seemingly terrible events.
Before I prayed, I had seen Robbie’s suffering as meaningless, and I saw the circumstances of the shooting as a confirmation of the hopelessness of our society to ever attain true racial harmony. But as I prayed, I realized that God is present even in the midst of brokenness. I realized that Robbie’s suffering does not have to be in vain. I realized that this police officer’s mistake was not random, but perhaps it might be used to shine the light of truth on the racism that remains in our law enforcement system and society in general. I realized that God can take this negative, and turn it into something positive.

Now my cousin is expected to be discharged from the hospital soon, and I have a much more positive outlook on what has happened. It is still difficult to accept this tragedy, but I am first joyful that Robbie has been recovering physically. Secondly, this trial has really drawn my family close together. We are already a strong family, but times like this, seem to strengthen us even further. Thirdly, I notice how much publicity the case has gotten, and I realize that it might be a turning point in how police work is done locally and maybe even nationally. Less than 24 hours after my cousin was shot, another black man was shot in the back by a police officer in Oakland while he lay unarmed and pinned face down to the ground by officers (this man unfortunately died). Perhaps, the timing of these cases, near the inauguration of our first black President, and the MLK holiday will set in motion some real self-examination of our country. While Obama’s inauguration is clearly an amazing milestone that America should be proud of, Dr. King’s dream is far from coming to fruition. We cannot rest on our laurels and declare America cured from the disease of racism just because we have a black president. As the Bob Marley song says, “until there are no longer first class and second class citizens” of the nation, there will not be peace in the land. And maybe…just maybe, Robbie’ story will help to arouse the conscience of the nation to change. Jesus was an innocent man unfairly persecuted, but his suffering brought about redemption to the entire world, so I know that God can use suffering for redemptive purposes. I pray that Robbie’s pain will help to redeem our nation as well.
And even if none of this happens…even if the media loses interest in Robbie’s story, and things go back to business as usual across the nation, I know that God remains in control…that He has a divine plan, and can use our pain to bring about healing and blessings. It may not happen in a way that I can see, but it will certainly happen. I am already blessed, because I have been reminded how precious each an every day is. I have been reminded to cherish my family. I have been reminded how important prayer is. But mostly, I am blessed, because after all of this craziness, I still have my cousin.

Yours in accepting God’s plan,
chad

It is by suffering that human beings become angels
~Victor Hugo

Case #3: Nyanya Means Tomato. (Case Reports from Kijabe Hospital)

2008-12-22T14:28:00.005-05:00

It was Monday…my clinic day. I can’t complain, because the day had gone very smoothly, and I was seeing my final patient at about 4:30pm, instead of my clinic dragging on beyond 5pm (which the staff just love). However, as is often the case with the last patient of the day, her problem would turn out to be a difficult one to treat, and remind me how cruel this world can be to the sick and suffering.

SW is a 90 year old woman who spoke no English and little Swahili, but fortunately had a family member with her who spoke Swahili with whom I could communicate with through another interpreter. As best as I could understand she suffered from a seizure disorder, and unfortunately, she also lives in a home where the cooking is done over an open fire. About 2 months before her visit with me she had burned her left foot in the fire during a seizure. She initially was “cared for” at a district hospital, where she remained for 30 days. I am certain that the burns were full thickness, but she was not treated by any effort to graft this deep wound. Apparently, she just sat there occasionally getting dressing changes, until they finally discharged her home for more dressing changes (supposedly via home nursing care).

When I walked in the room, I could smell that she had a bad infection in the foot. The family friend who was with them who spoke Swahili told me that nurses had been coming to change it daily, but when I looked at the dressing, it appeared old and filthy. Clearly she had been walking outside on the ground, as evidenced by the tell-tell red clay dirt that is so ubiquitous in Kenya that was staining the dressing. She was also confused (new in the last 24 hours, and complaining of severe pain). She appeared septic (with systemic symptoms of her infection), so I decided to unwrap the foot and see how bad the wounds were. What I saw was unconscionable…Her entire lower leg was swollen, and cellulitic. The wound was purulent, foul smelling, with desiccated tendons and some exposed infected bone at the base. I could not believe that a nurse had been seeing this wound everyday. I immediately decided to admit her, and began to talk to the family about what would likely be an amputation given her septic picture.

SW with her dirty dressing prior to unwrapping

Purulent Wound 60 days after flame burn

What made this case so frustrating is that this elderly woman did not have to lose her foot. She just made an unfortunate decision of where to go to get her initial care. I have no doubt, that had she come to our hospital after her burn, she would have been debrided, grafted, healed and walking again in a months time. Instead, this 90 year old woman was ignored, and even had to walk around on her infected mistreated foot.
After giving her antibiotics, I did her amputation the following morning, a few days later her mental status cleared up, and she proved to be the sweetest patient on the ward (except when I would unwrap her stump dressing…I thought she was gonna punch me). Eventually she was ready for discharge, but I was hesitant. I know what an amputation means in rural Kenya. It means total dependence, and given what had happened previously, I had my doubts that she would be cared for properly. Unfortunately, I had to let her go, as her sponsor (the British woman who is an employer for her daughter, could not afford for me to continue to hold her). I reluctantly signed the discharge paperwork.

I have not seen her in four weeks, and I am not sure if she got some post-op care at a local clinic or if she has died. I really don’t want to think about it. I want to believe that she is okay at home , but I know the odds are unlikely that this is the case. There are too many cases like her of problems that are so easily treatable, but the patients get poor care or no care from some place that calls itself a hospital.
But what makes me most nauseated is that this delicate woman was too old to be treated this way. She had to walk around on that painful infected foot, because there is no social insurance for the elderly to help support them in their most helpless days, so she had to go fetch water, and cook, and do everything despite her condition. And it is ironic because there is so much reverence for the elderly in African culture.

The Swahili word for grandmother is nyanya which also means tomato. I laughed when my Swahili instructor first told me this, but he explained to me that it is a term of endearment, because you handle a tomato with care, so you also treat your grandmother with great love and care. I thought that sentiment was beautiful, and I thought of my own departed grandmothers. And this woman reminded me of them. We could not communicate with one word, but she could say so much with her eyes and smile. She could say “thank-you”, and “I’m glad to see you this morning”, and “you’re okay with me, young man” all with her facial expressions. She was precious. She was valuable. She was beautiful. She was a nyanya, and she deserved better.

Lamenting the bruising of the elderly,
chad

“We should provide for old age that it may have no urgent wants of this world to absorb it from meditation on the next.”
~Pearl S. Buck

Case #2: No Follow-Up. (Case Reports from Kijabe Hospital)

2008-12-21T13:46:00.003-05:00

Someone who read a previous post on my blog wanted to know what became of the young man who presented almost a week after an accident that left the mid-portion of his top lip avulsed. As much as I would like to report on his final post-operative outcome, and show you a picture of what he looked like in clinic when we removed his sutures, I cannot, because he, like so many patients, has not returned for his follow-up appointment.

SK is a 19 year-old male who was riding a motorcycle at a moderate rate of speed when a car cut him off. He went over the handlebars where he suffered injuries mostly to his face. This included a mandibular fracture, soft tissue injury/loss to the upper lip, and several small lacerations and abrasions. He was initially cared for at an outside hospital, where one of the doctors wired his teeth to stabilize the mandibular fracture. They made no attempt to treat the soft tissue injuries however, and after ~5 days, he asked to be discharged so that he could seek help elsewhere. He was seen on PTD #6, by myself in clinic where his injury was documented below.

SK's lip 6 days after the accident

He was admitted to the hospital, and brought to the operating theater the following day for debridement and repair. In the theater, he was found to have disruption of the obicularis oris muscle. The overlying skin and mucosa was raised off the obicularis muscle. The muscle was then approximated with several interrupted sutures. The overlying skin was then brought together in an “T” formation (see below).

SK's lip in OR after attempted repair

He was discharged the next day and instructed to return for suture removal, but he has not returned. Likely, he went elsewhere to have the sutures removed. This happens quite frequently at Kijabe Hospital where patients do not return for their follow-up appointment. Usually, it is just a problem of the expense and inconvenience of traveling all the way back to Kijabe hospital for follow-up care, but one can’t help but wonder if there has been some bad outcome in the time since you discharged them. Some take the attitude that “no news is good news”, and that if there is a problem, the patient will return, but I am not sure if this is true. Sometimes a no-show mean the patient was unhappy with their care, or worse, they are too sick to come in or even dead. Follow-up is very important for physicians to know if their treatment is effective, and when practicing with as much uncertainty as we do in Africa, the lack of follow-up is even more problematic. I had never fixed a facial laceration like the one on this young man, so I was anxious to see how it would come out to know whether my approach had worked. If a patient comes in with a similar injury, I will probably do the same thing, and be just as uncertain whether the repair will work. Experience should build confidence, but without follow-up, I remain essentially inexperienced and uncomfortable about how to fix the problem even though I have seen it before. I am learning that in Africa, I have to be comfortable with uncertainty.

Comfortably uncertain,

chad

“Medicine is a science of uncertainty and an art of probability.”
~William Osler

Building Bridges: Thoughts on world security from an American living abroad

2008-12-13T22:06:00.002-05:00

The recent terrorist attacks in Mumbai have given me pause to consider why the world is becoming a more and more hostile place. Despite aggressive counter-terrorism measures being put in place across the globe, world security continues to seemingly decline. The boldness of this last attack to send heavily armed street infantry into several public places and murder, take hostages, and disrupt the financial center of India for several days was especially discouraging, because it confirms that there are a growing number of terrorists ready and willing to engage in these suicide missions. Since all that has been going on, I got a few concerned notes about my well-being here in Kenya.
First, let me assure you that I am in an extremely quiet community in rural Kenya, that is not on any list of potential terrorist targets. I do occasionally leave the relatively safety of Kijabe, but so far, the most threatening thing I have encountered has been some harassment by a few unkind policemen on highway checkpoints.
I must say though, that East Africa is subject to some security problems. In particular, social-political conditions are slowly deteriorating in nearby Somalia. After 18 years of civil war, and fighting, the nation is falling under increasing control of Islamic Fundamentalists much like the Taliban in Afghanistan. Ethiopia recently announced that it is pulling its forces out of Somalia after a long occupation to assist with policing the nation. So with this withdrawal, almost certainly there will be even further degeneration of law and order, opening the door for al-Qaida, and the like, to increase their activity there. So with the recent turn of events, one can’t help but get a bit nervous being in a nation that shares a border with an increasingly unruly, ungoverned, and dangerous state.
But what happens between Somalia and the surrounding countries is beyond my control. I can’t do anything to prevent an attack, right?

Actually maybe, I can.
I care for many Somali patients here in Kijabe. Because quality medical care is generally unavailable there, people come all the way from Mogadishu and further to our hospital when they are sick. They ride past many hospitals in Nairobi to get here. Given our excellent reputation in the Somali community for professional, comprehensive, compassionate, and affordable care, they come to our little rural mission hospital instead of the big fancy hospitals in Nairobi. I have learned quite a bit about Somali culture in my brief time here. They are predominantly Muslim, but have a large amount of variability in how they express their faith from the devout and deeply religious to relatively secular individuals who only maintain the cultural aspects of Islam without any spiritual investment. What I have learned about these Somali patients is that they are like most Africans, in that they are very appreciative of my efforts, even if I fail to help them. But I also see an incredible amount of suffering evident in their lives. While most come in for the typical health problems affecting East Africans, many of the patients are coming to see me for sub-acute injuries resulting from gun shot wounds suffered in this nearly lawless nation. And even those who have non-traumatic health problems are often presenting with end-stage disease from their condition being neglected for so long in Somalia. And beneath their suffering, I also see a lot of frustration with their circumstances. Even though, they try desperately to maintain optimism toward life in general, it is clear that the outlook for Somalia appears bleak at this time. And a people with no hope is a fertile environment to cultivate terrorists.
For young men growing up without any hope of realizing their dreams or making an impact on society though some constructive means, the alternative is to join forces with an organization that seems more effective in voicing their frustrations, even if the voice is through violence. These are young men with the same energy, creativity, and intelligence that could populate universities and industry, but with little infrastructure to direct their energies positively, organizations like al-Qaida are able to captivate the imagination of these frustrated youth. They brainwash them into scapegoating Western society, Jews, Christians, or some other target for being at fault for their circumstances. They then teach them the very un-Islamic idea that hatred and violence is the righteous means to be heard in the world. Of course, it seems ludicrous that anyone would fall for such propaganda, but when you see the desperation and suffering that these people endure, then it is not that hard to fathom. In a country where nothing is stable enough to encourage self-improvement, education, community development, or home building…the only remaining endeavor is to contribute to the malevolence.

Now this may frighten you to be reminded about what is happening in many nations around the world. It is natural to fear violent and ruthless gangs that are gaining more recruits in distant countries. But fear is a dangerous emotion…it often causes us to do things that are unproductive. Like a child who fears a needle even though the medication is for his own good, fear must be managed with foresight and wisdom, or else one becomes a slave to it. The appropriate response to terrorism is fear, but we must not overreact and do counterproductive things that only make more attacks inevitable. Fear may cause us to “wage war on terrorism” in a way that only exacerbates the problem. We have seen the futility of attempting to exercise military might to bring order to these lawless nations. I’m not saying that there is no role for military intervention, but victory cannot be achieved merely by trying to crush the terrorists with physical force. Victory is achieved by supporting anti-terrorist governments and stabilizing communities so that the terrorists are eradicated from the inside out. But if we as Western society allow our fear to dictate our response to terrorism, and we go into foreign lands with guns-a-blazing to kill the terrorists, we will incur some substantial collateral damage to the innocent, which only creates more animosity against the West and therefore more terrorists.
Some would advocate not having any presence what-so-ever in these terrorist “hot spots”. But that is an even more “yellow” response than using brutal military force to get rid of terrorists. By ignoring the oppression and suffering of the common man in places like Somalia, we offer no protection to those who would want to maintain law and order, and resist the terrorists. If these men and women are abandoned by the West, then how will they stand against the heavily armed terror networks, and moreover, will they want to rid their countries of terrorists if they feel the West has become apathetic to their suffering.

The fearful response of trying to build “higher walls” around the West to protect ourselves just does not work. It only further supports the ideology of the terrorist that the West is unsympathetic to the suffering of people outside of its borders. But if these nations see that the West remains interested in their welfare (and not just protecting its own foreign interests), then the peace-loving citizens of those countries will root out the terrorists from their own countries. We have to maintain our presence, and even increase our presence in places like Somalia and Afghanistan…not with might, but with support of social infrastructure and political freedom/democracy. We must increase our presence in these countries to serve them. Helping restore order and productive society is the only way to defeat terrorists.

Building higher walls out of fear is not the key to security and peace…the key to world security is building bridges out of love. If the people of Somalia and other unstable nations see Westerners supporting them, and standing along side them to help alleviate their suffering, then there won’t be a crop of disgruntled youth to be cultivated for terrorism. But if we ignore their suffering, and allow their society to erode (or worse…if we seek to profit from the erosion), then there will be a bountiful harvest of hopeless frustrated young people to continue undertaking suicide missions and wreaking havoc in our streets.

