tag:blogger.com,1999:blog-56400576018716761792024-03-05T04:49:22.316-05:00Approach a scalpel with wordsPoet, Physician, Returned Peace Corps Volunteer
Jennifer Stellahttp://www.blogger.com/profile/01985168402480341835noreply@blogger.comBlogger18125tag:blogger.com,1999:blog-5640057601871676179.post-31429116943239483042017-11-19T23:52:00.001-05:002017-11-28T00:11:11.287-05:00Evidence-free<!--[if gte mso 9]><xml>
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<!--StartFragment-->
<br />
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US"><a href="http://scalpelwithwords.blogspot.com/2017/11/zone-sans-evidence.html">Version Francaise</a></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: right;">
DRC</div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US"> South of the
Equator, rains come in the morning. In terms of living in Africa, truly living,
I've been in a very narrow band on either side of the Equator, but on the
mirrored side from here (Mvangan), my favorite thing was the sound of rain on
the tin eaves at night, going to sleep to that. Morning rains were rarer, but
they at least delayed going to work -- and meetings would either happen on
time, happen hours late, or not happen at all. I wasn't a doctor, then. The
plan tonight was for a bonfire/ effigy burning in honor of Guy Fawkes
day--though there's one English volunteer in this post, we've decided to
celebrate everyone's holidays. The rain makes it a little more difficult today.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US"> Rains in the morning. Rainy season
that was supposed to start a month ago, (also by the internal calendar I keep
by heart from Cameroon -- from January, dry season, small dry season, small
rainy season, rainy season). Precise dates over decades and centuries governing
planting, harvesting, and when that changes (global climate change), you don't
know when to plant, it might be too early or too late, and the crop might
either exist less, the same, or be destroyed. Nearer to here, insecurity during
the (north of the Tropic of Cancer) summer, meant that people fled their
villages, are returning slowly, and will not be able to plant this year, or
partially, or not at all, or because of the delayed rains it will be okay. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US"></span></div>
<a name='more'></a><div style="text-align: justify;">
<br /></div>
<br />
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US"> In medicine, sometimes we say things
are "evidence-free zones." Nothing to guide you, going on blind faith
and/or prior knowledge and/or hope and/or there's nothing else left.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">I only see
patients here with HIV and/or tuberculosis. What I like about HIV is also the
worst thing about it. Everything (can be) is more complicated. The differential
diagnosis expands and changes. It's a different context. Because anything can
and still does (and this makes the truly general internist in me happy) happen.
That's HIV in Africa, anyway. Practicing in the US, it's often a different
story, it truly is (can be) just another chronic disease to manage, more
medications and different things to know, and (usually) requires no specialty
care. This is a different story.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US"> With TB, it can manifest anywhere in
the body, as almost anything. And that's why I love it (syphilis is actually
very similar. And in the US, we say that of lupus).<b> </b>Protean. Ever changing. Slippery. And we do have tests for TB
here, more than I might have imagined (also, less). But sometimes they're all
negative and you have to decide on probabilities, test characteristics,
clinical judgment, and blind faith. And now, when they ask for the doctor's
opinion before starting TB treatmenta for someone we have not proven has TB...
that's me. That's my "clinical judgment." That's my "blind
faith." Do I even have that? Maybe, here. Evidence-free zone. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US"> I changed posts this week. I've been
in the hospital less, so there's only been one death, thus far, under my (brief
hands) of care. He actually died an hour after my colleague and I saw him, my
colleague swiftly threaded the spinal needle into his back for perfectly clear
fluid, and we hoped for a diagnosis before starting treatment (for what I was convinced
he had), what had put him into a coma with a fever of 41 deg C/ 106 deg F for
days, and we hadn't known about him. When we went to get the results in the
morning, we learned he had died. Found the chart. An hour later. Would I still,
with negative tests, started a treatment that could potentially have killed him
in a different way, with no proof? Likely enough. Sometimes it's out of
desperation. Though how different is it with some chemotherapies? Last ditch
attempt. Maybe. Maybe a few more weeks or months or years. Here, often enough,
given when people come to the hospital, it's measured in days.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">Fewer deaths, last
week. With my hands on. I don't know what this week will bring.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US"> In this post, before starting to see
patients in the clinics we go to the field, I've attended support groups for
the HIV+ patients (translated for me, diligently and thoughtfully, by my
colleagues). They have really put an emphasis on and effort into psychosocial
programs, including group and individual sessions, which have been remarkable
to see. One woman's story involved seeing her husband murdered in front of her
when an armed group pulled everyone out of their houses (Not close to where I
am. She moved here). And many of the discussions revolved around shame.
Auto-stigmatisation, community rejection even upon the perception that you're
sick. And after recounting experiences, family not wanting to touch them, eat
with them, live with them, talk to them anymore (some people do have more
positive stories), they turned expectantly to me for more insights. How,
Doctor, can we be better deal with shame?<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US"> I have nothing to add. I have heard
some of this before, in other practices in other cities, on another continent,
in another universe. Patients removing labels from prescription bottles, hiding
them, losing them. Being rejected from their families, communities. And here, I
am, at times, very deliberate in saying that I'm an HIV doctor in the United
States as well, that I've had patients there die from AIDS, that many of the
medications are the same (...or were...), that I describe the illness in the
same way, and that some of the lessons I taught, last week, at a nursing
school, were actually just translated from presentations I did over the past
year in English. a</span><o:p></o:p></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">*post mostly
written November 5th and completed November 12th<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US">But no one has
asked me before what to do, in my professional medical opinion, about shame.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US"> The things people want to know in
medicine, the things that actually matter to them, are rarely things I know.
Eye twitching. Random pain or skin reactions that come and then go away. The
real mechanism of palpitations (when you feel them, and why then? It isn't
related to heart rate). And shame. The question wasn't about combating stigma,
not that day. We're asking people to give "testimonies" of their
experiences, on World AIDS Day. Several have volunteered, want to tell about
their journey from diagnosis to now, how sick they were and how much better
they look. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US"> The nurses here know the medications
(there are few), know the labs to draw (there are few), know the common signs
and symptoms and diagnoses. They know the patients, some for years. But maybe,
just maybe, someone new, from the outside, could give the patients a different
perspective on this topic, a way to rationalize and treat and attack. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="EN-US"> I have nothing.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<!--EndFragment-->Jennifer Stellahttp://www.blogger.com/profile/01985168402480341835noreply@blogger.com0tag:blogger.com,1999:blog-5640057601871676179.post-8317087410128991202017-11-19T23:49:00.000-05:002017-11-28T00:15:33.316-05:00Zone sans Evidence<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-size: 12pt;"> Au sud de l'Equateur, la
pluie vient le matin. En termes de vivre en Afrique, vraiment y habiter, j'ai
été dans une bande étroite, des deux côtés de l'Equateur, mais au côté miroire d'ici
(Mvangan), ma chose préférée, c'était le son de la pluie sur les toits en tôle
la nuit, m'endormir à cette musique. Les pluies matinales étaient rares, mais
au moins ils retardaient le travail -- et soit les réunions se feraient, soit
ils seraient des heures plus tard, soit ils n'existeraient plus. Je n'étais pas
médecin, à l'époque. Le plan ce soir* c'était pour un feu de camp/ brûlure
d'effigie -- il n'y a qu'une anglaise à ce poste, mais on a décidé de célébrer
les fêtes de tout le monde. La pluie nous complique les plans aujourd'hui.</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-size: 10.0pt; line-height: 150%; mso-ansi-language: FR;">*5 novembre<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="font-size: 10.0pt; line-height: 150%; mso-ansi-language: FR;"><span style="mso-tab-count: 1;"> </span></span><span style="mso-ansi-language: FR;">La pluie le matin. La saison de pluie qui devait
commencer il y a plus d'un mois (aussi, par le calendrier interne que je
connais par cœur depuis Cameroun -- de janvier, saison sèche, petite saison
sèche, petite saison de pluie, saison de pluie). Des dates précises pour des
décennies, des siècles, qui gouvernent le temps de semer, le temps de cueillir,
et quand cela change (changement climatique globale...), tu ne sais pas quand
semer ou planter, ça pourrait être trop tôt ou trop tard, et la récolte
pourrait être moins, la même, ou être détruite. Proche d'ici, la situation
d'insecurité pendant l'été (au nord du tropique de cancer), veut dire que les
gens ont fuit leur villages et ils retournent lentement (ou pas du tout), et
ils ne pourraient pas planter ou semer cette année, ou partiellement, ou pas du
tout, ou à cause de la pluie retardée ça ira quand-même.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<a name='more'></a><br />
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: FR;"><span style="mso-tab-count: 1;"> </span>Dans la médecine, parfois
on dit que certaines choses sont dans des "zones sans preuves." Rien
pour te guider, tu avances avec la foie absolue/aveugle et/ou connaissances
et/ou espoir et/ou il n'y a rien d'autre qui reste. Ici, je ne vois que des
patients avec le VIH et/ou tuberculose. Ce que j'aime avec le VIH, c'est aussi
la pire chose. Tout est (peut être) plus compliqué. Le diagnostique différentiel
s'élargie et change. Ce n'est plus le même contexte. Parce que tout peut arriver
et le fait toujours (ce qui rend heureux l'interniste généraliste en moi). Au
moins, c'est le VIH en Afrique. Travaillant aux Etats-Unis, c'est souvent une
histoire différente, c'est réellement (peut être) une maladie chronique à gérer
comme d'autres, plus de médicaments et des nuances à savoir, et (la plupart du
temps) ça ne nécessite pas vraiment un spécialiste. Ici, ce n'est pas l'histoire.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: FR;"><span style="mso-tab-count: 1;"> </span>Avec la tuberculose, ça
peut se manifester partout dans le corps, dans presque n'importe quelle
manière. Et voilà pourquoi je l'aime. (Le syphilis est actuellement très
similaire de ce point de vue. Et aux E-U, nous le disons du lupus).
Protéiforme. Toujours en train de changer. Glissant. Et nous avons des tests
pour la TB ici, plus que je m'aurai pu imaginer (aussi, moins). Mais parfois
les résultats sont tous négatifs et tu es obligé de décider avec des
probabilités, caractéristiques des tests, jugement clinique, et la foie
aveugle. Et maintenant, quand ils demandent l'opinion du médecin avant de
lancer le traitement pour la TB pour quelqu'un qui n'a pas de preuve de
TB...c'est moi. C'est mon "jugement clinique." C'est ma "foie
aveugle." Est-ce que je l'ai, même? Peut-être, ici. Zone sans preuves.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: FR;"><span style="mso-tab-count: 1;"> </span>J'ai changé de postes
cette semaine. J'ai passé moins de temps à l'hôpital, donc il n'y a eu
seulement un décès, à présent, sous mes mains (brièves). Il est décédé une
heure après que mon collègue et moi l'ont vu, mon collègue a rapidement inséré
l'aiguille spinale dans son dos pour un liquide cérébro-spinale parfaitement
clair, et on ésperait avoir un diagnostique avant de lancer le traitement pour
(ce que j'étais convaincue qu'il avait), qui lui avait mis dans un coma avec
une fièvre de 41 deg C/106 deg F pendant des jours, et on ne savait pas qu'il
était là. Quand on est parti chercher les résultats des examens, le matin, on a
appris qu'il est décédé. Douze ans. On a trouvé le dossier. C'était une heure
plus tard. Est-ce que, avec des tests négatifs, j'aurais quand-même instauré un
traitement qui aurait eu le potentiel de le tuer d'une autre manière? Probablement.
Parfois, ça vient de la déséspération. Pourtant, est-ce vraiment différent avec
la chimiothérapie? Essaie de dernier recours, parfois. Peut-être. Peut-être
quelques semaines ou mois ou années de plus. Ici, le plus souvent, étant donné
à quel stade de maladies les patients viennent à l'hôpital, c'est mesuré en
jours.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: FR;">Moins de décès, la semaine dernière. Sous mes mains. Je ne sais pas ce que
cette semaine apportera.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: FR;"><span style="mso-tab-count: 1;"> </span>Dans ce poste, avant
d'aller voir les patients dans les centres de santé plus éloignés de la ville,
j'ai assisté à plusieurs groupes de support pour les patients VIH-positifs
(traduit du Swahili pour moi, avec diligence et considération, par mes
collègues). Ils ont vraiment mis une emphase sur et effort dans les programmes
psychosociales, y inclus les sessions individuelles et de groupes, ce qui ont
été vraiment remarquables à voir. L'histoire d'une femme incluait voir le
meurtre de son mari devant elle quand un groupe armé a forcé tout le village de
sortir de leurs maisons (pas près d'où je suis. Elle a déménagé). Et beaucoup
des discussions tournait autour de la honte. L'auto-stigmatisation, le rejet
communautaire même pour la perception de "la" maladie. Et après avoir
raconté leurs expériences, la famille qui ne voulait plus les toucher, manger
avec eux, vivre avec eux, parler avec eux (il y en a, quand même, qui ont des
histoires positives), ils se sont tournés vers moi pour plus de perspicacité,
perspective. Comment, Docteur, peut-on mieux combattre la honte?<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: FR;"><span style="mso-tab-count: 1;"> </span>Je n'ai rien à ajouter.
J'ai entendu un peu de cela dans d'autres contextes, dans d'autres centres dans
d'autres villes, sur un autre continent, dans un autre univers. Des patients
qui enlèvent les étiquettes des bouteilles de médicaments, qui les cachent, les
perdent. Etre rejeté par leurs familles, leurs communautés. Et me voici,
parfois, très délibère à dire que je traite aussi le VIH aux Etats-Unis, que
j'ai eu des patients là-bas qui sont morts du SIDA, que beaucoup des
médicaments sont les mêmes (ou l'étaient...), que je décris la maladie de la même
manière, et que plusieurs des leçons que j'ai enseigné, la semaine dernière,
étaient traduites des présentations que j'ai déjà fait aux Etats-Unis, en
anglais.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: FR;"><span style="mso-tab-count: 1;"> </span>Je ne sais pas, ne comprends
pas, la plupart des choses que les personnes veulent vraiment savoir en
médecine, ce qui leur est le plus important. Les battements randonnés de l'œil.
Le mécanisme des palpitations (quand tu les ressens, et pourquoi à ce moment?
Ce n'a pas une relation à la fréquence cardiaque). Et la honte. La question
n'était pas autour de combattre le stigma, pas ce jour-ci. Nous demandons aux PVV
(personnes vivant avec le VIH) de faire le témoignage de leurs expériences pour
la Journée Mondiale du SIDA. Plusieurs se sont dit volontiers, veulent parler
de leur parcours du dépistage/diagnostique à maintenant, comment ils étaient
malade et qu'ils vont mieux aujourd'hui.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span style="mso-ansi-language: FR;"><span style="mso-tab-count: 1;"> </span>Les infirmiers ici
connaissent les médicaments (il n'y en a pas beaucoup), savent les tests du
labo à faire (il n'y en a pas beaucoup), savent les signes et symptômes les
plus communs. Ils connaissent les patients, parfois pour des années. Mais
peut-être, peut-être, une nouvelle personne, de l'extérieurs, l'ex-pat,
pourrait donner aux patients un autre perspective au sujet, une façon de
raisonner et traiter et attaquer.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
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<i style="mso-bidi-font-style: normal;">All views represented
here are mine alone and do not represent Médecins Sans Frontières.</i></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="text-align: right;">
Democratic Republic of Congo</div>
<div class="MsoNormal" style="text-align: right;">
<br /></div>
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Version française</div>
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<br /></div>
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</div>
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<br /></div>
<div class="MsoNormal">
"AFYA!" <span style="mso-tab-count: 2;"> </span>"KWA
WOTE!" </div>
<div class="MsoNormal">
"AFYA!"<span style="mso-tab-count: 2;"> </span>"KWA
WOTE!"</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-justify: inter-ideograph;">
I wanted to write about life this week. So I'll start with my
favorite thing about health in Congo. Every health-related meeting I've been
to, every support group, every time someone speaks they start and end with
"AFYA!" (health) to which the group responds "KWA WOTE!"
(for everyone). There's an incredible energy within it. It makes it easy to
feel like an insider. And it adds to my very rudimentary Kiswahili (without
it...there is no speaking with patients. Not much beyond "Bonjour."
At all). This includes the group of PVV (Personnes Vivant avec le VIH, or
People Living with AIDS) who actually search for patients who are "lost-to-follow-up"
(have missed appointments for over two months). For patients who are newly
diagnosed, they accompany them home. So many meanings in that word. We've been
discussing plans for World AIDS Day (December 1st), and they're creating plays,
songs, there will be dancing...apparently, "karaoke" just means a
band with instruments. I have to admit I was very disappointed by the (to my
ears) misnomer. (There's at least one Congolese song I could do, at this
point...the lyrics are mainly "Sawa Sawa," which means "okay,
okay"). </div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-justify: inter-ideograph;">
There's life, here.</div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-justify: inter-ideograph;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-justify: inter-ideograph;">
I don't need to mention the 3-month-old who died during my
consultation (in obvious respiratory distress, complications from likely AIDS).