So what does this have to do with you and me? It has everything to do with you and me. Never underestimate the influence that we as individuals can have on world problems.
First, we must use our political voice to support “bridge-building counter-terrorism” and support politicians who share in this way of thinking. We must not allow the war-hawks and fear-mongers to spread propaganda that supports military force as the solution to world security. These politicians are often serving the special interests of the defense industry, and are more interested in selling guns, tanks, and missiles than bringing about world peace. We can engage in direct political action to protest militarism, and to support keeping our borders open to the world. We can campaign for like-minded politicians, and most importantly we can exercise our right to vote.
Second, we can give financially to relief organizations that are doing the work of restoring civility to the most unstable parts of the world. Now this may seem like an unrealistic statement in our current economic climate, but I assure you that even during a recession, Westerners still have plenty of financial excess compared to people who are not able to access clean water, health care, or a safe place to sleep. Our current economic woes have put many people on the fringe of financial security, but there are still millions of individuals who have the financial resources to help meet the needs of the world’s poorest individuals.
Thirdly, if we have the means and the opportunity, we can serve our brothers and sisters in these far off countries directly. Not everyone needs to quit their job, and move to Kabul to open an orphanage, but many individuals can make a personal impact in these countries. It’s an enriching experience to travel the world and live and work with people different from ourselves whether it be for 10 days or 10 years. Here at my hospital in Kenya, there are several groups that organize short medical mission trips to the large Somali refugee camps in North Eastern Kenya, as well as medical mission trips to the country itself. Every patient who is treated on these trips, is one more individual who will associate a Western face with goodwill and love. I know that not everyone can travel abroad and engage in relief work, but many of us can support individuals who do so.
Just the opportunity for our hospital to care for so many Somali patients has built a bridge between our hospital and the Somali people. We have earned a reputation for caring and helping in their community even though Kijabe hospital is known to be a Christian mission hospital (staffed by many American/European/Australian physicians). I am reminded of the first Somali patient I cared for at Kijabe hospital. Hassan presented with a diabetic foot infection in his right leg. The infection was drained, and the medical service worked hard to control his blood sugar and prescribe the right antibiotics, but the infection grew worse and he required a below-knee amputation of his leg. That is when I came into the picture fresh from America. I did the amputation, and cared for him as he recovered. On the day he was discharged, Hassan demanded I come see him in the middle of the day. He wanted to have his picture taken with his doctor, and say thank-you one last time. I was awe-struck. I felt like a butcher who showed up, and cut off his leg, but Hassan saw me as an angel of mercy. Hassan and his family don’t share my faith or my language, but an act of service was able to build a bridge across our cultural gap and make us friends. When the proponents of terror come spreading their propaganda that Christians or Westerners are evil, Hassan and his family will know better, and this little bridge of love does so much to break the back of hatred, misunderstanding, and terror.
So, any opportunity we have to serve the world’s most hurting people is not only an opportunity to do something moral and right, it is also an opportunity to stabilize the world from terror threats. This is not just the president’s job, or the U.N., or G8. The responsibility belongs to us all. We all have something to lose by ignoring the oppressed, but we also have so much to gain by reaching out across the cultural divide to meet someone else’s needs.

Will this approach to terrorism expose us to some danger? The answer is yes, it will. Several relief workers were killed just last month in Somalia. But in comparison with the number of men and women who have died on military missions trying to catch a handful of terrorists, insurgents, etc, this is nothing. In the end, fewer individuals will die if we take the courageous route…the loving route to fighting terrorism. It cannot be defeated with hate and fear…that’s like pouring gasoline on a fire. We have to win the hearts and minds of the people living in desperation. This cannot be done with bullets and bombs. This is accomplished with clean water, food, books, medical supplies, teachers, nurses, schools, orphanages, hospitals…this is accomplished with love.

Yours in building bridges,
chad

“Darkness cannot drive out darkness; only light can do that. Hate cannot drive out hate; only love can do that.”
~Martin Luther King, Jr.

Case #1: It's Not Rocket Science (Case reports from Kijabe Hospital)

2008-12-07T12:20:00.006-05:00

DM is a 50 year-old man who suffered a fall down an embankment after being pushed while walking along a road. He shortly thereafter presented to a large hospital in Nairobi with complaints of inability to move his left arm and unable to walk due to left leg weakness. After obtaining films, the physicians diagnosed him with a left scapular fracture, and acute on chronic left hip disease (even though the films looked normal to the Kijabe clinicians who reviewed them.) He was referred to Kijabe hospital for a left hip replacement. This is one of the ironic things about health care in Kenya. Even though the patient was being seen in a 1000+ bed hospital in the largest city in the nation, he was referred to our little 200 bed rural hospital, because we are the only affordable option for the procedure they thought he needed.

So 13 days after his injury, he was able to make it to our hospital to be evaluated for a hip replacement, since he had lost the ability to walk and move his left arm after the fall.
Fortunately, when the patient was seen by the registrar (resident) in Casualty (ER), the astute clinician was able to diagnoses hemiplegia, and referred the patient for a CT scan of the head. This meant going back to Nairobi, because we don’t have a CT scanner in our hospital. The next day, the patient returned to Casualty with the CT shown below.

DM’s CT Scan showing his lenticular hematoma with mass effect

Obviously, he had an epidural hematoma. The time was about 5pm, when I saw the scan and heard the story, so we were able to organize, and get him in the OR quickly (even though his symptoms had been stable through the 2 weeks). His head was shaved, prepped and draped, and I proceeded to perform a craniotomy by drilling 2 right-sided burr holes. I was unable to evacuate the hematoma through the burr holes, since it was too organized (old clot), so I drilled a 3rd hole, and used the Gigli saw between the 3 holes to do a small craniectomy. We then were able to easily scoop out the clot. I returned the bone flap, and closed the scalp incision. And went home wondering how much the procedure would help.

The following morning, the patient was able to move his left arm, and lift his left leg off the bed. By POD#2, he was walking, and on POD#3 he was discharged to home with a gait better than mine.

Post-op Day#3: Going Home

This was without a doubt the most satisfying operation of the week. Up until this case, my experience with neurosurgery has had some relatively unimpressive outcomes. (I have gotten quite a few closed head injury with low GCS and lateralizing signs, but unless your burr holes allow you to find a discreet hematoma, extradural or subdural, the end result is usually poor.) But to see a man who has been hemiplegic for 2 weeks, and then be restored to normal is quite exciting. I’m thankful that God allowed me to participate in and witness the healing.
What is more amazing is that I was never trained to do any of this. I did ~3 weeks of neurosurgery when I was an intern in 2001, and have not so much as touched the brain since then. (Anyone looking at that stellate incision I made could ascertain my lack of training.) But amazingly, by just doing my best and praying that God will do the rest, I have been able to grow more confident in many procedures I was not trained to do. Just by reading a few chapters, talking things over with my local colleagues, and some neurosurgeon consultations via email, I have been taking care of basic neurosurgery routinely in only a brief period of time. Then again …it’s not rocket science.

In amazement,
chad

“If you act like you know what you’re doing, you can do anything you want – except neurosurgery.”
~Sharon Stone

Learning to Give Thanks Again

2008-11-27T23:41:00.001-05:00

Some days I think Kijabe Hospital is the most amazing little hospital in the world, and some days I cannot imagine a more frustrating place to be a surgeon. Today started out as one of the frustrating days…

What I have learned in my brief time working in East Africa, is that the professional culture is very different here. In particular, one of the most limiting factors in my ability to care for patients has been the nursing care on the wards. Part of the problem is that the nurses have too many patients and that their training is limited, but another part of the problem is a lack of accountability or standards in the care they deliver. My orders routinely get overlooked or ignored, and I have no recourse with which to deal with sub-standard care. I never sense any remorse or apologetic attitude for the most negligent care. I have admitted patients who are quite sick, and made rounds on them the following morning to see that not one order was carried out, no IV fluids, no meds, no labs, nothing. In the US, a patient who is admitted and ignored or overlooked for 12 hours would be shameful. The nurse would at least have a very good excuse. When I bring it to the attention of the nurse who was assigned to the patient overnight, the response is one of, “that’s unfortunate”. Let me be clear...the nurses are not apathetic, disinterested, or difficult. They are kind, thoughtful, and good-spirited. There are systems flaws that make good nursing care difficult, but the attitude of the nurses to overcome or change the system to give good care is absent…bad care just “happens”. Even though they were assigned to that patient, the lack of care or inappropriate care is seen as something that happened passively, not something they were responsible for. I discussed this with my Swahili instructor, and he explained to me how even the syntax of the language is bent toward using passive forms of verbs. (The vase broke vs. I broke the vase.)
So in the setting of this culture, in particular the nursing care, I have had my moments of exasperation.

Today was Thanksgiving in the US, but I felt anything but thankful after rounds this morning. I walked on the floor to see my patients. One woman had sat on the floor for about 20 hours without a crucial order being done…something that was central to her care, and to me obvious that it needed to be done. We went through the usual futile discussion about who was responsible, but as usual, no one was responsible...it “just happened”…or in this case did not happen. I had spent about 90 minutes of precious theater (OR) time debriding and placing a negative pressure (VAC) dressing on her perineum, and this had all been in vain (since the nurses forgot to reconnect the suction). I would have to take her back to the OR and likely cancel an elective case or two for the day, making me fall further behind in my attempts to provide good and timely care to my patients. And here the nurse stood in front of me with a blank expression as I asked why they did not reconnect the suction to her dressing. No apologies, no excuses, no promises that it won’t happen again, just agreement that it was unfortunate what “happened”. I left the floor frustrated and angry.

I spent the evening thinking about the experience. After my initial frustration, I was able to come to a point where I understood. The culture here is different, not to mention the low nurse to patient ratio, and limited exposure to surgical nursing training. I can accept that things will “happen”, but it makes it hard for me to invest myself totally in patient care. In other words, why should I give 100%, and work hard for the patients, if all my work will be undone by a health care system that just does not seem to be a 100% health system. For a moment I was tempted to think the way to avoid frustration is to not try so hard…to only give 50 or 75% of my best, so that I won’t be upset by poor outcomes. Why lose sleep, come in at night, wake up early, operate on weekends or evenings only to have my efforts be in vain? Maybe I should just coast a little more. One of the Kenyan physicians even suggested this strategy to me. His attitude is that one should not work too hard to avoid burn out.
But I cannot reconcile this attitude to everything I have been taught. Don’t get me wrong…I definitely make time for myself, and recognize the need for quiet time and time away from the hospital, but for the time and energy one dedicates to taking care of patients, I can’t accept anything but 100% commitment to treating their problems. I am reminded of Paul’s words in Col 3:23 that one must “do whatever one does heartily as to the Lord”. I am here to serve and do my best to care for sick people, regardless of how much the hospital helps or resists that mission. I have to remember that I work for God. There is no reason to get frustrated and lose my desire to serve, because it is God that allows me to do what I do. When my efforts to restore someone to health are successful, it is only by God’s grace that my efforts succeed. So how can I be so incredulous to think that I will only work hard if I think everyone else is meeting my expectations for good care. The patients deserve my best, no matter what the rest of the hospital is able to provide. I have to recognize the limitations of nursing here, and think carefully about what to expect on the floor, but that does not give me the excuse to neglect patients’ problems or give half-hearted attempts to care for them. On the contrary, I may have to spend more of my time doing the “nurse’s job” or educating them, and making sure that they will give good care. (I guarantee I never leave the hospital again without making sure a VAC is on suction.) I must remain invested in patient care, and be an example of dedication, instead of allowing my frustrations to make me succumb to a less than idealistic attitude about patient care.

I’m glad that I had the evening to consider this all. Thanksgiving here in Africa was an afterthought. Only the Americans were celebrating, and most were too busy working to do much except scarf down a bit of turkey in between seeing patients. But now that the day is done, I recognize that my frustrations this morning were the result of losing the Thanksgiving attitude. I am reminded to be thankful for the things that do work well at this little mission hospital. It is amazing how much good work is done with so little financial resources. I am reminded to be thankful for what the nurses do instead of what they don’t do. I am reminded to be thankful that I am even well-bodied enough to work at all. To be thankful that I am not a patient. To be thankful that my patients by-in-large get better. To be thankful that I am able to participate in their healing in any way. To be thankful that God has allowed me to thrive in Africa, and live such a rich and full life.
I give thanks today for the privilege and honor to be able serve. If I can keep that attitude, I don’t imagine anything will be able to frustrate me for long here in Kijabe.

Yours in thanks giving,
chad

“The unthankful heart discovers no mercies; but the thankful heart will find, in every hour, some heavenly blessings.”
~Henry Ward Beecher

Financial and Professional Update

2008-11-22T23:41:00.004-05:00

I woke up this morning to very good news. I checked my email, and found a message from the Durant Fellowship Committee. They had sent me a message saying that of the 11 applicants, I was one of the 3 who had been chosen to receive the fellowship. The fellowship is more than just a nice award to put on my curriculum vitae; it is funding that should meet 90% of my needs while I am here in Africa. Please join me in thanking God for this blessing to allow me to continue my work here in Africa without financial worry.

To back up for a moment, I first began to seriously consider this post-residency trip to Africa about two years ago. Over the next year, my plans solidified, but a comprehensive funding source to pay for an extensive trip never materialized. In case I did not make this clear before, I am here in Africa volunteering as a surgeon for free. Additionally, I have to pay for travel, lodging, food, and many other costs to be here. Prior to leaving Boston I was able to complete an application for the Durant Fellowship which is a stipend and training for those wishing to spend 6 months to a year working abroad in an international resource limited setting. (Originally, it was explicitly for working in refugee camps, but the scope has been broadened). So, I felt good about my application, but also understood that I was competing against 10 other applicants for one of 3 fellowships. Even without securing funding, I felt led to be faithful, and come to Africa anyway. Every time worry crept into my mind that my financial needs might not be met, I would remember the many promises of God to be faithful to those who are obedient to Him. So for this financial blessing to come to fruition (7 weeks after I already left for Kenya) is worthy of celebration and praise. God is indeed faithful, and I have wanted for nothing at any point during this trip.

***

The other update I want to post on the blog is that the fellowship match results have come out, and I will be returning to the MGH for my trauma fellowship from 2009-2011. As many of you know, I went across the US for interviews at many well-known trauma centers including Miami (Jackson Memorial Hospital), Atlanta (Grady Hospital affiliated with Emory), Philadelphia (Hosp of University of Pennsylvania), and Los Angeles (USC/LA County Hopsital). While I was very impressed with these programs, the mentorship at these places does not compare with what I have at “home” at MGH with Dr. Velmahos, Alam, and DeMoya. I am a little disappointed to not be able to live closer to family (LA), but I am thrilled that these three surgeons will be in charge of my professional growth as they are doctors, scholars, and gentleman of the highest caliber. Mostly, I am excited to be returning to the MGH which has become a second home for me. And after living in Africa, I am sure that Boston will feel like it is right around the corner from Texas and California.

Yours in celebration of good news,

chad

“Success is not the key to happiness. Happiness is the key to success. If you love what you are doing, you will be successful.”

~Albert Schweitzer

Tragedy

2008-11-16T15:39:00.005-05:00

Bad news is never welcomed, but today’s tragic news was particularly discouraging. I was on my way to the hospital, when I was called by one of the residents to tell me that there was a patient who had been in a RTA (road traffic accident); a high speed head-on collision. I went to Casualty to see the woman who was the passenger in the car. She was actually stable, and other than some abrasions, and sternal tenderness, she looked quite well. The resident and I discussed the case, and settled on a plan. He then casually mentioned to me, that he had to go to the operating theater to assist the orthopedic team with the operation on the car’s driver. The driver had suffered a cervical-spine injury with paralysis. As he begin to head off, he mentioned that the patient was a member of the operating theater staff. My stomach tightened. He told me it was David Chege. The bottom fell out of my stomach, as I exclaimed, “No!” in disbelief.

I have only been at Kijabe hospital for about 6 weeks, but I have grown quite fond of Chege. He is one of the more experienced surgical techs in the theater. Since he usually covers my room, I have worked with him more than most other staff since I have been here. We have quickly become friends, and I am always happy to see him when I walk into my room. I know that I will have expert help that day. He is calm, intelligent, patient, and ever helpful…even when I am sweating and struggling during a procedure. In addition to being excellent at his job, he is a good person. During any break between cases, he is usually quietly reading one of the Bibles scattered about in the theater. He is always above reproach in his language, attitude, and actions. This has been a good influence on me, teaching me to try to leave my American sarcasm and whining behind in the states. To top it off, he has a good sense of humor, and has been able to get me to laugh during the most frustrating of moments with a grin so big, you can see the corners of his smile even when he is wearing a surgical mask.
On Friday, I had just seen Chege looking quite well as he drove out of the hospital parking lot with his little compact car crowded with passengers (at least 6). I had waved to him, and he flashed that big smile, as he dutifully headed out to drop off his car load of passengers. In his facial expression, I could see that he felt privileged to be able to help so many co-workers get home.

So after just 6 weeks of knowing this man, I have come to depend on him technically and personally. So, to get this news was devastating. I hoped the resident had gotten the details confused. How could this be? I walked with the resident to the theater, and went into the room to see Chege lying on the trolley. He had not been sedated yet, but was as calm as could be, actually trying to be helpful in his helpless state...true to form for this remarkable man. I put on a brave face, and walked up to him, and tried to say something encouraging, but I think my voice gave me away. I got out of the way to let the orthopedists do their job, and left to try to make some rounds, when my eyes filled with tears. Amazingly, despite all the adversity and difficulties I have had since departing Boston, this was the first time I have shed tears since arriving here in Kenya. I have seen a lot of suffering here in Kenya, but this was too personal. It seemed so unfair, so random. How can God allow someone who is such a good person to suffer such a terrible injury, and so many petty, mean, and selfish people to go on with their wretched lives without any such interruption in their miserable routines. In that moment, it was hard for me to see God as good…

I have now had the day to absorb the news. Chege is currently in our little ICU. He is currently quadriplegic, and I have spent the rest of the day trying to resist the temptation to fall into despair. There is nothing more damaging to our faith and well-being than circumstances that make us think that life is meaningless. This news has shaken me. Don’t get me wrong. I know that God is in control. I know that nothing happens beyond His omniscient and omnipotent presence. I know He has a plan. I know that we do not suffer in vain. But at the moment, I don’t feel like God is in control. I feel like our efforts to do good are wasted. All of Chege’s goodness has not protected him from this awful accident, and a part of me is angry and hurt that God could allow this. But I cannot let the disillusioned part of me, overwhelm the part of me that knows that “all things work together for good to them that love God”(Rom 8:28).

What is ironic about my state of mind today, is that just 24 hours ago, my faith felt stronger than ever. Seeing a community of people so devoted to service has encouraged me. Despite the challenges of trying to be a physician in a resource limited setting, I have felt like our work here is special and blessed. Even when patients are not healed physically, they are often comforted by doctors and nurses who care…who stand beside them in their darkest hour. To be honest, I have been in a process of spiritual growth that I have never known. On Friday night, I was walking home thinking about the many patients I have with problems that seem to great for me to fix, and for some reason I looked up into the Southern African sky. And at that exact moment, I saw a shooting star racing across the cosmos for just a couple of seconds. Now I know shooting stars are just meteors reaching the Earth’s upper atmosphere , but to just happen to glance up and see this sight was like having God wink at me, and tell me everything is going to be alright. It was as if God had sent me my own personal celestial test message.

And then today happened. So I am writing now soliciting your prayers for Chege. I believe in the power of prayer, and that the prayers of the righteous availeth much (Jam 5:16). Pray that Chege would be healed. Perhaps God will use this as an opportunity to show his power, and our faith will grow by witnessing a miracle. But more importantly than praying for healing, pray that Chege’s faith remain intact. Pray that his response to this devastating injury would be to remain thankful that God still has him in the palm of His hand. And pray for our little Kijabe community. Pray that this tragedy would not discourage us, but remind us how precious every day really is. Pray that we continue on our mission to care for the sick. Pray that we remain faithful. Pray that God will find a way to wink at us all, and remind us that everything will be alright.

Faithfully yours,
chad

“I say to you in conclusion, life is hard, at times as hard as crucible steel. It has its bleak and difficult moments. Like the ever-flowing waters of the river, life has its moments of drought and its moments of flood. Like the ever-changing cycle of the seasons, life has the soothing warmth of its summers and the piercing chill of its winters. And if one will hold on, he will discover that God walks with him, and that God is able to lift you from the fatigue of despair to the buoyancy of hope, and transform dark and desolate valleys into sunlit paths of inner peace.”
~Martin Luther King, Jr.

Obama Day

2008-11-06T14:14:00.004-05:00

I’m sitting at my desk at 4pm, on a Thursday in Kijabe staring out the window at the beautiful Upper Rift Valley stretched out before me as I write. The clean African air is blowing through the window on a gentle breeze. The distant sound of Kenyan young men playing football (soccer) and Kenyan young women cheering them on is providing a pleasant soundtrack to this serene moment. Today is a special day. The world seems calmer and the future looks brighter. Despite all that is wrong in the world and in Kenya, peace and positivity appears to be on the horizon. Why? Because today is Obama Day in Kenya.

In general, I have observed that Kenyans know how to celebrate and express joy, but today the energy in the air is more electric than ever before. Today was declared a national holiday by the president of Kenya in honor of Barak Obama’s victory in the American presidential election. So people are celebrating an unanticipated midweek break from work and routine, but more than that, they are celebrating an adopted Kenyan son who has risen to the highest office in the world, and all of Kenya is unanimous that his election victory is good news.

On the face of it, I’m not sure why Kenya is so jubilant regarding Obama’s victory. Perhaps, it’s merely pride in a man who is half Kenyan doing well on the world stage. Perhaps, they believe that Kenya will benefit from some preferential treatment by the president of the most powerful nation in the world. While these reasons may be part of the excitement, I think Kenya’s excitement is merely a reflection of the excitement of the world at large.
People around the world are surprisingly well-informed about American politics, and for good reason. America’s influence on the circumstances of the world is clear. American policy is the single largest influence on geo-politics. Even domestic problems in America can trigger global changes, as made obvious by our banking crisis creating world wide economic ripples.
So it is understandable that the world was following this election so closely. In the eyes of the world, this election was pivotal in repairing the worlds problems, from global warming/climate change, to economic depression, and of course to conflict around the world including Iraq and Afghanistan. In the US, Obama only had a few point lead in the popular vote over McCain, but he is wildly popular abroad. Obama has captured the imagination of people around the world, and for some reason, they believe he is the man who can make the world a better place. But in particular, for people who have historically been most pessimistic about politics, young people, poor people, and non-whites, he has inspired optimism and interest never seen before. And no place is it more palpable than here in Kenya where Obama has near 100% approval.

I have read his book, The Audacity of Hope, and Obama does inspire his readers with his creativity and commitment to rise above party politics to meet the needs of everyman. He believes that politics and government can “work”. He believes that consistent leadership from Washington can restore America’s faith in the political and civic mechanism. I confess that his optimism is contagious, as upon completing the book earlier this year, I was filled with hope that his political vision might come to fruition. Of course, we have a few months before we find out whether he can accomplish any of the goals he has set forth, and the problems seem massive that he is inheriting from the current administration. But on today, in Kenya on November 6th, 2008, I am celebrating Obama day. I am enjoying a moment of reflection, and praying that the man can withstand the trials and tribulations of the hardest job in the world. Praying that he can make government “work” again. And praying that he is right when he says: “yes, we can”.

An American living in Kenya supporting a Kenyan living in America,
chad

"It took a lot of blood, sweat and tears to get to where we are today, but we have just begun. Today we begin in earnest the work of making sure that the world we leave our children is just a little bit better than the one we inhabit today."
~Barack Obama

Differences

2008-10-24T07:34:00.000-04:00

I have been in Kenya now for about three weeks, and I feel like I have almost gotten into a bit of a rhythm at the hospital. Today is a clinic day, and just like back home, no surgeon wants to be in clinic…we want to be in the OR, but you have to see patients in the office to do surgery…kind of like penance. So there I was in clinic at about 3pm…it seemed like I had already seen 50 patients, but there was still a crowd in the waiting room, and the worse part was, I had skipped lunch to catch up. So with my stomach growling, I picked up another chart, walked into the waiting room and announced the name as best I could. (This had become a joke throughout the day as all the patients would laugh at my attempt to pronounce what seemed to them to be common last names like Mbugwa.) An 18-year-old Somali girl stood up along with her mother and they began to walk toward me. As I walked the patient to the exam room, she looked relatively normal, but by this time, I have learned to expect the unusual...

***

After three weeks here, I have seen many clinical problems that look identical to pathology I have seen in the US: gallstones, diabetic foot infections, varicose veins, breast lumps, enlarged prostates, and various malignancies, but there is often a subtle, but significant difference in the presentation or problem compared to what I have seen in the US.

For instance, patient expectations are different here. I had a patient and her son wait 6 hours to see me in clinic for follow up of a below-knee-amputation she had a few months prior. This patient had already had her left leg amputated secondary to a diabetic infection years before, and now she had recovered from her more recent right leg amputation. I looked at the right stump, and it had healed as beautifully as the left. I beamed that all was well, and that the stump could not have looked better. Then the son explained that he was not concerned about how the stump looked. He had come in to see if his mother was ready to begin “walking on her knees”. He did not want prosthetics made for her…he wanted my approval to let her start crawling around on her knees and hands. He wanted her to be able to go to the bathroom by herself, and “work around the house”. I tried to persuade him to go to the CURE hospital to have her fitted for prosthetics, but he was convinced this was a waste of time. He had seen other amputees walking on their knees and stumps, and wanted to know when his mother could start doing so…

Pictures of a woman's hand after an electrical injury: She presented one month after injury

I have seen quite a number of trauma patients, and while gun shot wounds and motor vehicle accidents are the same no matter where you go, the interesting thing is WHEN they present. For instance, I have a patient who was shot in the face with a high powered automatic rifle, breaking his mandible and ripping a gaping hole in the soft tissue of his cheek. This injury was not really that unusual, but you would think, a man who was shot in the face with a completely shattered mal-occluded mandible and a hole in his face might present right away…or not. He showed up more than 24 hours after the injury, which totally blew my mind.
Sometimes, it’s not that the patient did not seek care…they just went to the wrong place. For instance, I saw another man with a mandible fracture who had been in a motorcycle accident. He had gone to a local hospital, and one of the providers there knew how to stabilize mandibular fractures by wiring the teeth. But in addition to the fracture, the patient had a large avulsion of the mid-portion of his upper lip too, for which they did nothing. He presented to me about a week after the injury, essentially with no upper lip (see the picture below). Apparently, after they wired his jaw, they just admitted him and watched him…waiting for this to granulate in and heal. Fortunately, his father decided to seek a second opinion (albeit a bit late).
Young man with avulsed lip ~1 week after motorcycle accident

Of course the mechanism of traumatic injury is a little different here. First of all, people don’t just ride in cars in Kenya…They ride on the roof of cars, hanging out of the side of cars, standing on the bumper, or sometimes on bicycles being pulled by cars. Public transportation in Kenya falls far short of the need, and that is why you see this type of crowding into and onto cars, vans, and trucks. But when people are not falling off cars, there are still other interesting ways to get injured. So far, I have seen buffalo and hippo attack injuries. The hippo bite was impressive. The gentleman presented with an open femur fracture. The hippo snapped this guy’s thigh like it was a toothpick. I was warned, that I might see many such injuries from the herbivores, but I will never see a lion injury. (Lion attacks are extremely rare, but if they do attack, they finish the job I am told.)

Traumatic injuries are not the only diseases that present late here. As you can imagine disease is often very advanced when it presents to Kijabe. People tend to present in the latest stages of disease with massively disfiguring tumors, crater-sized wounds, disseminated infections, and fungating cancers. Most recently, I saw a man with a penile cancer that was so advanced, I could not believe he was still able to pass urine out of the thing he was calling his penis. (I am tempted to post the photo, but I won’t for obvious reasons). One of the most heart-breaking stories I have heard here (and there are many) was told by my orthopedic colleague. He told of a 14 year old patient who was seen in a hospital in Nairobi, and had been found to have a small bony tumor in his leg, and was diagnosed with a sarcoma. The only problem was that his family did not have the money to pay for the operation. Three months later, they returned to that hospital, but only had enough money to get another film showing the tumor increasing in size. Seven months after that, his brother brought him to Kijabe hospital when he was sick and malnourished with metastatic disease to his lungs. He died a few days after his palliative operation on his leg.

In addition to late presentations, there are unusual presentations. What I have learned in my brief time here is that if you have a mass of unknown etiology, suspect TB. I have seen TB everywhere in the past 3 weeks. I saw TB lymphadenitis (scrofula). I saw TB in the mesentery of the small bowel. I saw TB orchitis (the testicle). You name it…TB granulomas can be found there. In the US, TB is always on the bottom of the list of possible explanations for disease, but here in East Africa, TB is one of your leading diagnoses for any sick patient.

In three weeks of being a physician in Kenya, I have learned to expect different pathology, different problems, and different patient reactions. It’s just different here. I feel much more accustomed to those differences now than I was on day 1, but I expect I will still be adjusting to the differences even when my time is done in June.

***

So after my introduction to surgery in Kenya, I sat in clinic and interviewed this 18-year-old girl and her mother, expecting some surprise, but it turned out to be a relatively routine problem. She had a thyroid goiter, but had normal thyroid functions. After discussing the options, we settled on a plan, and I was about to escort them out of the room, when I noticed she had a x-ray jacket. Someone had apparently ordered a chest x-ray. I decided to take a quick look at it. The lungs were normal, as was the trachea with no apparent mass effect from the goiter. I went to put the film back in the jacket, when I noticed what looked like an artifact over her left shoulder, and motioned to it briefly that it appeared to be a foreign body. The mother then casually said that it was “nothing”…just some shrapnel from a bomb in Mogadishu when she was younger… To them, bomb shrapnel was common place...but to me, it was just another one of those differences that is slowly changing my perspective here in Africa.

Noting Differences,

chad

The rapprochement of peoples is only possible when differences of culture and outlook are respected and appreciated rather than feared and condemned, when the common bond of human dignity is recognized as the essential bond for a peaceful world.
~J. William Fulbright

Tour of Kijabe Hospital

2008-10-22T13:34:00.010-04:00

The Entrance to Casualty (the E.R.)

Patients waiting to see me in surgical clinic...at 3pm.

Well lit corridor on the wards at Kijabe on a sunny day

Not so well lit at night (especially during last night's power outage)

Wairegi (Men's Ward)

Salome (Women's Ward)

5 Bed ICU (Note that the patient on the right is in an incubator)

PICU/NICU/MICU/SICU

OR #2: One of the most modern parts of the hospital

(Note the videoscopic tower)

Wherever the art of medicine is loved, there is also a love of humanity.

~Hippocrates

Update: Arrival in Kijabe

2008-10-05T10:45:00.004-04:00

Road to Kijabe

View of Upper Rift Valley at dusk

View of south side hospital entrance

Dear friends and family,
I have finally arrived in Kijabe, Kenya. It is truly beautiful here. The pictures above give you an idea of the surrounding landscape. Kijabe means “place of the wind”. Kijabe is a rural town with an approximate population of 16,000 located along the edge of the Upper Rift Valley in a farming community nestled in a mildly rugged area of hills and mountains and is only about 60km from Nairobi. My living conditions are surprisingly comfortable with indoor plumbing. There is not much need for air conditioning since we are at 7000 ft elevation, and there is a fireplace for really cold nights. We also have electricity (but it does go out on a relatively frequent basis).