Or how pediatric AIDS was the first thing I learned to diagnose in 2005, <a href="http://jenny-and-cameroon.blogspot.com/2007/05/dear-all-note-of-context.html">eight
years before I was officially a doctor</a>.</div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-justify: inter-ideograph;">
</div>
<a name='more'></a><br />
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-justify: inter-ideograph;">
It's been awhile.</div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-justify: inter-ideograph;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-justify: inter-ideograph;">
Transmission of HIV from mother to baby, throughout
pregnancy, during labor and birth, and while breastfeeding (or, more usually,
not) is something we've learned to and can prevent. Usually. When conditions
allow. One part is that here, not only is formula expensive, not only is it
stigmatizing because then people assume you have HIV, but access to clean water
is so uncertain that it's actually much safer to take the risk of transmission
than to take the risk of giving a baby formula mixed with water. Official WHO (World
Health Organization) recommendations. This, too, is something I learned in
2005. And it hasn't changed.</div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-justify: inter-ideograph;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-justify: inter-ideograph;">
I'm not writing about that, not right now. Because the
patients before and after the baby were well. Complaints I could easily have
heard in the Bronx, or anywhere. "I had stomach pains after eating manioc
leaves, and a lot of itching." "When did that happen?" "A
week ago." "And how is it now?" "Gone." Another
patient got hydrocortisone (or, I wrote for it, and she would have gotten it if
it were in stock) for eczema. At the most remote health center we're currently
working in, I saw the most stable patients I've seen in two weeks. </div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-justify: inter-ideograph;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-justify: inter-ideograph;">
There was no time to mourn the infant. I wanted a minute, or
five, or fifty. But my colleague brought the next patient in immediately,
handing me the chart. And so it goes. Before she died, we were planning to
evacuate her with us to the hospital...no way to really treat respiratory
distress <i style="mso-bidi-font-style: normal;">en brousse</i>. There would be oxygen
and more antibiotics at the hospital, at least. I might have actually been
holding her head (three months old, couldn't hold her head up, weighed less
than 8 pounds) while she died, helping her mother dress her after undressing
for the scale. My part doesn't matter. </div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-justify: inter-ideograph;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-justify: inter-ideograph;">
I know what active dying looks like. Somehow, this week, I
have chosen to forego that hard-earned knowledge and recognition. Hoping I
could help, well, anyone. In two weeks at post, four of my patients have died
(at least. Two others, I suspect might have/ could soon, but they left the
hospital AMA, "Against Medical Advice."). In my first year of residency,
the first part of it, the actively dying were the patients I checked on most
anxiously. But I did the same for the passively dying ones, until I could tell
the difference. <a href="http://jenny-and-cameroon.blogspot.com/2010/09/mon-amie.html">And there
are always surprises.</a></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-justify: inter-ideograph;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-justify: inter-ideograph;">
Passive dying. Passive labor. Active dying. Active labor. You
leave this world in the order you came into it. </div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-justify: inter-ideograph;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify; text-justify: inter-ideograph;">
This week, I'll still try to end with life. I'm leaving this
post tomorrow for my second (...I'll be back in two weeks). My colleagues here
-- and by that, I mostly mean my national staff colleagues, or >90% of MSF
-- are incredible. They are who I spend my days with; occasionally, with one
other ex-pat when we go into the field, but she and I have different jobs. They
are who make MSF run. They are here, have been here, some for the entire life
of the project (this one in particular is 6 years old). One of my closest
colleagues has been working with MSF since 2002, ie for most of his career.
Ex-pats come and go, hopefully contribute something(s), add to the direction of
the project, capacity-building, physically and personally helping with
interventions, seeing patients, etc. But in DRC -- (and I assume it's the same
in other MSF countries, but thus far, I only know this one), the real face, workforce,
and energy of MSF is Congolese. I'm here to work. But I will learn, I will
actually gain, far, far more than I can ever do. And that, too, is something
I've known since 2005 and my first weeks in Cameroon.</div>
Jennifer Stellahttp://www.blogger.com/profile/01985168402480341835noreply@blogger.com0tag:blogger.com,1999:blog-5640057601871676179.post-72200459432319328832017-10-30T00:33:00.001-04:002017-10-30T00:41:24.838-04:00Le plus que ça change<!--[if gte mso 9]><xml>
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<br />
<div class="MsoNormal" style="line-height: 150%;">
<i style="mso-bidi-font-style: normal;"><span lang="FR" style="mso-ansi-language: FR;">Toutes les opinions représentées
ci-dessous sont les miennes et ne représentent pas Médecins Sans Frontières.</span></i><br />
<br />
<div style="text-align: right;">
<span lang="FR" style="mso-ansi-language: FR;">République Démocratique du Congo </span><i style="mso-bidi-font-style: normal;"><span lang="FR" style="mso-ansi-language: FR;"><br /></span></i></div>
</div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
"AFYA!" <span style="mso-tab-count: 2;"> </span>"KWA WOTE!" </div>
<div class="MsoNormal" style="line-height: 150%;">
"AFYA!"<span style="mso-tab-count: 2;"> </span>"KWA WOTE!"</div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="FR" style="mso-ansi-language: FR;">Cette semaine, je voulais écrire de la vie. Alors je commence avec ma chose
préférée liée à la santé au Congo. Chaque réunion dans le cadre de la santé à
laquelle j'ai assisté, chaque groupe de support, chaque fois que quelqu'un
parle il commence et termine avec "AFYA!" (santé), et le groupe
répond "KWA WOTE!" (pour tout le monde). Il y a une énergie incroyable
dedans. C'est facile de se sentir membre du group, impliqué. Et cela ajoute à mon
Kiswahili très rudimentaire (sans le Kiswhaili...c'est impossible à parler aux
patients. Peu après "Bonjour" et "Comment ça va?"). Y
inclus le groupe des PVV (Personnes Vivant avec le VIH) qui font la recherche
sur le terrain des patients qui sont "perdus de vue" (ont manqué les
rendez-vous pour plus de deux mois). Pour les patients qui sont nouvellement
diagnostiqués avec le VIH, ils les accompagnent chez eux. Quel mot complexe.
Nous sommes en train de discuter les plans pour la Journée Mondiale du SIDA (le
1er décembre) et ils créent des pièces de théâtre, écrivent des chansons, il y
aura de la danse...apparemment, "karaoke" veut dire simplement un
groupe de musiciens avec instruments. Je dois admettre que j'étais très décçue
par la (à mes oreilles) fausse cognate. (Il y a au moins une chanson congolaise
que je pourrais faire, déjà...la plupart des paroles sont "Sawa
Sawa", ou, "Ça va, Ça va").</span></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="FR" style="mso-ansi-language: FR;">Il y a de la vie, ici.</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="FR" style="mso-ansi-language: FR;">Je n'ai pas besoin de mentionner le bébé de trois mois qui est décédée
pendant ma consultation (en détresse respiratoire très apparente, des
complication du SIDA probable). Ou comment le SIDA pédiatrique est la première
chose que j'ai appris à diagnostiquer en 2005, <a href="http://jenny-and-cameroon.blogspot.com/2007/05/dear-all-note-of-context.html">huit
ans avant que je ne devienne officiellement médecin</a>. </span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<a name='more'></a><br />
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="FR" style="mso-ansi-language: FR;">Ça fait longtemps.</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="FR" style="mso-ansi-language: FR;">La transmission du VIH de la mère au bébé, pendant la grossesse, pendant
l'accouchement et la naissance, et pendant l'allaitement (ou, la plupart du
temps, pas) est quelque chose qu'on a appris à et peut prévenir. La plupart du
temps. Conditions permettantes. Une partie, c'est que, ici, non seulement est
le lait artificiel cher, non seulement entraine-t-il la stigmatisation parce
qu'on présume que tu as le VIH, mais l'accès à l'eau propre est tellement
difficile et précaire qu'il est actuellement plus prudent de prendre le risque
de la transmission du VIH que de prendre le risque de donner à un bébé le lait
artificiel mélangé avec de l'eau. Recommendation officielle de l'OMS
(Organizatione Mondiale de la Santé). Ça, aussi, c'est quelque chose que j'ai
appris en 2005. Et ça n'a pas changé. </span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="FR" style="mso-ansi-language: FR;">En ce moment, je n'écris pas de cela. Parce que les patients avant et après
le bébé allaient bien. Des plaintes que j'aurais facilement pu entendre dans le
Bronx, ou n'importe où. "J'avais mal à l'estomac après avoir mangé les
feuilles de manioc, et beacoup de démangeaisons." "C'était quand?"