To remind you, about half of Kenyans live on about one US dollar per day. The hospital here in Kijabe therefore cares for a large number of relatively poor patients. About one-third of the patients are from the nearby community, but the other two-thirds are from far away. Kijabe hospital has an excellent reputation in this region of Africa, and a surprising number of the patients are from nearby Somalia which has even worse access to health care than rural Kenya.

I am still getting settled, but I took a tour of the hospital on Friday. As you can imagine, there was overcrowding of the wards, and the outpatient department was quite busy with the waiting areas overflowing into the nearby courtyard with patients waiting to see a physician. Despite the challenging conditions, the 200+ bed hospital is able to provide some surprisingly comprehensive and sophisticated care. Kijabe does not have CT scanners, but it does have x-ray, ultrasound, a laboratory, a blood bank, and it is the pathology referral center for more than 50 other smaller hospitals in the surrounding area. There is a children’s hospital next door, as well as the AIDS Relief Center which are remarkable institutions in themselves.

I met the other three general surgeons on Friday. I will be working with Dr. Irungu for the next month, until I am up to speed, at which time he is going to turn over his service to me for my remaining time here. (Dr. Irungu is going on to concentrate exclusively on pediatric surgery.) The other two surgeons are Dr. Davis who is a relatively young American surgeon (about 2 years out from residency), and Dr. Bird who is a more seasoned surgeon originally from Australia. I will take call roughly every third night. The problems we encounter as surgeons are similar to that of surgeons in the US with a few exceptions (I did not see one obese patient the entire time I was touring the hospital…). There is a substantial amount of trauma mostly from RTAs (Road Traffic Accidents), but some penetrating trauma with the occasional unusual injury (e.g. hippo attacks). There are many burns since people often cook at home over an open fire. There is also a large amount of thyroid disease, diabetes, breast disease, AIDS, and benign prostate disease. I have much to learn and look forward to starting this week.

In addition to working here in the hospital, groups of doctors from Kijabe Hospital often travel to severely underserved areas of Kenya or to nearby countries such as Somalia. I have been invited to participate in some of these trips to the camps of displaced persons from nearby countries as well as Kenyans still displaced from the violence last January. I am very excited about the prospect of being allowed to participate in meeting the medical needs of those in the most dire of circumstances.

I hope to be updating this blog at least once every couple of weeks. It may prove difficult with the amount of clinical work (and the inconsistent internet access). I will use the blog as my primary means of communicating how things are going. I would love to hear from you especially by email (but keep in mind my limited ability to reply to all messages). Also I have furnished my contact information (i.e. mailing address) in a previous post should you need it. As far as financial contributions go, I am still waiting to hear about the Durant Fellowship in November, so I will wait to solicit direct financial support until that time. (However, I am more than happy to receive any small contribution you would like to make in the meantime.)

As I walked home tonight, I looked up and saw the beautiful African night sky with all the bright stars, and I could not help but think that Kijabe is truly a special place. It's just a tiny outpost really, but there is a concentration of "goodness" here, and an amazing amount of energy focused on healing and helping. I have a hard time expressing my anticipation of the work I will do here, but I expect it to be a very exciting time. I hope to learn much and serve more. Please continue to keep me in your prayers as I endeavor to do my very best to care for the sick here in Kenya.

Kwa herini,
chad

A great city is not to be confused with a populous one.

~Aristotle

Contact Information

2008-10-04T17:27:00.003-04:00

Dear friends and family:
I have arrived safely in Kenya.

I have a mailbox in the hospital if you would like to send me something, but keep in mind it may take 4-6 weeks to arrive, and that it's pretty expensive to mail to East Africa.
My mailing address is:

Dr. Chad Wilson
AIC Kijabe Hospital
P.O. Box 20
Kijabe 00220
Kenya

***

To call me from the US, keep in mind that I am 7-11 hours ahead of you depending on your time zone and daylight savings...

Home phone: 011 254 203 246 455
Mobile phone: 011 254 738 128 170

the 011 is for calling out of US, and the 254 is the country code for Kenya.

***

As always, you can reach me by email at dr.chadwilson@gmail.com

Blessings,

chad

My home is in my head.

~Bob Marley

What Have I Gotten Myself Into?

2008-10-04T16:31:00.002-04:00

It started out like so many other trips to Logan airport. There was a cheerful cab driver who picked me up from my apartment. He talked about how slow Tuesdays were, and provided some polite conversation about current events especially the recent presidential debates. I arrived at the terminal, checked my bags at the ticket desk, and breezed through security with great efficiency allowing me some time to relax and grab something to nibble on before the flight. I boarded the plane, and got my usual window seat. My neighbors were an older married couple, but seemed like the quiet type, so I settled in for what was looking like a comfortable flight. The plane took-off over Massachusetts Bay like every flight out of Logan, but this time something different happened. The 747 never changed direction, it just kept heading East…
While the heading the plane took did not actually surprise me (since I knew the destination before we left), it was that moment when I actually realized what I was doing. It took the unusual flight path over the Atlantic Ocean to jar my mind and make me realize what I was embarking on. Suddenly, I said to myself, “What have you gotten yourself into Chad?” I was traveling far away to a small rural town in the middle of Africa for nine months to practice surgery in the most challenging of circumstances. I gasped quietly as my mind was filled with doubts about the wisdom of this decision. There was so much uncertainty that awaited. So much distance from the people and things that seemed safe and comforting. So much to lose. After planning this trip for more than a year, I suddenly felt very unsettled. I wanted the plane to turn around and take me back to what was easy, comfortable, and known…instead of what awaited in Kenya that seemed difficult, uncomfortable, and unknown.

Fortunately, this moment was brief. My nerves had gotten the better of me for just a moment, before I was able to re-center myself by remembering what got me here in the first place. The opportunity to travel, to learn, to grow, and to help those most in need which is the most professional fulfilling thing a physician can do. I began to pray, and ask God to keep my mind in peace about the trip. To not allow anxiety to writhe its way into my mind. Eventually, calm came over me, and I was once again eager to arrive and experience all that Kijabe Hospital has to offer.

***

I suppose this is not the last time during this mission trip that I am going to wonder what I have gotten myself into. I’m sure it will happen again as I face all types of unusual and adverse circumstances of working in a new environment. It’s human nature to second guess any decision we make that puts us at risk or takes us out of our comfort zone, whether it be moving to Africa to take care of the sick, starting a new business, getting married, or becoming a new parent. We all share these moments of paralyzing anxiety from time to time. But there is very little worthwhile that can be achieved without some risk of failure, hurt, or harm. Each of us has a part of our personality that is completely risk averse...that does not want to lose money, get embarrassed, or suffer a fall. While we all need “survival instincts” to keep us from taking unnecessary risks, what makes us human and not animals is our ability to overcome our natural inclinations, and strive to accomplish great things...things that serve our fellow man and not just our own wants, needs, and fears. The human spirit is what causes someone to overcome their own “survival instincts” to run into a burning building to save a baby or even just to extend a helpful hand when one sees their neighbor struggling.
The apostle Paul described this duality to the human condition when he said that “the flesh lusts against the spirit and the spirit lusts against the flesh” (Gal 5:17). Paul went on to say that the two parts of every human are in conflict with one another. He pointed out that no one is inherently “good” or “bad”, but that we all have two sides. If we choose to feed our flesh, we will reap a harvest of "fleshly" things including hatred, bitterness, selfish ambition, envy, discord, and rage. But he also pointed out that we feed our spirit we will reap the “fruit of the spirit” including love, joy, peace, patience, and gentleness.
Whether you are a Christian or not, most of us can identify with the internal conflict Paul describes. We all have our selfish moments and we all have our selfless moments. What I have learned, in my own experience, is that these selfless acts do in deed yield “fruit” that bring internal contentment. And while these endeavors sometimes cost us personally, the price is always worthwhile when compared to having inner peace. It’s not that we should should strive to be “saints” or being willing to suffer in vain. Living a spirit-fed life will bring happiness. The happiest people in the world are not the ones serving themselves…they are the people serving others. The only difficult part is overcoming those selfish instincts that try to prevent us from putting ourselves at risk…overcoming that “what am I getting myself into” moment and moving ahead in faith knowing that peace and joy await those who serve…not to mention improving our fellow man's circumstances.

I know the next nine months are going to stretch me…but I am prepared to be stretched a modest amount if it means that someone might have their health restored who otherwise might not. My discomfort is a small price to pay for the comfort of a mother whose child who has a life-threatening problem that I have the expertise to treat. When I think about the next 9 months from that perspective, I have no lingering doubts or uncertainty about this trip. In fact, I am certain that it will be fulfilling, life-changing, and well-worth the sacrifice.

Happy about what I have gotten myself into,
chad

"A man does what he must - in spite of personal consequences, in spite of obstacles and dangers and pressures - and that is the basis of all human morality."
~John F. Kennedy

The Thing In The Chest That Pumps Blood

2008-09-26T01:39:00.014-04:00

You stand outside the door of a hotel room in the Four Seasons in downtown Philadelphia. Your dark suit is too warm, your hands a bit clammy, and your mouth is dry, as you swallow hard trying to calm yourself. You look down the hall and see several other tense young men and women waiting as well. You are about to take your final exam in general surgery.

You have worked 5+ years learning surgery.
You have spent more than 500 nights in the hospital.
You have performed over 1000 operations.
You have done thousands of physical examinations.
You have written tens of thousands of doctor’s orders.
You have read hundreds of articles, chapters, and books.
You have attended hundreds of conferences, lectures, and meetings.
You have come to work before sunrise almost every day for 5 years.
You have worked well past the point of exhaustion.
You have gone home at 10 o’clock at night only to curl up with a textbook to prepare for the next day’s cases.
You have lived and breathed surgery for five years…
And here you stand outside a hotel room where all of your work will be measured in three 30 minute oral examinations.

You would probably expect to be pretty anxious for you board exams, but the one thing surgical residency taught you was how to handle pressure. You’d rather face a couple of examiners than a torn portal vein any day. So you gird yourself with the same resolve you have used to face the countless challenges over the last 5 years. Shoulders back, chin up, let’s go!

The door swings open, and the board examiners invite you in, introduce themselves, sit you down, and then start reading the cases. The examiners seem cold as they walk you through the various clinical scenarios. They never confirm a satisfactory answer with even as much as a smile. Although when you forget something or make a poor choice, the examiners make it abundantly clear that you are off the mark. “Is there anything else you need to do before going to the operating room?” Your mind races, but you are not sure what they mean…you hesitate too long, and they demand a decision. You try your best to be systematic, to give conservative safe answers, to remember physiology, operative technique, and everything else you have learned. On some of the cases, you feel confident that you handled them well, but on many cases you are uncertain, and on some, you are certain that you totally screwed up. The next 90 minutes go by blindingly fast and after the last case is complete, you are relieved, but a bit bewildered… not to mention dissatisfied with yourself for your performance on the questions you feel you did not answer well…the other thing residency has taught you is to demand excellence from yourself.

Some of your co-examinees are eager to talk after the exam to compare experiences, confirm correct answers, and comfort one another. Some however are the opposite, and quietly gather their belongings, eager to escape the venue all together. None of the examinees, talkative or quiet, appear confident that they have performed well on the exam, which is some consolation that you all share in the trauma you have just endured.

You make your way to the airport in a fog, and head back home replaying the exam in your head. You lick your psychological wounds over the next couple of days as you await the examination results to be posted online.

You log into the ABS (American Board of Surgery) website at 12 noon EST, when the results are to be posted. Your heart rate accelerates as you navigate the site to check your results. You scroll down the page as you recall the years of school and exams from the SAT to the MCAT to anatomy quizzes and clinical skills practicums in medical school to USMLEs to ABSITEs to the qualifying written board exam you passed a few weeks ago…all leading to this last final exam to become a surgeon. You reach the bottom of the page, and read the following sentence: The ABS wishes to inform you…

***

I have never had a fearful attitude about tests and exams. I see them as necessary to discern who has the knowledge needed to hold a position or have certain credentials. In fact, I have always celebrated difficult exams. Why? Because passing a difficult exam means much more than passing an easy one. If the exam is easy it has not measured anything in any depth, but if the exam is difficult, then the score of the examinee is much more useful in measuring that examinee’s abilities. I am not saying that exams (especially standardized exams and college admissions tests) do not have flaws. Clearly, these exams can be biased in the sense that they might not measure what we say they do. (The SAT is not a perfect measure of how well someone will perform in college, even though it is interpreted that way.) While I understand that exams have limitations, I recognize how important they are in our society. Exams help to maintain certain social standards. For instance, the exams to become a commercial pilot are arduous, but that allows for a high standard of safety in commercial aviation and is part of the reason flying is so statistically safe compared to driving. The relatively easy exam one must pass to obtain a drivers license sets a relatively low standard for the quality of drivers on the road. Society demands high standards not just among professionals, but of many manufactured goods and services (food and drug industry, restaurants, children’s toys, etc). We all support these high standards, especially if they are applied uniformly and fairly without bias. When I get on a plane I am very glad the pilot had to pass many difficult exams to demonstrate his/her competence.

I say all of this to explain why unlike many people who hate having to take exams, I have always liked exams. I don’t like failing them. (I was very upset when I failed my driver’s exam the first time by hitting a cone while trying to parallel park…maybe I should not have taken the exam in a 1989 Lincoln Continental.) While I don’t want to fail, I do like the thought that the exam is going to actually measure something important. I had to pass difficult exams to get through medical school and to obtain a medical license, but those difficult exams set a high standard for the medical profession, and that is more important to me than me feeling good about my score. I have never viewed exams as personal obstacles (or assaults) for me to overcome. I have always been able to step back, and say I am glad the exams are hard, because I want my credentials to be an authentic confirmation of my abilities to be a good doctor.

So for the last 20 years in high school, college, medical school, and even residency…while many of my classmates have been uptight about exams, I have always had a healthy appreciative attitude toward them. Even when I have been less well prepared and performed poorly, I appreciated the process. I have been able to face these many exams with very little anxiety, and often found it pleasurable to be able to measure my knowledge, and make sure that my education was coming along appropriately.
But this past Tuesday in Philadelphia, when I prepared to enter that hotel room, I experienced a different perspective.
I did not care about maintaining high standards in the surgical profession.
I did not appreciate that the reason we have to take this oral exam in surgery is to prevent unsafe surgeons from practicing.
I did not want the exam to be difficult.
I experienced a fear of failing that I had never known. I’m not sure if it was just the thought of having to pay another $1500 to take the exam over (exam fee is $900, plus airfare/ hotel, etc.). Maybe it was the face to face nature of the exam, and the fear of being judged by such accomplished surgeons. Maybe it was the horror stories I had heard of examiners trying to throw off the examinee by asking impossible questions, yelling, or other antics. I’m not sure why, but I felt very different about this exam. I was anxious, and very myopic. All I could see was myself, and how awful it would be for ME to fail. What if I misunderstand the question? What if my mind goes blank? What if I have to go to the bathroom? What if…what if…what if? Usually, I would be hoping for some challenging questions that would really test my knowledge, and maybe show me areas I needed to work on. But today, I wanted the exam to be easy. I wanted the questions to be no harder than, “what’s the name of that thing in the chest that pumps blood?”

This was a new experience for me. I guess after all the work, and everything I have done to get here, my desire to complete the process made me temporarily selfish. For a moment, patient care, and professional standards meant nothing, and passing was all I could think about. I feared the shame of failing more than I was concerned about the integrity of the board certification process. Fortunately, this was a very temporary feeling, and by the time the test started, I had regained my usual composure, and I actually felt quite calm during the test. When I checked the ABS website for my result two days later, the sentence read: We are pleased to inform you that you successfully passed this examination.

The test seemed quite challenging, but in hindsight, I am glad it was so. It’s very difficult to assess how you are doing on the exam, because the examiners are instructed to give you absolutely no positive feedback. Most everyone leaves the exam room with some doubts even when they have done very well, because of the way the exam is structured. Those two days of waiting for my score were uncomfortable, but it was worth the brief psychological discomfort to know that I have passed a very stringent process to get here and be able to practice surgery. I would hate to think that there are doctors with scalpels in their hands, who had not been thoroughly examined and approved to be safe surgeons. The ABS is actually developing stricter standards to maintain certification in the future, and I applaud these efforts. Even though it may mean a little more work for me, it will maintain and possibly raise standards in the surgical profession, and society will benefit from higher standards overall.

That said, I have to admit that for a moment, I was not on society’s side. I was only on Chad’s side. I wanted the easiest questions possible. I wanted the lowest standards imaginable. I wanted to pass. Fortunately, I did…even though the questions were much harder than naming the organ in the chest that pumps blood.

Yours in passing,
chad

To have striven, to have made the effort, to have been true to certain ideals - this alone is worth the struggle.
~William Osler

Interviews, Inoculations, and Intoxication

2008-09-02T21:52:00.004-04:00

As most of you know, I am getting very close to my departure date (September 30th) for my mission trip to Kenya. A lot has been going on in the last month so I wanted to update everyone on what’s been up as I prepare to go away.

I am still living in Boston, but I had to move from my apartment into a sublet for the month of September. I was very frustrated initially when my landlord told me she would not extend my lease for the last month I would be in Boston, but it ended up being a blessing in disguise. First, the move helped me streamline my belongings down to the essentials for the upcoming trip. Secondly, the sublet I found is a beautiful apartment that is fully furnished and is like living in a 5 star hotel for a month. But the best part about the move was just the confirmation that God takes care of all my needs. At the last minute, several challenges came up that literally brought me to my knees. I’m thankful for those stressors, because they reminded me how much of my life is beyond my control, and even with the best planning, things can go awry. But God sometimes uses a calamity to demonstrate his love, and to help us see some things we might not have otherwise seen. This was an invaluable lesson on the eve of a trip around the globe to be thankful and trust in Him even when things seem like they are spinning out of control.

***

My other painful experience last week was more humorous. I went to the MGH travel clinic to meet with one of my favorite MGH Infectious Disease doctors, Dr. Felsenstein. She proceeded to scare me half to death about all of the terrible diseases in the world. By the end of the consultation, I was ready to go live in a bubble. If that was not bad enough, then came the shots…SIX of them…three in each shoulder. The next day, I could hardly lift my arms (which happened to also be the day of the afore mentioned move out of my apartment…good timing, huh?) They say doctors make the worst patients, but I think I was quite brave. (And I did not even get a lollipop out of the deal!) In hindsight, being a pin cushion was not so bad, and I’m very glad that I have been given the appropriate information and medication to live in a tropical environment.

***

I have been doing more than just hanging out and going to doctors appointments. I have been picking up some moonlighting shifts at MGH on the cardiac surgery and burn services over the last month as well. Every time one of my friends sees me, they say… “I thought you were in Africa, what are you doing in the unit holding pressure on a groin?” The shifts have been somewhat educational, but usually a bit boring, since I am working primarily on nights and weekends when not much is happening. However, my last call was quite exciting: I was covering the burn unit, when I go a page from OR #37. The trauma team was in the middle of a procedure, and they had a trauma victim who had arrested at an outside hospital coming in by medflight in half an hour that needed to go straight to the OR. They did not have to say anything else, because I was in OR #31 with my boots, goggles, and adrenaline pumping within 5 minutes. We ended up doing an exploratory laparotomy and median sternotomy (i.e. a very big incision), which was a very valuable experience. I have opened the chest a few times in trauma patients, but never with a saw, so I was glad I got to put those cardiac surgery skills to some good use. The sight of the beating heart is still amazing to me after all these years. Unfortunately, we were a bit late with our heroic efforts, and although we were able to get him to the ICU, he succumbed to his injuries shortly thereafter. While it is always upsetting to lose a patient, I count these experiences as good ones, because I may have learned the skills needed to save the next guy who gets to us sooner.

***

In addition to moonlighting, I have been on the interview trail for my trauma fellowship ( to begin when I return from Kenya next summer). My interviews have taken me to some pretty cool places, and I have met some really amazing people as well. One of the first individuals I met is a surgeon named Joe Ayers from New York who had just finished his residency, and is spending the next nine months in Uganda before starting his trauma fellowship. We obviously hit it off, since we have nearly identical post-graduate plans. It was very encouraging to meet Joe, because I have had more than a fair share of strange looks and comments from people when I told them what I would be doing after residency. It confirmed to me that volunteering in Africa is a perfect way to use what I have learned, and to continue to learn and grow as a person and as a surgeon.
My top two places of the ones I have visited so far are Miami and Los Angeles. Jackson Memorial Hospital in Miami is a one of a kind county hospital that sees nearly all the Level 1 trauma in South Florida. It is an incredibly busy place and has the largest fellowship in the country. This was my first time in Miami, and I have to admit, I really enjoyed the informal Miami lifestyle. The current fellows all live on South Beach and they took us out on the town the night of the interview. Things don’t start on South Beach until after midnight, and by 4am they were still going strong. I had to go back to my hotel to pack my bags to catch my flight home. Note to self: If I do my fellowship in Miami, DO NOT live on South Beach.
My interview at LA County Hospital was equally compelling. I had déjà vu when I walked up the steps to the hospital, but it’s because the hospital façade has been used on so many movies and television shows, that it seemed familiar even though I had never been there. The best thing about LA is that my twin brother lives there, and I got to visit with him while I was in town interviewing. We had a good time as always. He is a DJ, and he was teaching me how to mix, cut, and scratch. I even got to “spin” a little at a get together he and his roommates were having at their house. It was great trip, but it has made my decision very difficult, and I still have more interviews to go, including my interview here at MGH.

***

In addition, to interviewing for trauma fellowship, I also interviewed for the Durant Fellowship in Refugee Medicine. The fellowship is named after the late Dr. Thomas Durant, a very special Boston physician who spent his career traveling around the world to some of the most unstable places on the planet to take care of people in their time of need. His story is truly an inspiring one, and the fellowship that bears his name supports MGH employees who want to go abroad as health care providers in refugee camps or other resource depleted environments (like rural Kenya). While I do pray that I am awarded the fellowship, I must say that just the process of interviewing was extremely encouraging and uplifting, especially talking to two of Dr. Durant’s sons, Sean and Stephen.

***

Finally, for the last month or so, I have been studying for my board examinations. I took the written exam on August 14…AND I PASSED!!! I have not gotten the official score report, but the American Board of Surgery website says I passed and they are allowing me to sit for my oral examination on September 23rd in Philadelphia, so I will be continuing a pretty rigorous study regimen for the next 3 weeks.
I do want to relate one interesting aside about the written exam. As many of you know I don’t drink…I never have really. When I as a teenager and a college student (when most people drink), I was too scared to touch a drop of alcohol out of fear I would immediately have my life come apart at the seams. (There is a long back story to that.) Anyway, as I have gotten older, my stance on alcohol has softened, but even though in my head, I know one drink is not going to kill me (in fact it may be beneficial), in my heart I have still been harboring those fears. Well after my written board exam, I faced my fears and celebrated the way most of my friends would have after a big test. Of course, I was still a nerd about the whole thing. I approached it like a science experiment, assessing my sobriety every 15 minutes and making mental notes about the effects of each subsequent glass, but one bottle of wine later, the only effect I was feeling was spinning, and not the good kind like on the dance floor…I’m talking about the bad kind of spinning…in your head. I didn’t really get sick or have a hangover the next day, so I count myself fortunate, but I think my days of drinking came and went in one night. Now at least, it’s an informed choice I have made to not drink (instead of a phobia), but I do have my one story (that everyone should have) about the time I got “totally wasted”.

So as I said, it’s been an interesting summer. I have the rest of the month to make final preparations for my trip to Kenya. I will be continuing to moonlight in the hospital, travel for interviews, and study for my oral boards, but come September 30, I will be on a 747 for some real adventure. I can’t wait to tell you all about it.

Yours in anticipation,
chad

"The best way to find yourself is to lose yourself in the service of others."
~Mahatma Gandhi

PS: I have to give credit for this quote to from the email signature of Toni, another very committed missionary I met this last month.

Blisters and Calluses

2008-07-09T22:13:00.009-04:00

I was in Texas this past weekend to visit my family before things get busy this summer with my hectic interview schedule. I got on the airplane this morning to return to Boston, and settled in my seat to study for my upcoming boards. Review books are often boring material, and I was suffering the added nuisance of having trouble turning the pages due to my tender fingers that were covered with several band aids. My fingers had gotten blistered the previous evening after I went to the driving range to hit some golf balls. I don’t play golf very often, but it’s an activity that two of my favorite people enjoy (my father and my uncle), so I found myself hitting golf balls on a hot sticky July evening in Texas...maybe not a well thought-out plan, but it was a good way to spend time with family.

One of the problems with being an infrequent golfer (in addition to losing at least a dozen balls every time you play), is that your fingers don’t have the necessary calluses to handle the substantial friction that is generated by your hands when you swing. As could be expected, several large blisters developed and ruptured on my fingers after we had hit a bucket of balls. (Of course, the remedy to this problem is to play more so that you develop thick hypertrophic skin at those key pressure points needed to grip the club and strike the ball.)

As I sat on the plane examining my fingers, I could not help but think about the upcoming new experiences I will have in Africa. Taking care of patients on the other side of the globe is going to probably be a psychologically abrasive experience initially. The adjustments will be countless: language barriers, culture shock, patients who present later in the course of their disease, limited technological resources, and homesickness…just to name a few. I’m sure my arrival to the hospital is going to expose a lot of soft vulnerable areas in my professional, physical, and emotional exterior that are going to hurt initially as I try to learn how to function in a foreign setting.

But the exciting thing about being in Kenya for such an extended period of time, is that I will be able to recover from that initial shock and adjust. I’m sure the first month will mostly be an educational experience for me, with the young hot shot (i.e. inexperienced) surgeon from Harvard learning “how it’s done” in the rest of the world away from the ivory tower. But hopefully, after that first month, I expect that the learning curve will start to flatten out, and my ability to contribute something to the hospital will climb higher and higher. And those areas of blistering will develop calluses (figuratively) from the persistent friction. I will be stronger and more able to serve my patients as time goes on, just like my father and uncle were able to hit the ball all day long without any pain whatsoever, because they developed their calluses long ago.

While no one looks forward to discomfort, I recognize that pain is a very useful response to the external environment. It alerts the individual to a new stress, and the body can respond appropriately. While it is often my instinct to avoid the stressor all together, I realize that I must suppress that instinct in order to achieve the most that life has to offer…whether it be a lower handicap on the golf course, or an amazing service opportunity in an exotic location. Of course there has to be some blistering along the way, but it’s okay because it only builds toughness in the end.

As I continue to look at my hands on the plane, I was less annoyed. I was thankful for the opportunity to spend some time with my family. I was thankful for the coaching on my swing (I had never hit the ball so straight). And, I was even thankful for the blisters…for the reminder that pain is a necessary step to becoming the man I want to be.

Yours in embracing adversity,
chad

“Do you know what pain is Dr. Wilson? Pain is weakness leaving your body.”
~Dr. Carlos Fernandez-Del Castillo

PS: Things are going well with my preparations to leave for Kenya. The next several weeks will be full of fellowship interviews, studying for the written boards, and some moonlighting to help cover domestic expenses while I’m away.

PPS: Due to requests, I’m posting the video from the change show below.
Return to Martha’s Vineyard: Lamattina’s Last Stand. (If you know John, this video is hilarious…Even if you don’t know him it’s kind of funny.)

Fundraising

2008-06-25T03:05:00.003-04:00

As most of you know, I moved to Africa in September for a mission trip to work in a rural hospital in Kijabe, Kenya. The hospital has just over 200 beds, and I am doing GENERAL surgery while here. To pay for some of the costs associated with the trip (travel, licenses, lodging, etc), I need to raise money for the trip. I am currently waiting to hear about a large source of funding from the Durant Fellowship at MGH. I will find out in November. Pending that decision, I may need to raise additional funds. (The total amount I need is about $11,000) If you would like to make a donation, you can do so one of several ways:

For convenience, I have an electronic account that you can donate to by Paypal or credit card via the internet. Just click the “donate” button on the header at the top of the page.

If you are making a more substantial donation and would like a receipt for tax purposes, I recommend that you make the donation directly to the World Medical Mission at Samaritan’s Purse. To do so, you can make a donation by sending in a check or by phone via credit card.

For checks: Make them payable to Samaritan’s Purse. Write “Dr. Wilson” and the project acct number (003494) on the memo line. Then mail it to the address below.

Samaritan's Purse
PO Box 3000
Boone, NC 28607
Attn: Ms. Linda Herman

Alternatively you can call Linda Herman at (828) 278-1168 and make a donation by credit card.

Thanks in advance for your support.
chad

Kijabe Hospital

The Close of a Chapter...

2008-06-24T23:48:00.008-04:00

A chapter of my life has come to a close today. On Friday, the department of surgery at my hospital had a small ceremony to mark the graduation of the senior residents before they head off in their different professional directions. I look forward to this event every year, as it is generally a very festive celebration and highly entertaining party with the residents doing their best to put on a good show.

But this year was most special, because I was one of the eight graduates being honored. As always, it was fun and filled with laughs, hugs, and congratulations. And while the excitement of graduating and seeing all of my colleagues there to support me was thrilling, a part of me was disheartened about leaving an institution that had grown to become part of me.

After all the funny skits, it was time for us to take our place at the front of that room that we had all given countless case presentations in. This time, we spoke about ourselves instead of about a patient. One by one, my classmates walked up, and they all made the most earnest and heartfelt remarks about their time as surgical residents. If you are not a surgeon, this sounds like what you would expect at a graduation ceremony. However, one rarely finds surgical residents not armed with sarcasm and wit, but the occasion proved too moving to allow even the most disaffected of graduates to escape the stage without at least some honest emotion breaking through.

Since my last name starts with a “W”, I am often last in these types of ceremonies, which was good, because I had not really gathered my thoughts about what I would say. Normally, this would cause me great anxiety since I am not a natural public speaker. But for some reason, time seemed to slow down as I listened to my classmates, and my mind became clearer and calmer than it had been all night.

I began to reflect on the last seven years of training. I thought back to when I interviewed for surgical residency. I told the chairman that I wanted to be a resident in a premier surgical department. I wanted my training to be second to none. I wanted the institution to make me the best surgeon possible. But in addition to my expectations of the residency, I expressed my desire to make sure that I gave something back to the residency as well. I wanted to leave the institution better for having trained me.

Well the residency certainly did its part and allowed me to learn the things needed to begin a solid career as a surgeon, but I had not really considered what would be my legacy to the hospital. I don’t think my surgical knowledge, clinical judgment, or technical skill had been particular exceptional. If anything, I think I was about average in these areas. Now, I would never admit to being an average surgeon in a room full of my peers, because that is not consistent with our culture. All eight of the surgical graduates pronounce themselves to be outstanding, and despite the mathematical improbability, we all rate our clinical skills to be at least one or two standard deviations above the mean. But for now, I will make a sober assessment of myself, and say that I am neither the best nor the worst graduate to finish the program.