"Il y a une semaine." "Et maintenant, c'est comment?"
"C'est parti." Un autre patient à reçu la hydrocortisone (ou, j'ai
écrit l'ordonnance, et il l'aurait eu si c'était en stock) pour l'eczéma. Au
centre de santé le plus éloignée et rurale ou on travail actuellement, j'ai vu
les patients les plus stables que j'ai rencontré dans deux semaines.</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="FR" style="mso-ansi-language: FR;">Il n'y avait pas le temps de pleurer le bébé. Je voulais une minute, ou
cinq, ou cinquante. Mais mon collègue est rentré avec un autre patient
immédiatement, me donnant son dossier. Et ainsi ça se passe. Avant qu'elle soit
décédée, on avait décidé de l'évacuer avec nous, à l'hôpital...pas de moyen de
traiter le détresse respiratoire <i style="mso-bidi-font-style: normal;">en
brousse</i>. Il y aurait au moins de l'oxygène et plus d'antibiotiques à
l'hôpital. Il est possible que je tenais sa tête (trois mois, ne pouvais pas
tenir sa tête, pesée moins de 4 kilos) pendant son décès; j'aidais sa mère à
l'habiller après le déshabillement pour la balance. Mon rôle n'au aucune
importance.</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="FR" style="mso-ansi-language: FR;">Je sais reconnaitre la mort dit "active."* Mais cette semaine, il
paraît que j'ai décidé d'oublier ces connaissances durement acquises. Espérant
que je pouvais aider...quelqu'un. Dans deux semaines à mon poste, quatre de mes
patients sont morts (au moins. Deux autres, je suspect pourrais l'être/ le
pourrais être bientôt, mais ils ont quitté l'hôpital "Contre Avis
Médicale"). Pendant ma première année de résidence, la première partie,
les patients en phase active de mourir étaient ceux que j'allais voir le plus
souvent et avec le plus d'anxiété. Mais je faisais la même chose pour les
patients en phase "passive" de mourir, avant que je pouvais
reconnaître la différence. <a href="http://jenny-and-cameroon.blogspot.com/2010/09/mon-amie.html">Et il y a
toujours des surprises. </a><span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="FR" style="mso-ansi-language: FR;"><span style="mso-spacerun: yes;"></span><span style="font-size: x-small;">*termes médicales traduits directement de l'anglais</span></span></div>
<br />
<br />
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="FR" style="mso-ansi-language: FR;">La mort passive. Le travail (de l'accouchement) passif. La mort active. Le
travail actif. On quitte se monde dans l'ordre qu'on l'est entré.</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<span lang="FR" style="mso-ansi-language: FR;">Cette semaine, je vais toujours essayer de terminer avec la vie. Je quitte
ce poste demain pour mon deuxième (...je reviens dans deux semaines). Mes
collègues ici -- et par cela, je veux dire en plus part mes collègues
congolais/staff nationale, or >90% de MSF -- sont incroyables. C'est avec
eux que je passe la journée; quelque fois avec une autre ex-pat, mais nous
avons des postes différents. C'est eux qui assurent le fonctionnement de MSF.
Quelques uns sont là, ont été là, pendant la vie entière du projet (pour
celui-là en particulier, 6 ans). Un de mes proches collègues a travaillé avec
MSF depuis 2002, c'est-à-dire pour la majorité de sa carrière. Les ex-pats
viennent et partent, avec l'espoir de contribuer quelque chose(s), ajouter à la
direction du projet, renforcer les capacités, physiquement et personnellement
aider avec des interventions, voir des patients, etc. Mais en RDC -- (et je
présume que c'est le même dans les autres pays MSF, mais à présent, je ne
connais que celui-là), la vraie face, main-d'œuvre, et énergie de MSF est
congolais. Je suis ici pour travailler. Mais je vais apprendre, je vais
actuellement acquérir, beaucoup, beaucoup plus que je ne pourrais jamais faire.
Et ça, aussi, c'est quelque chose que je connais depuis 2005 et mes premières
semaines au Cameroun.</span></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%; text-align: justify;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
Jennifer Stellahttp://www.blogger.com/profile/01985168402480341835noreply@blogger.com0tag:blogger.com,1999:blog-5640057601871676179.post-65871781857328555552017-10-22T10:30:00.000-04:002017-10-22T10:48:18.180-04:00Not enough blood or water<span style="font-size: large;"><a href="https://scalpelwithwords.blogspot.com/2017/10/insuffisance-de-sang-et-deau_22.html">Version francaise</a></span><br />
<br />
<div style="text-align: right;">
Democratic Republic of Congo</div>
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There's one example I use whenever
I talk about grief. How I came to understand grief in medicine. Grieving in
Africa. Grieving when children die. And how people keep going.</div>
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<br /></div>
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It was 10 years ago. A Sunday, late
morning. I was awake enough, outside on my porch, maybe reading, maybe walking
down to the hospital to see friends. I saw Doc running. Yvonne running. Cecile
running. Julie running. So I went. And in the salle de consultation was a
disheveled mother, listless child on her lap, Cecile connecting an IV from her
arm to the child's arm, there wasn't time for a real transfusion. I was there
for minutes or hours, or seconds, standing back, watching them work, not
knowing how valiant it was in the face of most likely futility. And
the child died. And I forget at which point or who noticed it first. There
weren't any chest compressions that I remember or anything else done for resuscitation.
But we didn't have oxygen, I don't think, and I know we didn't have anything
else.</div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
I remember the mother throwing
herself on the ground, screaming, outside la salle, where we'd have 100s lined
up for vaccinations. Banshee-wailing. It went on. I don't remember where the
child was at that time. It was the first time I had seen death happen, and I
don't know at what point it happened, and in the events of attempted, urgent
resuscitation, and I had wanted so badly to be in it. </div>
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I remember going back (500 ft) to
my house, lying on my bed, staring up at the ceiling through the mosquito net
canopy. I remember wandering into town that
afternoon and finding bananas, which I hadn't seen in weeks, I remember talking
to a friend after that (no power, but the landline in town was working that
day! 1/100 occurrence) and when they asked me how my day was, I said,
"Great! I found bananas!" And I meant it.
</div>
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<br /></div>
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Severe anemia. From malaria. Died
from not enough blood. It's a common story for malaria in kids. </div>
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<a name='more'></a><br />
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I remember thinking about the
mother wailing (I still hear her, I still see her) and the concept of letting
grief in so that you could let it out and get up again and keep moving because
you can't stop moving. I've told this story many times.
I've written many poems about this story. I don't remember the little girl's
name, but I'll put her on the level of <a href="https://jenny-and-cameroon.blogspot.com/2011/04/a-year-for-patients.html">my first patient who died in med school(K), the first newborn I took care of a few months later (also K)</a>. And so many other later.
</div>
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<br /></div>
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That child died in Mvangan,
Cameroon, in the summer (small rainy season) of 2007.</div>
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<br /></div>
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Yesterday, in a first for an
internist, a four-month-old girl died under my hands. Severe anemia (for the
doctors among you, her hemoglobin was 2.1 g/dl). From malaria. Died from not
enough blood. I was at the hospital to follow up on a few patients, but then
the HIV/TB nurses saw me and took me on rounds. In the intensive care ward, we
went to see a man, late 30s, with HIV, (I diagnosed) TB, and florid, beautiful
Kaposi's sarcoma on both his legs. I hadn't seen it so widespread in awhile. </div>
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I turned and saw another doctor
starting chest compressions on a baby, while bag masking her. I don't know why
I turned, because there wasn't sound, yet. It's soon after that, the mother
started crying, wailing. It's soon after that someone took her outside. One of
the nurses and I went over, to help, and the vague familiarities of ACLS
protocol came back (...I'm the only one with a watch. I should be timing) (How
much epinephrine have we given and when was the last one) (Do we have a fingerstick)
(Two fingers on the femoral pulse, check carotid) (Is air entry bilateral) (Are
compressions fast and deep enough) (Are we getting an oxygen level) (Has the
pulse come back?) (Yes. Briefly) (Can you hear the heart?) (No) (Can you hear
the heart?) (No) (How are her pupils?) (Fixed and dilated) (Is there a pulse?)
(No) (How long has it been?) (20 minutes). Not my code. Not my call. With her
hemoglobin level and without blood --- even if we acquired it then (and I don't
know if memory serves correctly about the mother to child transfusing above) --
there really is nothing we could have done. I know that now. And I know that
about the child in Mvangan. This time, I was the doctor, my hands were there,
and the child died. Democratic Republic of Congo. Also in the equatorial
rainforest. October 2017.</div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
Doing compressions on an infant
isn't the athletic event it can be in adults, the exhaustion after 2 minutes,
kneeling on the bed, all your force directed into the heels of your palms,
coming back from a 45-minute code sweaty, exhausted, probably borderline
hypoglycemic.</div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
I never counted the adults who died
under my hands. I've counted my own patients who've died. But most of the ones
I did compressions on, whose ribs I broke, whose time of death I might have called,
whose heart I might (rarely, rarely) have helped to restart, were anonymous
except if I was writing the code leader note or death note or looking up labs
or prescribing medications. I have no idea how many. Many.</div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
I know how many children. One.</div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
And counting.</div>
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<br /></div>
Jennifer Stellahttp://www.blogger.com/profile/01985168402480341835noreply@blogger.com0tag:blogger.com,1999:blog-5640057601871676179.post-5020565675472251292017-10-22T09:00:00.000-04:002017-10-22T10:50:01.270-04:00Insuffisance de sang et d'eau<div style="text-align: right;">
<!--[if gte mso 9]><xml>
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</xml><![endif]--><span lang="FR" style="mso-ansi-language: FR;"> </span><span lang="FR" style="mso-ansi-language: FR;">République Démocratique du Congo</span>
</div>
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<br /></div>
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<span lang="FR" style="mso-ansi-language: FR;">Il y a un exemple que j'utilise quand je parle du chagrin. Comment j'ai
commencé à le comprendre, dans la médecine. Vivre les décès, faire le deuil en
Afrique. Vivre les décès des enfants. Et comment les gens continuent.</span></div>
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<span lang="FR" style="mso-ansi-language: FR;"><span style="mso-tab-count: 1;"> </span></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FR" style="mso-ansi-language: FR;">Il y a dix ans. C'était un dimanche, tard dans la matinée. J'étais assez
réveillée, dehors sur ma véranda, peut-être lisant, peut-être allant à
l'hôpital voire les amis. J'ai vu Doc en train de courir. Yvonne courrait.
Cécile courrait. Julie courrait. Alors je suis allée. Et dans la salle de
consulte, il y avait une femme désespérée, débraillée, avec un enfant
léthargique sur ses genoux, Cécile en train de connecter une voie intraveineuse
entre son bras et le bras de son enfant, il n'y avait pas le temps pour une
vraie transfusion. Le sang coulait. J'étais là pendant des minutes ou des
heures, ou quelques secondes, un peu à l'écart, les regardant travailler, pas
comprenant à quel niveau c'était vaillant de leur part dans la face de, plus
probablement, la futilité. </span><br />
</div>
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<span lang="FR" style="mso-ansi-language: FR;">Et l'enfant est décédée. Elle a donné l'âme, aux termes de l'expression.
Pendant qu'on la regardait, pendant que mes collègues, mes chers amis,
faisaient de leur mieux. J'oublie à quel point ou qui s'en est aperçu en
premier. Dans mes souvenirs, il n'y a pas de compressions thoraciques, ou rien
d'autre fait pour la réanimation. Mais je ne crois pas qu'on avait même de
l'oxygène, et je sais qu'on avait rien d'autre qu'il aurait fallu. </span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FR" style="mso-ansi-language: FR;">Je me souviens de la mère qui s'est jetée sur l'herbe dehors de la salle,
hurlant, où parfois on aurait une centaine des personnes attendant les vaccins.
Je me souviens de ses gémissements, comme une banshie. Ça continuait. Je ne me
souviens pas d'où était sa fille, décédée à l'âge de trois ans.<span style="mso-spacerun: yes;"> </span>C'était la première fois que j'ai vu la mort,
active, devant mes yeux, le passage, et je ne sais pas quand ça s'est passé. Et
pendant les actes urgentes pour la réanimation, je voulais tant être parmi ceux
qui agissait. (Voilà pourquoi j'ai quitté le Cameroun, pour devenir médecin).</span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FR" style="mso-ansi-language: FR;">Je me souviens de rentrer chez moi (500 pieds), de m'étendre sur mon lit,
de fixer sur le plafond de ma chambre à travers la canopée de la
moustiquaire.<span style="mso-spacerun: yes;"> </span>Je me souviens de me promener au centre ville, cet après-midi et de trouver
des bananes, que je n'avais pas vu depuis plusieurs semaines, je me souviens de
parler avec une amie après cette grande découverte (il n'y avait pas de
courant, mais le téléphone fixe pour tout Mvangan fonctionnait ce jour-ci !
Evènement d'un jour sur cent), et quand elle m'a demandé comment j'avais passé
la journée, je lui ai dit, "C'était fantastique J'ai trouvé des bananes !"
Et j'étais sincère. Je n'avais oubliée la petite fille, morte à l'âge de trois
ans. Je l'avais pleuré. Je la vois, je pense à elle, dix ans plus tard. </span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FR" style="mso-ansi-language: FR;">Morte à cause d'une anémie aigue. Du paludisme. Morte à cause de manque de
sang. C'est une histoire très courante pour le paludisme chez les enfants. Ici.</span></div>
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<br />
<a name='more'></a><br /></div>
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<span lang="FR" style="mso-ansi-language: FR;">Je me souviens de penser à la maman et ses gémissements. Je l'entends
toujours, je la vois toujours. Je me souviens de penser au concept de laisser
entrer toute la peine, la douleur, pour que tu puisses la lâcher et te lever
encore, le lendemain, et de continuer à avancer parce que ce n'est pas possible
d'arrêter d'avancer. </span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FR" style="mso-ansi-language: FR;">J'ai déjà raconté cette histoire plusieurs fois. J'ai écrit plusieurs
poèmes au sujet de cette petite fille. Je ne me souviens pas de son nom, ou de
si je l'ai jamais su, mais je la mets au niveau de<a href="https://jenny-and-cameroon.blogspot.com/2011/04/a-year-for-patients.html"> ma première patiente décédéeen cours de la fac de médecine, K, etdu premier nouveau-né duquel j’étais chargée, 5 mois plus tard, aussi K</a>. Et tant d'autres après.</span></div>
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<br /></div>
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<span lang="FR" style="mso-ansi-language: FR;">Cet enfant est décédé à Mvangan, au Cameroun, pendant l'été de 2007.</span></div>
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<span lang="FR" style="mso-ansi-language: FR;">Hier, dans un premier temps pour une interniste, un bébé de 4 mois est décédé
sous mes mains. L'anémie aigue (pour les médecins, parmi vous, son taux d’hémoglobine
était de 2.1 g/dl). Du paludisme. Morte à cause de manque de sang. J'étais à
l'hôpital pour faire le suivi de quelques patients, mais l'infirmière du VIH/TB
m'a vu et m'a amené faire la ronde. Dans l'unité des soins intensifs, on est
allées voir un homme de 37 ans, avec le VIH, probablement la tuberculose, et un
sarcome de Kaposi fleurissant aux jambes. Ca faisait longtemps que je n'avais
pas vu aussi étendu. </span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FR" style="mso-ansi-language: FR;">Je me suis retournée et j'ai vu un autre médecin en train de faire les
compressions thoraciques sur un bébé, lui donnant de l'oxygène par masque en
même temps avec l'autre main. Je ne sais pas pourquoi je me suis retournée,
parce qu'il n'y avait aucun bruit, pas encore. C'est peu de temps après que la
mère s'est mise à pleurer, à hurler. C'est peu de temps après que quelqu'un l'a
amené dehors. Je suis allée aider avec un des infirmiers, et le protocole ACLS
pour les bébés me revenait vaguement en tête. (Je suis la seule avec une
montre...je devrais marquer le temps) (Combien d'adrénaline est-ce qu'on a
donné et quand a été le dernier) ( Est-ce qu'on connait son taux de glycémie)
(Deux doigts au pouls fémoral, vérifier le carotide) (Est-ce que l'entrée de
l'oxygène est bilatérale) (Les compressions sont aussi vite et profonde que
nécessaire) (Est-ce qu'on a son niveau d'oxygène) (Le pouls est-il revenu)
(Oui, brièvement, trois fois) (Peux-tu entendre les battements du cœur) (Non)
(Peux-tu entendre les battements du cœur) (Non) (Comment sont ses pupilles)
(Fixées et dilatées) (Y va-t-il un pouls) (Non) (Ca fait combien de temps)
(Vingt minutes). Pas ma réanimation. Pas à moi, la décision. Avec son taux de
hémoglobine et sans le sang -- et même si on en avait maintenant, ça serait
trop tard. (Je ne sais pas si mes souvenirs me servent bien quand je vois la
transfusion mère-enfant décrite en haut). Il y a, en vérité, rien de plus qu'on
aurait pu faire. Je le sais maintenant. Et je le sais pour l'enfant de Mvangan.