So what did I bring to the MGH? I have won no national awards. I did not develop any new surgical techniques or clinical insights. My research was interesting to me, and I published a modest number of papers, but I don’t think my scientific career would distinguish me as exceptional. Despite the self-deprecating litany above, I actually feel very proud of my time here. I am proud, because I came to work faithfully for seven years, and I did “surgery” the best way I knew how. Don’t get me wrong, I had lazy moments, I had frustrated moments, and I had cynical moments, but through it all, I tried to hold onto my idealism about being a physician, and I gave it my all…most days.

In the final analysis, what I gave to the residency was me. I gave it my twenties. I gave it time with my family. I gave it weddings, funerals, and graduations of my loved ones. I gave it blood. I gave it sweat. And yes, I gave it tears. I worked when I was healthy and upbeat. I worked when I was sick and depressed. I worked when I was refreshed, and I worked when I was exhausted. I operated when it was a pleasure, and I operated when it was torture. I took care of patients who were kind, respectful, and appreciative. I took care of people who were violent, mean, and unlovable. I gave it everything within me, and it hurt me sometimes. The residency caused pain in my body. It played tricks with my mind. And more than once it broke my heart and nearly broke my spirit.

Now I would be bitter if I had given all of that, and all I had become was an average surgeon, but the balance sheet is not complete. Because my seven years gave me some things I never would have expected. It gave me friends too numerous to count. It gave me more than a dozen surrogate mothers who “looked after me” while I was here. It taught me that endurance is more important than speed and strength. It taught me that service is the highest calling. It confirmed my faith that flawed people are capable of showing flawless character. It gave me an appreciation for my own health. It made me a professional. It made me a man. It gave me the exhilaration of saving someone’s life. It gave me the sobriety of watching someone die. It gave my mind focus. It gave my hands power. It gave my heart fortitude. And it gave my life meaning…

Sure enough, my time came to stand before the crowded amphitheater and express my final thoughts. I cannot remember exactly what I said. I do remember that I told the people in the audience that to me, they were family, and that I would miss them. I did not have the words then and really don’t have the words now to say exactly what this place has meant to me. It has shaped me in ways I never would have guessed, and I walk away with no regrets. I will never forget what I have learned in the last seven years.

Although we all had different ways of expressing it, the words of the graduating senior residents all had one thing in common: A deep respect for the process of training a surgeon and a fondness for the institution that had trained us. I hope the new interns who were in the audience that night remember our words. They have some tough days and long nights ahead for the chapter is just starting for them as it closes for us.

Turning the page,
chad

I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least part of the work.
~Harvey Cushing

Love, Sacrifice, and the Pursuit of Happiness

2008-03-16T19:47:00.006-04:00

Note of introduction: For those of you who do not know, I am completing my surgical residency this summer, and plan to go to Africa for 9 months to work as a surgeon in a missionary hospital in Kijabe, Kenya. This is the first of many posts/notes that I will be making to document my experience. This is primarily a way for me to communicate with family, friends, financial supporters, and anyone else who might be interested in my trip abroad.

Today, while washing my hands at the scrub sink outside the operating room, I remembered why I became a surgeon. One of my colleagues came along side me to wash her hands and started a polite conversation. The brief discussion wandered into current events, and she recalled my interest in going to Kenya next year as a medical missionary, and she asked me if the recent civil unrest there after the disputed election in December had changed my mind about going. At first, I tried to assure her that things seemed to be calming down since those first few violent weeks, but she insisted that it would be foolish to plan a trip there at this time. She expressed her opinion that ethnic animosities in African nations make law and order impossible, and that I should not risk all the hard work that I have invested in training myself to be a surgeon, just to go to some violent part of the world, and risk injury to myself. I paused for a moment as she cautioned me, and I finally replied:

“It is true that some harm may come to me in a country on the brink of civil war, but the people who need medical care there cannot afford for me to wait until it’s convenient to serve them.”

The reason I’m in medicine…is to serve. Not to serve only when it is safe and convenient, but to serve those in need even when there is a cost to me. Do not get me wrong. I do not have a death wish. I would like to enjoy peace, safety, and prosperity, but sometimes we have to accept less than ideal circumstances to serve where the need is great. I’m not endorsing that one walk into the midst of trouble without considering the dangers involved, but we must be willing to face some adversity to do anything worthwhile.

Real service requires sacrifice…and my secure surroundings may need to be compromised in order to serve the most needy people. While on the surface, it may seem that just being a surgeon is a noble and service-oriented profession, and that one does not need to go overseas to serve, but the question of true service is measured by sacrifice and motivation. It is not sacrificial for me to work in a prosperous surgical practice, when my fundamental motivation is financial gain. I would be primarily serving myself (especially, since I don’t have any financial dependents.) I’m not discounting all private practice surgeons as being self-serving individuals. A private practice surgeon can still make his primary motivation to care for the sick, while earning an honest living to support himself and loved ones and doing something he enjoys. But for me, it is clear that I have a unique opportunity to serve, and that the greatest good I can do with my skills at this point in my life is to serve an underserved population that might not have access to any surgical care if volunteers are not willing to forsake more lucrative and comfortable practice settings.

So I was able to answer my colleague confidently. “Yes, I still want to go to Kenya this year.” I remembered why I have endured all of these long hours and sleepless nights. I did not come this far to serve myself, but to serve others. Of course, I would like to have some degree of financial and personal security, but if some increased risk of violence to my person is necessary to make the situation better for the hundreds of thousands who have been recently displaced by this unrest, than how can I turn a blind eye to their needs. Additionally, I have faith that God would not let my service be in vain. My fundamental belief about the world is that every act of kindness, love, or goodwill (no matter how small) makes the world a better place, and that every act of selfishness, fear, and hate (no matter how small) makes the world a little more hostile and broken. I want my life to be one that is marked by service, and not fear or selfishness. I believe that my service will be a seed that will yield a real harvest of goodwill and positive change. Do not think I am naïve. I understand that I may suffer in the process, but I have faith that God will provide me with what I need to endure any suffering no matter how great.

***

My colleague described Africa and Africans as they and them, but she described the US and Americans as we and us. She rationalized that we were somehow different from Africans and did not deserve to share in their suffering (unless it could be done conveniently and comfortably in a controlled-manner). But what must become clear is that Africa is we, and that in these modern times, the world is a single global community. If Africa hurts, America will eventually hurt too. But if Africa is healed, America and Americans will benefit. Think of all the creativity and intelligence that is wasted in parts of the world where poverty, underemployment, and illiteracy are so stifling that one is relieved to merely survive the day.

It’s not just the moral thing to serve those in need, but it is prudent as well. If the problems of the world’s poor and oppressed people are ignored or hidden, then the poor and oppressed will become bitter, and bitterness will turn to hate, and hate eventually spills over to the rest of the world. And hatred in someone with nothing to lose is a dangerous thing. (As an aside, Western media is controlled almost exclusively by business interest that want to obscure the worlds problems from our consciousness so that we will continue to be dutiful consumers of things we do not need, but this is a topic for another day.) On the other hand, if the poorest most oppressed individuals are given hope (for instance: opportunity for education, means to achieve financial advancement, political and civil liberty, and in my case access to quality health care), then that seed of hope will inspire more self-realization and social stability/growth. And while I don’t expect that I can save all of Africa by taking care of a few sick individuals, I do believe in the power that a little kindness can have in the world. Love can create a domino effect. Perhaps I will inspire one of my friends to dedicate his life to serving others, and he will inspire another, and another… Or perhaps, some child that I treat in Kenya will remember the dedicated surgeon who treated him, and he may dedicate his life to easing suffering instead of inflicting it. My faith makes me believe that any one person’s selfless act can make a difference and interrupt the cycle of human suffering that often seems inevitable and insurmountable.

***

To whom much is given, much is required. I have been given much. I have been given health, a sharp mind, education, and medical training, just to name a few of my blessings. Now is the time in my life to serve those who have been given less. I understand that some sacrifice may be necessary, but when I consider what an opportunity to heal broken bodies and spirits that this will be, I can’t help but get excited about going away. And this leads me to my last point.

A friend of mine thought that the reason I was going to Africa was guilt. He thought I was being compelled by some religious conviction to respond to the poverty in Africa, and prodded by the guilt and shame of my middle class lifestyle. But there is no reluctance in my heart to go. I am going, because I think this is what is going to make me happy. I know there may be trials, but I also know the joy that comes when I serve others. While I obviously enjoy the thrills of life (like a vacation getaway to the mountains), I don’t know of anything that provides more lasting happiness than loving others. I believe that we were designed to love and serve other people. We all know that loving and serving brings joy to marriage, parenthood, and family life. But it also brings happiness to our professional life and to our civic life. The happiest most fulfilled people in the world are those that find ways to serve others in every facet of their life. Likewise, it is difficult to truly be happy if someone is spending a large portion of his time doing something that serves no one, and a sure recipe for misery is to spend all of one’s time serving oneself.

The American Declaration of Independence states that one of our inalienable rights is the “pursuit of happiness”. And while everyone is free to pursue happiness in the way that they see fit, many Americans have found themselves pursuing status, wealth, fame and power as an end. In my opinion, these things can’t make anyone happy. They are not an end, but a means to achieve happiness. They can only make one happy if he recognizes that wealth and power are resources that can allow one to love and serve other people more effectively. Wealthy people can be pitiful and miserly folks, but those rich individuals who realize that their wealth allows them to employ thousands, influence civic and political process (for good), and give away millions to worthy causes are able to avoid the pitfalls of self-indulgence. Wealthy philanthropists are some of the happiest people in the world. It’s not what they have that makes them happy, but what they are able to do with it.

The word “philanthropy” comes from the Greek words phila and anthropos which literally means “to love - human beings”. Whether you call it the “Golden Rule” (do unto others as you would have them do to you) or the Mosaic Commandment to love your neighbor as yourself, philanthropy is not a religious requirement to avoid damnation…It is a guideline to pursue and attain happiness. I am pursuing happiness as I embark on this trip to Kenya. I have not been coerced or pressured by guilt. I believe that there will be sacrifice required, but it will be a small price to pay for the fulfillment of living a life of purpose.

Sadly, some of my friends and colleagues have been very critical of this decision. They cannot see why someone who is just about to realize a major leap in his pay scale after so many years of training would delay those financial rewards. Further more, they shake their heads and lament why I would put myself at risk by going abroad for 9 months to a country struggling to maintain order. I shake my head too…knowing that they may never be able to pursue the happiness that is found in service, because they are too busy pursuing the American dream (or nightmare) that has been sold to them in our consumer media. They may continue to chase “happiness” and occasionally experience a thrill, but I don’t think they will ever attain happiness until they find a purpose in their life that is focused on “loving human beings”, whether it be their children, family and friends, their community, or strangers in a far-off land.

Serving the people of Kenya is a pursuit that I believe will help me attain happiness. I hope I can continue to grow in my dedication to love my neighbor as myself. Moreover, I hope that my trip is an inspiration to others to find new ways to love their neighbors as well. I believe that faith leads to more faith, that hope leads to more hope…that love leads to more love…and that all three lead to happiness.

Yours in the pursuit of happiness,

chad

Love is the master key that opens the gates of happiness.

~Oliver Wendell Holmes

Hypnotized

2007-03-05T10:25:00.000-05:00

I had a conversation yesterday morning that was so amazing that I had to share it. Perhaps amazement is not the correct term, but rather disturbing at how unaware Americans remain about the world around us.

The setting of this conversation was a Sunday morning drive to church in a full sized sports utility vehicle (SUV). The owner of the car remarked about some recent models of cars she had seen, at which time the other front seat passenger asked what type of car she would be getting next (even though the current SUV is running quite well and is at most 4 years old). She remarked that she wanted a BIGGER SUV. I was mostly disinterested in the conversation until I heard this comment, and could not resist the temptation to ask: "Do you feel any moral impediment to buying a bigger vehicle given the problems of global warming and American oil addiction when you don't even need the space you have in your current SUV?" This was followed by a long pause, which I assumed she was using to formulate her argument as to why she still wanted a bigger SUV. I thought she would question the association of automobile carbon emissions and global warming or talk about personal safety issues given the increased risk of injury when colliding with other large SUVs, but instead I was totally shocked to hear her just reply "no", and that she wanted a bigger SUV, because they seemed more comfortable and "roomy". I asked did she believe that her choice of car had any ramifications on the environment or the geopolitical landscape, and again a long pause was followed by, "I never considered it."

I just sat dumbfounded, that in the year 2007, after everything we have seen with American oil dependence, conflicts in the Middle East, global warming, Hurricane Katrina and the unstable gas prices that followed, that an American could still be making a consumer decision about purchasing a vehicle with absolutely no thought about the impact that decision was having on the world at large. I tried to tell myself that this individual was an aberration, but as I surveyed the church parking lot we were pulling into, I saw that at least half the cars were SUVs, and of the hundreds of cars I saw, maybe two or three could have been classified as fuel efficient.

My heart just sank as I realized how misinformed or uniformed the typical American still remains in 2007. Here I was thinking that the problem of getting Americans to consume less fossil fuel in our gas tanks had to do with the government tax structures that makes buying an SUV affordable, and the infrastructure and city planning that makes 20 mile commutes the norm, and the aggressive marketing techniques of automobile manufactures to create consumer desire for the behemoth vehicles. But in reality, the problem is much worse than that. In fact, what makes Americans uniquely American, is our ability to remain so profoundly ignorant about the world we live in. I mean, this person I talked to has a college degree, uses a computer on a daily basis, and has traveled out of the country a dozen times on vacation, but her mind is so totally captivated by the consumer oriented mass media that she only has a vague sense of the problems of global warming, the conflict in Iraq, or persistent famine and disease in 3rd world countries. However, she could tell you exactly what is at stake with the paternity of the Anna Nicole Smith's baby, and all of the facts associated with this "news story". She has a strong opinion about the superiority of behemoth SUV manufacturer #1 versus #2, even though that opinion is not shaped by any objective evidence, but just the marketing messages that have totally saturated her brain. I can't understand how someone of any reasonable intellect can live in the same world as me, and remain barely superficially aware of the problems facing the world today that threaten to change the very fabric of our society, but have a well thought out prediction of who will be this year's American Idol.

It disgusts me so much, and I have no idea how to wake America up. I don't mean to imply that we are uniformly stupid. A small part of our population is truly informed, but the bulk of our country remains self-absorbed, ignorant, and in my opinion totally hypnotized by mass media. They are told what to think (or not to think at all) and they do. However they have been conditioned to passionately defend their right to consume. If you place luxury taxes on gas-guzzling cars they protest. They have been programmed to believe that the American dream is a 3000 square foot home on a 1.5 acre lot in a gated community 30 miles from their place of employment. They will fight for the chance to own and pay the energy bill to air condition 3 times the amount of cubic feet that a family of four needs. They will cry that their civil liberty is being violated if they cannot water that 1.5 acre lawn daily. They will charge disenfranchisement if they are not allowed to select a lifestyle that consumes 5 times the ecological resources that a typical family of four in Europe consumes. They don't have time to consider the impact of their daily consumer decisions, because they are too busy consuming as much as they possibly can.