Cette fois-ci, j'étais médecin, mes mains y étaient, et l'enfant est morte.
République Démocratique du Congo. Aussi dans la forêt équatoriale. Octobre
2017.</span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FR" style="mso-ansi-language: FR;">Faire les compressions thoraciques pour un bébé n'est pas l'événement
d'athlétisme que cela peut-être avec les adultes, l'épuisement après 2 minutes,
à genou sur le lit, toute ta force dirigée dans les paumes des mains, revenant
d'une réanimation de 45 minutes en sueur, épuisée, probablement à la limite de
la hypoglycémie. </span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FR" style="mso-ansi-language: FR;">Je n'ai jamais compté les adultes qui sont morts sous mes mains. J'ai
compté mes patients qui sont morts en cour de mon travail avec eux. Mais la
plupart auxquels j'ai fait des compressions, pour lesquels j'ai brisé leurs
côtes, pour lesquels j'ai annoncé le temps officiel du décès et la cessation
des efforts de la réanimation, pour lesquels j'ai aidé à (rarement) faire
redémarrer le cœur, m'étaient anonymes. Peut-être que je connaissais le nom si
j'avais à signer le certificat du décès ou écrire la note du dirigeant des
efforts ou chercher les testes sanguines ou prescrire les médicaments en
urgence. Je n'ai aucune idée de combien. Beaucoup.</span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FR" style="mso-ansi-language: FR;">Je sais combien d'enfants. Un.</span></div>
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<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="FR" style="mso-ansi-language: FR;">Le commencement.</span></div>
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<br /></div>
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<br /></div>
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<br /></div>
Jennifer Stellahttp://www.blogger.com/profile/01985168402480341835noreply@blogger.com0tag:blogger.com,1999:blog-5640057601871676179.post-72684117272598980462016-03-06T11:00:00.000-05:002016-03-06T11:00:17.820-05:00The Poet-Doctor Returns to AfricaDisclaimer: This was written Feb 29-March 2, but I'm posting it on March 6th, from Uganda. I am currently in Kisoro, I've been in the hospital since Thursday, and there will be more regarding that, soon. There will be/are real time delays, as with internet.<br />
<br />
*****<br />
<br />
le 29 fevrier ->2 mars 2016<br />
<br />
It’s been almost three years. And this is the first plane ticket I have personally paid for. Then again, it’s the first time going that I have a job. Then again, it’s the first time I’m going as a doctor. My (nascent) career trajectory has spanned this. Next time, I’ll be on my own, maybe with Peace Corps, maybe MSF. A friend in med school commented once, it was hard to imagine there was a time when I hadn’t been to Africa. It’s true. Now 1/3 of my life since that first moment. In first grade, so enamored of geography before I’d seen anything other than the country of my birth, my most native tongue, France, snd the country that has claimed most of my years and words. I named Africa my second-favorite continent (Europe was first), and Ouagadougou was my favorite capital (Burkina Faso). My favorite movie was Cheetah—a Disney movie in the 80s, two kids and their Maasai friend trekking across the Serengeti in search of a cheetah (duma) they had rescued from the poacher that killed its mother, taking this one for greyhound racing. And in 2008, before going to Kenya, I downloaded “Jambo Bwana,” from the movie’s soundtrack. I named the kitten who came with my house in Migori (as did hundreds of of bats under the eaves) Duma. I went on safari, overland, in Maasai Mara (the Kenyan side of the Serengeti). I saw a cheetah.<br />
<br />
<span class="Apple-tab-span" style="white-space: pre;"> </span>I wrote about this almost three years ago. What it feels like to return to Africa. The light. The Equatorial light, existing in the back of my eyes like uncapturable jungle greens, makes me ache. The Constant Gardener has it right. Paris has a light. So does Equatorial Africa.<br />
<br />
<span class="Apple-tab-span" style="white-space: pre;"> </span>I wonder if, in this direction, I´ll see the Sahara in the same way. I wonder if, descending, I’ll feel the rush of warm air into the plane. I wonder if, in landing, the plane will erupt into applause. Flying to Cameroon is that way.<br />
<br />
*****<br />
<br />
<span class="Apple-tab-span" style="white-space: pre;"> </span>I wept the first time I flew away from Africa. I kissed my fingertips and touched the tarmac in Douala (…and our Kenya Airways plane turned around soon after take-off, we landed in Douala, and, 26 hours later, I left again). When I returned to Africa (Kenya) six months later, I kissed my fingertips and pressed them to the earth. A year after that, I was back in Cameroon. You can go home again. I have. But in the between times—Africa makes me ache. Everyone, everything I know there, wondering who will be alive, the next time. Or have died of what. It’s funny to think of it as a continent, in so many ways (though the country I consider home is called “Africa in miniature.”) Or anything unified, really, when even within countries borders are arbitrary, so being from one nationality means many divergent cultures, traditions.<br />
<br />
<span class="Apple-tab-span" style="white-space: pre;"> </span>It’s been almost three years. I’ve traveled to the developing/Southern/non-Western (not true, for Central America), Global South three times on vacation in the past three years. But the first time I went to Africa, first time I went anywhere but the US or Europe, I moved in. Comfortable, stubborn, familiar in a plaster and stone house in the equatorial rainforest, with mostly walls, five rooms, and in the annual migratory path of the biting ants that can kill a child (a swarm of hundreds of thousands acting as one organism, in through a living room window, out through the kitchen at the other end). <br />
<br />
In Cameroon in April 2013, my last time anywhere in Africa, I was such an almost-doctor that all I had left of med school upon my return was graduation. This time, I’m such an almost (terrifyingly so) – attending that upon my return, I have 2.5 months left of residency. But now. Now I refuse to tell my patients I’m leaving. Not yet. There’s a minuscule “maybe” in there. But really I wonder if they’ll forgive me, if they’ll believe I didn’t say it, couldn’t say it yet, I nodded dumbly to “few months follow-up,” because, well, maybe. I wonder if they’ll believe I didn’t say it because it hurt too much. And now. Now I tell my patients I’m going to Uganda, they tell me to be careful, they tell me to come back.<br />
<br />
In the years before personal TVs in seat-backs and interactive maps, I used to think that flying over the North Atlantic—icebergs visible, sometimes—was the most exciting thing. I’d look for the maps of the flight path, posted somewhere near the galley, back bathrooms. Now I’m breathless, flying over the Sahara. It defines and divides the continent—North, or Sub-Saharan. The anticipation of crossing it, majestic, immense, impossible so, is of what lies south. The scattered clouds. Most of the time, I fly to Africa during the day. It’s not my second-favorite continent anymore.<br />
<br />
******<br />
<br />
In Brussels. Two hours until I leave for Africa. One hour before boarding the plane to Kigali. I’m not wearing pagne, not this time (on the way to Cameroon, I generally wear Eto'o Fils), but there is some pagne packed in a bag of mostly medical supplies. That bag, as I am, is en route to its 9th African country. Walking around the gates of this terminal closed off by customs, I chance upon one scheduled for Yaounde. It is Wednesday—I think the one from Brussels is the MWF flight. My heart, to be both blandly general and exquisitely specific—aches. Maybe it’s a mistake to not be going. Not this time. East Africa isn’t home, it isn’t as loud and chaotic and colorful and full of spice (literal and figurative). Even considering my friends in Kenya, where I too, promised I would be back to Migori, and hoped to mean it. But there is a sense of belonging in Africa. Both appearing so starkly Other...mzungu (ntangen…white…foreign) and feeling like I belong. One of the most difficult parts of reentry and readjustment after Peace Corps. But, as I’ve learned, you can go home.<br />
<br />
<span class="Apple-tab-span" style="white-space: pre;"> </span>From what I’ve heard and seen in pictures, this hospital, this town (Kisoro, Uganda, and also a district hospital like Mvangan was) is much more developed than Mvangan—thus also busier. And there is no French or Bulu to fall onto, but constant translation. I’ve been called “dokita” (Bulu) and “docteur” and “doctor” many times before in Africa. For this first time, it’s true. I wrote my applications to medical school from Cameroon, about Cameroon, I worked (though mostly in public health) in the hospital there. I returned to the US briefly, then on to Kenya to start tentative steps in medicine, the summer before I started school. Then again to Cameroon in 2009, summer between 1st and 2nd years of medical school, both doing research and doing consultations (precepted!) in the hospital in Yaounde. And then 4th year of med school, back to Cameroon, both in the ER and medicine wards in Yaounde and doing surgeries out en brousse. And now. At every step of my career, I've been back. This only guarantees that I will work in Africa...and in Cameroon...again.<br />