We associate capitalism with democracy, and the freedom to vote our elected officials into office is very important in any healthy democracy, but we also "vote" with our dollars. We endorse global warming when we buy fuel inefficient cars. We endorse sweat shops when we buy certain brands of sneakers. We endorse bloodshed in Africa when we buy diamond jewelry (there is no such thing as a "moral" fair trade diamond, but we can discuss that at some other time). We endorse deforestation, urban sprawl, totalitarian political regimes, civil injustice, and oppression with our daily consumer decisions. Our choice of what to wear, where to live, and how to get back and forth from the holy consumer tabernacle...the mall...does affect the world at large and it only takes a few minutes to just actually notice what's in the news beyond Brittany's shaved head to put it all together.

You don't have to be in Mensa to appreciate the connections between the things we buy and the dilemmas that face our nation...you just have to be awake. Unfortunately, the advertising executives and media moguls of our consumer American culture are experts in hypnosis. They have placed America into a trance with millions of us walking around (actually driving around) like zombies...back and forth to work, to make more money, to buy more stuff to put in our bigger house that is further away from where we go everyday...and what is crazy is these things don't even make us happy. We just end up living in debt...slaves to our desire to consume, when the things that would make us happy and feel more alive are actually more affordable: Spending less money on status symbols, and more on education, cultural and artistic experiences, charitable donations, and travel (only 40% of Americans even have passports). Working less and spending less time commuting to work which allows more time with our loved ones to do things that enrich our lives. Walking or biking to work to get some actual exercise. Enjoying the richness of nature (an afternoon mountain hike or evening walk along the beach is a much better date than paying $10 to sit next to the object of you affection in a dark theater, watch an unremarkable movie, eat a $5 box of milk duds, and drink a $6 super-sized beverage.)

It's all so simple really, but my fellow Americans are so perfectly hypnotized that they cannot see it. When you talk to most Americans about the environmental, social, and political sequelae of their consumer decisions, they get angry at you. They sense that you are trying to encroach on their right to have the "American dream"... big cars in a 3 car garage next to big house filled with expensive stuff. They are so well programmed to believe that status symbols will make them happy, that they will become irate at your suggestion that they should modify their consumer behavior in any way. It's like all they can see and think about are the things they don't have and how much those things are going to enhance their empty lives.
I wish I could just snap my fingers to end the trance, but it's not that easy. Marketers are clever, and they have worked tirelessly since World War II to develop our consumer culture to create the most ravenous society in history, and it's going to take major deprogramming to affect any change. But every person who is awake and aware is needed to help figuratively (maybe even literally) throw water in the face of our hypnotized brothers and sisters to help them snap out of it and see the way things really are around them. It can be done. I know because I was one of them.

Yours in wakefulness,
chad

"Any ad consciously attended to is comical. Ads are not meant for conscious consumption. They are intended as subliminal pills for the subconscious in order to exercise a hypnotic spell"
~Marshall McLuhan

Ready To Die

2006-11-13T21:11:00.000-05:00

FAVELA: (Fa-vel-a) – in Brazil, an urban slum or ghetto; illegal squatter settlement.

Little known fact:
From 1987 to 2001, 467 minors died as a result of violence in Israel and Palestine. During the same time period 3937 minors were murdered in a single city on the other side of the world. That city is Rio de Janeiro, and unlike Israel, Brazil’s reign of violence and chaos has received little attention. Of course, when the conflict in the Middle East escalates, gas prices become unstable, and the victims are often middle class, educated whites. American media outlets take less interest in the poor, under-educated, mostly black victims of violence in Brazil, and these deaths never seem to have a direct effect on the American economy or way of life.
The conflict in Rio has taken place in the streets of the favelas (or ghettos) mostly as a result of drug trafficking and semi-organized crime. A corrupt and under-paid police force traffics both drugs and guns into the cities worst areas, and then they sit back and referee as the rival drug cartels battle one another for supremacy in the favelas. The drug lords and their small armies of teenaged gangsters have made the streets into a war zone, but as long as the only victims are drug dealers and other people from the favela, no one really cares. Of course when the violence spills over into the mainstream population (which not only threatens Rio’s middle class citizens, but also hurts their huge tourism industry), the police respond by imposing marshal law in the favelas and indiscriminately assaulting and murdering any one in their path, often children and women included. Conditions in the favelas are so desperate and hopeless, that drugs seem like the only escape, and the youth of the favela have few role models or organizations to identify with other than a corrupt and brutal police force and the drug cartels. It’s no wonder, that so many of the boys in the favelas are hoodlums before they are 12 years old, trying to prove themselves worthy of becoming a drug dealer.

Amidst all this suffering and chaos comes a very inspiring story about some young citizens of the favelas that decide they had seen enough drugs, violence, and police brutality. Describing themselves as “warriors for peace”, these young people are using non-violent demonstration mostly through music, dance, and other performing arts to show the youth of the favelas that there is an alternative to joining the drug cartels. The movie Favela Rising is a documentary that follows the “AfroReggae” movement and its impact on the Vigário Geral favela, one of Rio de Janeiro’s worst slums. The film makers tell most of the story from the perspective of one of AfroReggae’s biggest heroes, Anderson Sa, a young man who was fast on his way to becoming a drug dealer when he crossed paths with the then fledgling organiazation known as Grupo Cultural AfroReggae. The group had recently been started by a local DJ and resident of Anderson’s favela named Jose Junior after a terrible act of police brutality in Vigário Geral left the favela at the brink of cultural collapse. Citing the “Shiva Effect”, that out of chaos new life can be born, Grupo Cultural AfroReggae seized the moment and began using the one thing they understood, music, to recruit youth away from the suffering of the drug trade. They formed a music group called Banda AfroReggae that focused on drumming but also fused reggae, hip-hop, and the Brazilian genres of samba, carioca, funk, and axé, and primarily performed free concerts in the favelas. Shortly thereafter, Grupo Cultural AfroReggae started a newsletter that focused on music, but also talked about the social conditions in the favelas as well. I don’t want to give away the entire storyline of the movie, but needless to say, what started out as a handful of young men with no money, no resources, and no idea how to fight violence, has blossomed into a full fledged NGO with both intrinsic support from world tours and CD sales as well as extrinsic financial support from several private sector foundations and the Brazilian government. I HIGHLY recommend you rent/buy Favela Rising. It’s one of the most inspiring things I have seen in a long while.

***

After watching the movie, I have two brief commentaries to make.

First, I could not help but reflect on how powerful the medium of music is. Much of the music that Banda AfroReggae performs is political and social commentary told lyrically through the very fitting musical vehicle of rap and hip-hop. As I listened to these young men perform songs that express their experience of ghetto life as well as inspire young people to avoid the pitfalls of poverty, I was provoked to both awe and frustration. I’m awed by how influential their music is and what it has done for their community, but frustrated by what has become of American hip-hop, which by in large seems to have sold out for fame and money. Perhaps, I’m being hard on the American artists. It’s really what the radio stations promote, and who the record labels choose to invest in that dictates what becomes “popular” music. And record labels and radio station are in business to make money. Hip-hop went from being a genre of music to a culture, and as the dominant youth culture it has a tremendous effect on the consumer choices that American youth make. Twenty years ago, when Def Jam was just signing Public Enemy, hip-hop had a relatively small audience, and the artists who were socially conscious where some of the most popular in business. Today Def Jam is run by Sean Carter (aka Jay-Z), who is perhaps the quintessential commercial rapper. While his talent is undeniable, his songs and music videos often sound like a rapid fire product placement campaign, and last week I saw that he kicked off his “unretirement” album release with a new Budweiser commercial…afterall, it is the king of beers.
As I shake my head in disgust, I say to myself, how can we form a grassroots movement here in the US to help our youth to realize their potential. We have more financial resources for community programs than Brazil, so why can’t we see the value of captivating the hearts and minds of America’s youth by promoting artists that inspire kids to invest in themselves…not in consumer products. The sad fact is that this is a capitalistic society where sustaining consumerism is more important than sustaining civility, and many people benefit by keeping America’s youth ignorant and uninspired, as long as they remain good consumers of things they do not really need. The sad fact is many of these artists are endorsing consumerism and products for free. They don’t even realize they are being used. (In 50-Cent’s P.I.M.P. video, the opening scene features 50 scrolling through his Ipod for a song…probably an endorsement that he was not paid very much for, if at all. Makes you wonder exactly who is being pimped) So instead of having artist use their influence for social advancement, they use it to convince us all that we need jewelry, rims, champagne, trendy clothes, and sneakers. But hip-hop still has its edge, and if we attain all those things necessary to keep it real, we still must be ready to kill or die if someone disrespects us and steps on our sneakers.

Which brings me to my second comment. Hip-hop artists often claim that they are prepared to die. Both Tupac and the Notorious B.I.G. are good examples of artists whose lives were intertwined with violence, but both stated that they were psychologically prepared to die. (Biggie’s first album was entitled Ready to Die.) The question is this: Ready to die for what? When watching Favela Rising, it becomes clear that the young people who stand up to drug dealers and the police on behalf of the community are placing themselves in harms way to be positive role models in their community, and it is clear that they are “ready to die”. But this is the ultimate act of love for your community, to risk your own money, time, and even your life to see things change for the better for your neighbors. On the contrary, our American hip-hop culture is training a generation to be prepared to suffer for no other reason than to “keep it real”. Instead of acts of love, hip-hop culture promotes acts of avarice. Young boys in Brazil are learning to measure themselves by social conscientiousness, responsibility, and artistic creativity. Meanwhile, our young boys are measuring themselves in don’t-give-a-fuck-ditude, irresponsibility, and all creativity is buried in the desire to achieve the carbon-copy image of urban success (i.e. does your chain hang low?).

I was so totally inspired by this film to see what happens when just a minority of individuals stands up for their beliefs. Instead of being ready to die on the streets selling drugs, these Brazilian “warriors for peace” are ready to die on the streets offering the gift of life and freedom from psychological enslavement. Even though conditions and circumstances seem impossibly desperate, they stood up and continue to stand for an ideal of peace and community that one day the favela can be a place where people want to live. They are ready to go to the grave, because they realize that the cause is bigger than their lives.

Maybe we in America could be as commited to an ideal as Grupo Cultural AfroReggae. Tupac said he was committed to thug-life to the grave, but was the “ideal” of thug life anything worth dying for. I fear that Tupac and many of America’s youth suffer from a misguided idealism that has caused them to strive for the very thing that keeps them enslaved mentally. Carter G. Woodson summed it up so eloquently in his book The Mis-Education of the Negro:

"If you control a man's thinking you do not have to worry about his action. When you determine what a man shall think you do not have to concern yourself about what he will do. If you make a person feel that he/she is inferior, you do not have to compel him/her to accept an inferior status, he/she will seek for it. If you make a person think he/she is a justly outcast, you do not have to order that person to the back door, that person will go without being told, and if there is no back door, the very nature of that person will demand one."

Many American youth today are demanding a back door. Their thinking is controlled and their imagination is held captive by forces that seek to keep them mentally imprisoned. They are perfect and predictable consumers who are ready to die to maintain their self-imposed slavery. They are ready to kill too, but there is no need to worry, because they will be too busy trying to kill each other…to ever stop to direct their violent tendencies toward their oppressor.

But Grupo Cultural AfroReggae shows that it does not have to be this way…A handful of young people were ready to die to make the favela a better place to live, and they have changed the course of history in Brazil. In the midst of chaos, the Shiva effect was witnessed as their movement rose out of death and destruction to form something new and beautiful like a phoenix rising from the ashes of the flame. Maybe there are a handful of young people here in America who are ready to die to see their “favela” rise too.

Your brother in life and death,
chad

“To be ready to die, we have to be ready to live—to live with such care, humility, passion and fearlessness that the future disappears in the fullness of the eternal present. Only then will the precious time we have in this human form be able to make a real difference in this world.”
~Andrew Cohen

Deciding To Be Evil

2006-10-29T12:25:00.000-05:00

The Intellectual Insurgent recently posted on the topic of evil personality disorders. The Insurgent says that evil is the opposite of life, and she maintains that some people are inherently evil. This is an excerpt from her post.

"People Of The Lie", by Christian psychiatrist Scott Peck, is the beginning point for a real discussion about evil. In this thought-provoking work, Peck approached the concept of evil from a psychiatric perspective -- evil is the opposite of life (as evil is live spelled backwards), i.e. it is anything that has its purpose to distort reality.

The symptoms of an evil personality disorder are
consistent destructive scapegoating behavior, which may often be quite subtle.excessive, albeit covert, intolerance to criticism and other forms of narcissistic injury.pronounced concern with one's public image and self-image of respectability, contributing to a a stability of lifestyle but also to a pretentiousness and denial of hateful feelings or vengeful motives.intellectual deviousness, with an increased likelihood of disturbance of thinking in times of stress. People who suffer from this disorder are people of the lie. Who they are, how they are weaved seamlessly into our society without notice and the destructive nature of their disorder is illuminated through several case studies in the book. They are people who are so narcissistic that they would rather distort reality, kill, lie and cheat than ever admit their own imperfection.

Are they people beyond redemption?

Applying Peck's definition and my own observations in life, I remain of the belief that there are people of the lie who are beyond redemption absent some drastic remedy such as a lobotomy or suffering brain damage.

I would alter the notion that evil is the opposite of life. I think evil is the opposite of love, and when I use the term love, I’m talking about love in the agape sense. (One of the first things you learn when studying the Bible, is that modern versions of the New Testament translate 3 different Greek words with the word “love”: eros- romantic love; philia- familial, pleutonic, or brotherly love; and agape- unconditional or selfless love.) Agape is the love that would provoke a stranger to jump into a lake to save a drowning child.

Any act of agape love is done with out any expectation to receive anything in return. Any one who has ever suffered for another person or put themselves at risk with no expectation to benefit personally, but only to help another person is expressing agape love. It’s why we respect firefighters so much (even though their motivation may not be selfless, but for career advancement or personal glory). When a young lawyer asked Jesus about the commandment to “love thy neighbor”, Jesus told him the parable of the Good Samaritan to demonstrate what agape love looked like (Recall from the parable that a couple of “religious” persons rode by and ignored the traveler who had been ambushed and left for dead by bandits on the side of the Jericho road, but it was the “secular” Samaritan who got off his ass and helped the injured man.) Many of the greatest acts of love in history have been by people like Mother Theresa, Martin Luther King, Jr, and Gandhi, but most acts of agape love do not earn fame or recognition. Agape is the definition of “good”, and thus in my mind is the antithesis of evil.

An evil act is motivated by selfishness. (Sadistic behavior is evil, because the sadist seeks to serve his desire to see physical suffering, but even the masochist’s behavior is often evil, because he is serving his own desire to suffer pain.) The greatest acts of evil in history can be traced back to rudimentary selfish motivations such as fear, greed, lust, and jealousy. (e.g. the Holocaust, the Middle Passage Slave Trade, and the Rwandan genocide).

***

The distinction that I would like to make about love and evil is that these words describe behavior or human acts. One has to decide to do something that is an act of love versus and act of evil. Insurgent, you describe some people as having evil personality disorders which makes them inherently evil. I disagree with this notion. I don’t think anyone can be inherently evil. I recognize that people have personality disorders, but a person’s personality is the result of their genetic make-up and their life experiences (mostly their childhood experiences). We do not choose our personalities, but our personalities are simple traits of our person like being tall, short, or handsome.