<br />
******<br />
<br />
<span class="Apple-tab-span" style="white-space: pre;"> </span>I’m on the plane now, watching the countdown of minutes, miles on the screen. I can see the Sahara, though it’s unfortunately cloudy. You can just make out the color underneath.<br />
<br />
The temperature is warmer than it was, maybe, but it’s really in landing that I’ll be able to tell. Or not. There isn’t the same portentous humidity on the East side, though, as I’m going very close to the Equator in Uganda, and I lived at 2 degrees north in Mvangan, there are certain similarities. But as I saw in Kenya, there were some trees that were the same, patches, looked like vestiges of what is still rainforest on the other side and in the middle of the continent. But the light will be right. It’s rainy season, and the rain on the tin roof at night will be right. The clouds are lifting. I can see more of the Sahara. And now it’s the Nile, I’m on the East side of the plane. Few oases along the banks; the map notes Khartoum, and I can just make out a larger cluster. It grows dark before we reach the southern edge of the desert, the Sahel, the transitions.<br />
<br />
<span class="Apple-tab-span" style="white-space: pre;"> </span>It’s a tradition I learned in African dance. The drums speak. Dance is about doing what the drums tell you, listening, and then not listening but becoming part of the music. Your body being inside the music. If the drummers keep going, you do. If they switch abruptly, you do. They direct everything. It’s one of the things I love best about it. The complete abandon that is necessary. And becoming rhythm, music, speech. At the end, the dancers go in front of each drummer, pressing both hands together as if in prayer, lowering your head to kiss your fingertips, and pressing them to the ground in front of each drum. Each drummer. They are above human, they are to be respected and revered. They create you. That’s where I learned. Malian dance class. 2002. It’s an amazingly, incredibly diverse continent, with >200 languages and ethnicities in Cameroon alone, with every landscape imaginable and history from prior to it. I recognize it, but still, there is something intangible and specific about returning to the diverse, heterogenous continent.<br />
<br />
I hope we land on the tarmac, I hope there is an external stair, I hope we descend immediately into African air and African soil.<br />
Regardless, I know what to do. I know what I will do. It’s been almost three years.<br />
Reverence.<br />
<br />
~j<br />
Disclaimer: This was written Feb 29-March 2, but I'm posting it on March 6th, from Uganda. I am currently in Kisoro, I've been in the hospital since Thursday, and there will be more regarding that, soon. There will be/are real time delays, as with internet.<br />
<br />
*****<br />
<br />
le 29 fevrier ->2 mars 2016<br />
<br />
It’s been almost three years. And this is the first plane ticket I have personally paid for. Then again, it’s the first time going that I have a job. Then again, it’s the first time I’m going as a doctor. My (nascent) career trajectory has spanned this. Next time, I’ll be on my own, maybe with Peace Corps, maybe MSF. A friend in med school commented once, it was hard to imagine there was a time when I hadn’t been to Africa. It’s true. Now 1/3 of my life since that first moment. In first grade, so enamored of geography before I’d seen anything other than the country of my birth, my most native tongue, France, snd the country that has claimed most of my years and words. I named Africa my second-favorite continent (Europe was first), and Ouagadougou was my favorite capital (Burkina Faso). My favorite movie was Cheetah—a Disney movie in the 80s, two kids and their Maasai friend trekking across the Serengeti in search of a cheetah (duma) they had rescued from the poacher that killed its mother, taking this one for greyhound racing. And in 2008, before going to Kenya, I downloaded “Jambo Bwana,” from the movie’s soundtrack. I named the kitten who came with my house in Migori (as did hundreds of of bats under the eaves) Duma. I went on safari, overland, in Maasai Mara (the Kenyan side of the Serengeti). I saw a cheetah.<br />
<br />
<span class="Apple-tab-span" style="white-space: pre;"> </span>I wrote about this almost three years ago. What it feels like to return to Africa. The light. The Equatorial light, existing in the back of my eyes like uncapturable jungle greens, makes me ache. The Constant Gardener has it right. Paris has a light. So does Equatorial Africa.<br />
<br />
<span class="Apple-tab-span" style="white-space: pre;"> </span>I wonder if, in this direction, I´ll see the Sahara in the same way. I wonder if, descending, I’ll feel the rush of warm air into the plane. I wonder if, in landing, the plane will erupt into applause. Flying to Cameroon is that way.<br />
<br />
*****<br />
<br />
<span class="Apple-tab-span" style="white-space: pre;"> </span>I wept the first time I flew away from Africa. I kissed my fingertips and touched the tarmac in Douala (…and our Kenya Airways plane turned around soon after take-off, we landed in Douala, and, 26 hours later, I left again). When I returned to Africa (Kenya) six months later, I kissed my fingertips and pressed them to the earth. A year after that, I was back in Cameroon. You can go home again. I have. But in the between times—Africa makes me ache. Everyone, everything I know there, wondering who will be alive, the next time. Or have died of what. It’s funny to think of it as a continent, in so many ways (though the country I consider home is called “Africa in miniature.”) Or anything unified, really, when even within countries borders are arbitrary, so being from one nationality means many divergent cultures, traditions.<br />
<br />
<span class="Apple-tab-span" style="white-space: pre;"> </span>It’s been almost three years. I’ve traveled to the developing/Southern/non-Western (not true, for Central America), Global South three times on vacation in the past three years. But the first time I went to Africa, first time I went anywhere but the US or Europe, I moved in. Comfortable, stubborn, familiar in a plaster and stone house in the equatorial rainforest, with mostly walls, five rooms, and in the annual migratory path of the biting ants that can kill a child (a swarm of hundreds of thousands acting as one organism, in through a living room window, out through the kitchen at the other end). <br />
<br />
In Cameroon in April 2013, my last time anywhere in Africa, I was such an almost-doctor that all I had left of med school upon my return was graduation. This time, I’m such an almost (terrifyingly so) – attending that upon my return, I have 2.5 months left of residency. But now. Now I refuse to tell my patients I’m leaving. Not yet. There’s a minuscule “maybe” in there. But really I wonder if they’ll forgive me, if they’ll believe I didn’t say it, couldn’t say it yet, I nodded dumbly to “few months follow-up,” because, well, maybe. I wonder if they’ll believe I didn’t say it because it hurt too much. And now. Now I tell my patients I’m going to Uganda, they tell me to be careful, they tell me to come back.<br />
<br />
In the years before personal TVs in seat-backs and interactive maps, I used to think that flying over the North Atlantic—icebergs visible, sometimes—was the most exciting thing. I’d look for the maps of the flight path, posted somewhere near the galley, back bathrooms. Now I’m breathless, flying over the Sahara. It defines and divides the continent—North, or Sub-Saharan. The anticipation of crossing it, majestic, immense, impossible so, is of what lies south. The scattered clouds. Most of the time, I fly to Africa during the day. It’s not my second-favorite continent anymore.<br />
<br />
******<br />
<br />
In Brussels. Two hours until I leave for Africa. One hour before boarding the plane to Kigali. I’m not wearing pagne, not this time (on the way to Cameroon, I generally wear Eto'o Fils), but there is some pagne packed in a bag of mostly medical supplies. That bag, as I am, is en route to its 9th African country. Walking around the gates of this terminal closed off by customs, I chance upon one scheduled for Yaounde. It is Wednesday—I think the one from Brussels is the MWF flight. My heart, to be both blandly general and exquisitely specific—aches. Maybe it’s a mistake to not be going. Not this time. East Africa isn’t home, it isn’t as loud and chaotic and colorful and full of spice (literal and figurative). Even considering my friends in Kenya, where I too, promised I would be back to Migori, and hoped to mean it. But there is a sense of belonging in Africa. Both appearing so starkly Other...mzungu (ntangen…white…foreign) and feeling like I belong. One of the most difficult parts of reentry and readjustment after Peace Corps. But, as I’ve learned, you can go home.<br />