Therefore the person who has an anti-social narcissistic personality disorder will have a predilection to evil behavior, but they still have to make decisions whether to gratify their desire to behave in an evil manner. Psychiatrists have proposed that these individuals cannot distinguish right from wrong. This is actually untrue. These people will claim to not recognize that their behavior is evil, but it’s their narcissism that does not want to admit fault. In actuality, even disordered persons are capable of distinguishing loving behavior from evil behavior, and can choose to behave lovingly, and some of the most disordered sociopaths have made decisions to no longer gratify their evil desires, but to do good instead. What separates the disordered individual from most people is that for them, a simple act of love such as offering a greeting to a person and wishing them a nice day is contrary to their selfish desires and takes tremendous effort. For most of us, that type of behavior come naturally. I recognize that a person with an antisocial personality disorder is potentially very dangerous, and once diagnosed should probably be monitored more closely in society than the average person, but to say that they are inherently evil is an unfair judgment.

We all have some proclivity for evil behavior. No matter how we are “wired” (personality), our character is determined by how we choose to act. I may have learned to tell lies easily to avoid problems as a child, but I can still decide to be honest despite my prodigious ability to tell mistruths. My honest character or dishonest character is determined by my choices to tell the truth, and not by how easily it is for me to do so. I think a person who has a charitable personality, but chooses to be self-serving is more evil than the person who has an anti-social personality, but decides to do their best to “love his neighbor”. The designation of evil should be assigned to someone’s behavior or their character. I fundamentally think this is how we all will be judged. I have often said that I believe that God “grades on a curve” and recognizes that not everyone is equally equipped to behave in a loving manner versus a evil manner. That is why we are admonished not to judge one another, because it is impossible to know what set of circumstances that any act took place in. You may have caught someone stealing, but perhaps he has a thief’s personality and upbringing, but he has decided only to steal for people who have no food to eat. “Thou shall not steal” is a commandment, but it is relative. This is why Jesus said that the two most important commandments are “to love God and then to love your neighbor as yourself”. These are the only two absolute commandments. All of the other commandments are relative and based on the first two commandments. For instance, “thou shall not kill”, but if homicide is required to protect the innocent and defenseless, then killing might actually be an act of love (i.e waging war against Nazi Germany). The New Covenant established by Jesus is based on love and not on commandments. The commandments were suppose to be guidelines, but they were impossible for anyone to keep. Instead, the Christian commission is to love our neighbors, to grow in faith more and more, that one might be able to love more and more selflessly…true agape love.

So I cannot agree with the notion that anyone is inherently (or hard-wired to be) evil. I think no matter what our personalities predisposes us to do, we still decide whether to follow those predispositions. What makes us human is our ability to choose what we will be.

Your sometimes loving, but sometimes evil brother,
chad

“For, were it not good that evil things should also exist, the omnipotent God would almost certainly not allow evil to be, since beyond doubt it is just as easy for Him not to allow what He does not will, as for Him to do what He will.”
~Saint Augustine

Man's Search for Meaning

2006-02-19T01:42:00.000-05:00

I was checking out a friend’s blog today, when I noticed some interesting posts regarding self-actualization and Maslow’s hierarchy.

For those unfamiliar with this behavioral model, in the 1950’s, Abraham Maslow synthesized a large amount of motivational data from animals and humans into this hierarchy of human needs (Figure). He postulated that a person would only seek to meet the “higher needs” if their “lower needs” were met (i.e. you would not be concerned about gaining esteem from your peers if you were starving to death). At the top of the pyramid, Maslow placed self-actualization which he defined as: to find self-fulfillment and realize one's potential. (He later went on to subdivide self-actualization into 4 different levels: cognitive needs, aesthetic needs, self-actualization, and self-transcendence). Maslow stated that self-actualized individuals were characterized by: 1) being problem-focused; 2) incorporating an ongoing freshness of appreciation of life; 3) a concern about personal growth; and 4) the ability to have peak experiences. Some of the people Maslow considered as self-actualized included Abraham Lincoln, Thomas Jefferson, Albert Einstein, and Eleanor Roosevelt.

The following is a comment I wanted to leave on my friend’s blog that got a bit lengthy. I’m sure more intelligent and well-trained people have commented on Maslow’s model, but this is my take on it:

I remember learning about Malsow's pyramid in freshman psychology back in college. At the time, I took his model to be useful in understanding human behavior, but now that I am thinking more critically about human behavior, I have to say that I think Maslow's model misses the mark of describing human behavior at the top of the pyramid.

I really don't see how self-actualization is on the same continuum or dimension as these other needs. The model makes sense to me below self-actualization, because all of these needs from "physiologic" to "esteem" represent the things the people do to serve themselves...Self actualization, on the other hand, seems to be related to how people observe and impact the world around them. If you look at the list of people that Maslow uses to represent self-actualized individuals, these are folks who were able to touch others or able to maintain their values despite the unpopularity of those values. Even the characteristics that Maslow noted characterize ways of relating with other people and the world around them more than how they meet some internal need.

My point is this: According to Maslow's model, people will not engage in self-actualization when their "lower needs" are not met, but I just don't think this is true. Does one really need to be well-fed and feel safe and loved to strive to "find self-fulfillment and realize one's potential"?

Historically, populations of people with unmet needs have often produced many self-actualized people. I am thinking of the civil rights participants of the 50’ and 60's whose safety needs and esteem needs were constantly undermined by a white supremacist culture. I would argue that Martin Luther King, Jr. was highly self-actualized despite living under the threat of violence at all times. Speaking of practitioners of non-violence, Gandhi even starved himself intentionally...He seemed to achieve self-actualization by denying his physical needs.

Perhaps the best example of self-actualization in the midst of unmet "lower" needs is that of Holocaust survivor and psychoanalyst Viktor Frankl. I have recently been re-reading his book, Man's Search for Meaning where Frankl gives a very insightful account of the psychology of the concentration camp inmate. Frankl notes that despite the physical conditions of starvation and bitter cold and the even more overwhelming emotional conditions of Auschwitz, some individuals were still able to maintain their values, and were able to use their suffering to "self-actualize". Frankl comments that this self-actualization was rare (his modesty does not allow him to include himself among those to achieve it), but he notes that it was no more rare than outside of camp life. One could argue that concentration camp life was a crucible that actually tested how "self-actualized" someone really was. Were they merely playing the part of a self-actualized person outwardly to have people respect them (and meet their esteem needs) or were they honestly seeking to reach their own personal potential despite their surroundings and circumstances. One might say that a chivalrous and generous man who degenerates into a self-centered thief at the mere thought of "going without" is not actually so chivalrous or generous at all.

My re-reading of Viktor Frankl’s book has been a very powerful reminder of how powerfully important the human will is. His depiction of the mental life of a concentration camp inmate reveals that these men and women had everything taken away from them that would seem to make life worth living, yet many found a way to maintain their desire to survive. There seemed to be some inner quality that was more important than the horror of the outward circumstances that determined whether people would give up or keep fighting to stay alive. Frankl eloquently describes his main theme, when he says:

Even though conditions such as lack of sleep, insufficient food and various mental stresses may suggest that the inmates were bound to react in certain ways, in the final analysis it becomes clear that the sort of person the prisoner became was the result of an inner decision, and not the result of camp influences alone. Fundamentally, therefore, any man can, even under such circumstances, decide what shall become of him - mentally and spiritually. He may retain his human dignity even in a concentration camp. I became acquainted with those martyrs whose behavior in camp, whose suffering and death, bore witness to the fact that the last inner freedom cannot be lost.

Condtions and circumstances could not possibly be worse than what they were in these camps, as everything was stripped from these individuals, but the the ability to survive was based on something that even the SS men could not forecable take away: “The last of the human freedoms is to choose one's attitudes”.

Frankl who was trained as a psychiatrist at the time of his interment in the concentration camps used his extreme experiences to develop a new psychoanalytic paradigm. Frankl’s contribution to psychoanalytic theory is that contrary to the Freudian or Adlerian point-of view that man’s most important internal conflicts are related to gratifying sexual desires (Freud’s “Pleasure Principle”) or empowering oneself relative to others is that man’s most important conflict is a need for meaning. His so-called “logotherapy (from the Greek word logos for meaning), outlines a psychotherapeutic strategy that is focused more on future goals and satisfying the will to meaning than other psychoanalytic approaches which often focus on past conflicts and the unalterable circumstances of our surroundings. Frankl’s therapeutic approach is considered existential since it focuses of the freedom of the will and personal responsibility and stoic since it holds that our attitude is more important than our surroundings in determining our well-being. The Stoic Epictetus held that 'Men are not moved by events but by their interpretations'. Even in facing death and suffering, by showing courage we can turn a situation into a supremely meaningful one. Frankl concedes that this therapeutic approach can be rigorous since it places so much responsibility on the patient, but if anyone is in a position to de-emphasize circumstance and past conflicts, a Holocaust survivor surely is.

Frankl’s unique training and profoundly intense experience with human suffering and deprivation shed light onto Maslow’s model of hierarchical needs. The model just does not seem to fit the observations we have of highly self-actualized individuals. While some people might not be able to spend any of their energy "self-actualizing" when their “lower needs” are not being met, others have proven to be able to self-actualize in spite of or even because of unmet need. As MLK pointed out, suffering can be redemptive. I would hate to think that my potential for self-fulfillment could only be realized if I was physically and emotionally comfortable, because this is a state that cannot be controlled. Disease, loss of loved ones, financial trouble, and every other type of human suffering is bound to come knocking. I hope that like Frankl, I can find meaning in that suffering when I answer the door.

Yours in getting to the top of the pyramid,
chad

"When we are no longer able to change a situation, we are challenged to change ourselves."
~Victor Frankl

As A Man Thinketh

2006-01-31T15:53:00.000-05:00

One of the observations I have made about life is that it is filled with confirmations that there is more to life than what I can see, hear, touch, taste and smell. There are times in our lives when coincidental occurrences, uncanny experiences, and ironic circumstances make it overwhelmingly obvious that there is something at work behind the scenes of what is observable that is interacting with the very real world that we live in. Whether you call it a glitch in the matrix, synchronicity, or angelic intervention, it’s difficult to deny that we all experience things that makes us feel like there is another dimension to life that we cannot measure. Since I am a Christian, I label it the “spiritual dimension”, but even if organized religion turns you off, most people can recognize that there is something unseen at work in the world. It must be difficult for a hardcore atheist to explain away all those feelings of the supernatural when they experience things that are difficult to explain in the natural.

I had one of those occurrences recently, and while it may not sound that supernatural to you, I assure you that the internal significance of this small happening has confirmed to me how real the spiritual world is.

This past holiday season brought with it a major challenge to my peace and well-being. To sum it up and be purposefully vague, one of the relationships in my life that I depend on most heavily for comfort and security was threatened by a clash in values. In hindsight, this conflict had been brewing for some time, but we were able to suppress our differences for the sake of a highly valued friendship for a long time. I think it was inevitable though that our outlooks would eventually cause us to collide, and it was no small collision. I think it had finally come down to a point where in order for us to both be honest with ourselves and one another, one or both of us had to say something that was unacceptable to the other. Anyway, this falling out had left me quite dismayed at the arrival of 2006, so I came moping into the New Year, but fortunately I had a conversation with a good friend here in New England who helped me to right myself spiritually and realize that no earthly relationship is so important that one should sacrifice their values for it. I gained a new perspective on what had transpired over the holidays, and wrote a difficult letter to this individual that I thought would heal the divide that had formed between us. But the letter was not received anything like I thought it would be for I had grossly underestimated the size of the chasm that had formed between us, and all the letter did was provide the torchlight to see how far apart we actually were. So in the days that followed the revelation of how much distance this relationship had to overcome, I began to doubt myself again. I began to think that something was possibly wrong with my values.

Well that’s where this coincidental gesture by a classmate woke up all my spiritual sensibilities with a brief message that was spiritually timely. A friend of mine from school who I have not known that long gave me this little book. What’s so ironic is that this young woman does not know me that well and had no idea that I was having any kind of personal challenge. (That’s not entirely true…she knew I was “struggling” with a bout of shingles. Maybe she was trying to make me feel better..) The point is that this relatively random act of kindness helped to ease all of the discord that was present in my mind regarding my injured relationship. The book spoke about the very values that seem to be a source of friction in that relationship. It could not have been more soothing or come at a better time.

The book she gave me is a very short (70-page) statement written over 100 years ago by a British writer named James Allen. This little collection of essays called As a Man Thinketh is basically a brief but profound piece on the power of thought, and although the title is an allusion to a scripture from the book of Proverbs, there is no biblical or Christian reference elsewhere in the book. Not to say that the book is anti-Christian; it is in fact consistent with Christian philosophy, but it does not rely on the specifics of the bible to ground it’s foundation. The only religious figure mentioned in the book (albeit briefly) is Buddha. Drawing from both Western and Eastern influences, Allen describes the spiritual laws regarding the power of the mind to effect circumstance. While Allen uses the term “spiritual laws”, one who is turned off by that terminology can easily substitute the phrase with “psychological principles” without altering the message of the book one iota. The fundamental message of the book (in my feeble attempt to encapsulate it) is that man is endowed with the God-like abilitie to think and create. He is self-aware, and can affect his circumstances through the action of his thoughts. Now Allen does not suppose that this is a matter of whim or that success (however you define it) can be achieved by merely wishing it so, but he points out that much of a man’s circumstances are predicated on how he interacts with the world, and much of how he interacts with the world is predicated on his character, and much of his character is predicated on how he thinks. While this may sound dull to some and obvious to others, Allen eloquently outlines these principles in a way that makes one realize the tremendous potential that thoughts have to either elevate or condemn an individual…and most importantly, that it is in every person’s means to control their thoughts. This is where some fatalists may disagree…they may believe that they are ultimately powerless and that circumstance cannot be influenced accept by those who have enjoyed good circumstances. But if one believes Allen’s spiritual truths, then one recognizes that it is the fatalistic thinking of the fatalist that is determining his circumstances. Ironically, one who believes that he has no power to affect his thoughts and thus his circumstances is indeed correct, because he will not take the creative step of choosing his thoughts, and his circumstances will remain beyond his influence.

So you may be saying…”So what chad…some girl gave you a century old coffee table book on what is essentially pop-psychology, and it made you feel better about a disagreement you had with someone you care about recently…What’s so supernatural about that?” While I will concede that on the surface, it sounds like I experienced a small coincidence augmented by a creative imagination looking for spirituality in the mundane. And I will even admit that the philosophy in the book is hardly novel…Hell, not too long ago, I read Man’s Search For Meaning by author, psychoanalyst, and Holocaust survivor Victor Frankl, and he pretty much said the same thing as Allen about the power of the mind. I probably could have read Norman Vincent Peale’s The Power of Positive Thinking as well as a litany of Christian books on the topic, and would have gotten a similar message. But the peace of mind that came with reading those pages, and the timeliness of the gesture from someone who had no idea what my state of mind was, and the precise expression of the thoughts and values that seem to represent the impediment to my relationship with the person who had caused me all of this doubt in the first place were too much for me to deny that something special had taken place. Even now, I fail to find the words to express how it felt to read those pages I guess that’s what makes every spiritual experience so personal. It’s so supernatural…so super-sensory, if you will, that it’s beyond your ability to describe with natural language, but the experience…the feeling…is real and while not physically tangible, it is unambiguously spiritually palpable.

Anyway, I wanted to suggest this book as something to glance at one day while you are sipping coffee at Barnes and Nobles, but more importantly I wanted to testify to my spiritual experience. Perhaps someone who reads this will have a revelation too about the spiritual nature of the things we call coincidental.
Or maybe you think that this was merely a psychological manifestation of my religious beliefs, my emotional state, and my imagination. Maybe you are right…maybe it was all in my head, but I thinketh not…

Yours in thought and deed,
chad

“As a man thinketh in his heart, so is he”
~Proverbs 23:7