<br />
<span class="Apple-tab-span" style="white-space: pre;"> </span>From what I’ve heard and seen in pictures, this hospital, this town (Kisoro, Uganda, and also a district hospital like Mvangan was) is much more developed than Mvangan—thus also busier. And there is no French or Bulu to fall onto, but constant translation. I’ve been called “dokita” (Bulu) and “docteur” and “doctor” many times before in Africa. For this first time, it’s true. I wrote my applications to medical school from Cameroon, about Cameroon, I worked (though mostly in public health) in the hospital there. I returned to the US briefly, then on to Kenya to start tentative steps in medicine, the summer before I started school. Then again to Cameroon in 2009, summer between 1st and 2nd years of medical school, both doing research and doing consultations (precepted!) in the hospital in Yaounde. And then 4th year of med school, back to Cameroon, both in the ER and medicine wards in Yaounde and doing surgeries out en brousse. And now. At every step of my career, I've been back. This only guarantees that I will work in Africa...and in Cameroon...again.<br />
<br />
******<br />
<br />
<span class="Apple-tab-span" style="white-space: pre;"> </span>I’m on the plane now, watching the countdown of minutes, miles on the screen. I can see the Sahara, though it’s unfortunately cloudy. You can just make out the color underneath.<br />
<br />
The temperature is warmer than it was, maybe, but it’s really in landing that I’ll be able to tell. Or not. There isn’t the same portentous humidity on the East side, though, as I’m going very close to the Equator in Uganda, and I lived at 2 degrees north in Mvangan, there are certain similarities. But as I saw in Kenya, there were some trees that were the same, patches, looked like vestiges of what is still rainforest on the other side and in the middle of the continent. But the light will be right. It’s rainy season, and the rain on the tin roof at night will be right. The clouds are lifting. I can see more of the Sahara. And now it’s the Nile, I’m on the East side of the plane. Few oases along the banks; the map notes Khartoum, and I can just make out a larger cluster. It grows dark before we reach the southern edge of the desert, the Sahel, the transitions.<br />
<br />
<span class="Apple-tab-span" style="white-space: pre;"> </span>It’s a tradition I learned in African dance. The drums speak. Dance is about doing what the drums tell you, listening, and then not listening but becoming part of the music. Your body being inside the music. If the drummers keep going, you do. If they switch abruptly, you do. They direct everything. It’s one of the things I love best about it. The complete abandon that is necessary. And becoming rhythm, music, speech. At the end, the dancers go in front of each drummer, pressing both hands together as if in prayer, lowering your head to kiss your fingertips, and pressing them to the ground in front of each drum. Each drummer. They are above human, they are to be respected and revered. They create you. That’s where I learned. Malian dance class. 2002. It’s an amazingly, incredibly diverse continent, with >200 languages and ethnicities in Cameroon alone, with every landscape imaginable and history from prior to it. I recognize it, but still, there is something intangible and specific about returning to the diverse, heterogenous continent.<br />
<br />
I hope we land on the tarmac, I hope there is an external stair, I hope we descend immediately into African air and African soil.<br />
Regardless, I know what to do. I know what I will do. It’s been almost three years.<br />
Reverence.<br />
<br />
~j<br />
<br />Jennifer Stellahttp://www.blogger.com/profile/01985168402480341835noreply@blogger.com0tag:blogger.com,1999:blog-5640057601871676179.post-13082156371690053142015-11-14T15:42:00.002-05:002015-11-14T15:51:30.382-05:00# Porte Ouverte<!--[if gte mso 9]><xml>
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<br />
<div align="right" class="MsoNormal" style="text-align: right;">
<span lang="EN-US">le 14
novembre 2015<o:p></o:p></span></div>
<div align="right" class="MsoNormal" style="text-align: right;">
<span lang="EN-US"> </span> </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">It was ten months ago that I wrote about
freedom of speech, of words, of the privilege of pens, and of those were
killed, in some ways, for that. #Je Suis Charlie. Today, yesterday, it’s
freedom of assembly. A concert (could “death metal” become more ironic?). A
soccer game. Restaurants. Freedom of movement, of passage. The borders are close
to closed. Famously, in the 1830s (as also depicted in <i>Les Misérables</i>), Paris was barricaded, fighting from the inside.
Seventy years ago, there was the Maginot line, there was “Free France” and my
grandparents fighting in the Resistance, there was my old favorite movie, <i>La Grande Vadrouille</i>, with the propeller
plane landing just over an invisible frontier and then escaping back to
England. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">I still don’t know how much we should take
for granted. There is a UN declaration. But not even every country is counted
in that.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">I commented to a friend that this—ISIS, all
of it—is like a terrible, blockbuster movie for July 4 weekend. Except I don’t
know who the hero is. There isn’t one. In another friend’s village in Cameroon,
he discovered that people believed that in action movies, those who die, die.
Ebola was that. I have trouble truly conceiving of so much destruction I have
not experienced except in fiction. I know personal tragic and tragedies. I’ve
seen babies, so many babies (and so many adults) die of AIDS. And TB. And
malaria. And diarrhea. And malnutrition. And tetanus (the most banal-sounding
shot I give my patients to check off the 10-year mark) : a five-day old with
lockjaw who died because he couldn’t feed. And there was nothing else to do. I’ve
seen that. I’ve been in shantytowns. I was in Kenya six months after buildings
and people were burned in the 2007 elections. I saw the burn marks. But I’ve
never been in it.<o:p></o:p></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhMnIjutNqkhjEJbB_EgxMJiudKwRDTrxViJaFJBxQpSnEqsRDvkwJLNmfztonFYFZMY6jV45GzxqYLE-wABmV-B7rxalwpwF5Mu92UY5CaF_Ne9bNUO_hOsCfgFbqXsX1WBlTNb1y1Mo16/s1600/11707385_10100889456903059_2710355850297559128_n.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhMnIjutNqkhjEJbB_EgxMJiudKwRDTrxViJaFJBxQpSnEqsRDvkwJLNmfztonFYFZMY6jV45GzxqYLE-wABmV-B7rxalwpwF5Mu92UY5CaF_Ne9bNUO_hOsCfgFbqXsX1WBlTNb1y1Mo16/s320/11707385_10100889456903059_2710355850297559128_n.jpg" width="320" /></a></div>
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<span lang="EN-US">In France…the example because it’s what I
write today and it’s what I know most…there are bomb scars on buildings. World
War II. I. There are plaques. Grandparents were in it. Parents vaguely remember
so little food. None of that exists in the US; save now the September 11
memorial and buildings. Maybe. The small shock of the skyline in older movies
and photographs. But war hasn’t been here; terror, not war; since the 1860s.
Not here. I’m writing in New York, I’m writing a 15-minute walk from the 9/11
memorial, having climbed the stairs from the subway station still marked “World
Trade Center.” I remember well the events. War has not happened here. Hate has
happened here, hate happens here. But it’s easier to go to war when you haven’t
been inside it, when it doesn’t threaten the lives of everyone left behind.
Indirectly. It’s easier to bomb. It’s easier for war games to be an exercise.
One of the people I love dearly is a naval officer. It’s easier as an exercise.<o:p></o:p></span></div>
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<span lang="EN-US">I don’t believe this in the name of
religion. We have that, the freedom of. They call it rape, pillage, murder in
the name of Islam. Take anyone or anything’s name instead. A thousand years
ago, and now, it was and is rape, pillage, murder in the name of Christianity.
Many thousands of years ago, and now, it was and is rape, pillage, murder in
the name of Judaism. Bombs, bombs, more people incinerating themselves and
nearby others, unmanned planes, bombs. When I was much closer to agnostic than
atheist (it’s now been maybe two decades), I figured that for any god, if my
only grave mistake, my major misstep, was not believing, I would be let into
whatever counted as a benevolent afterworld. Comforting, that was. Within the
construct of faith, to me, that seems true. Murder of non-believers does not.
But it doesn’t matter what I believe in now. None of this could be done in the
name of a higher power. Anything can be done in anyone’s name, anyone can be slandered,
libeled, vilified, raked through the proverbial mud and over the proverbial
coals in a misrepresentation. <o:p></o:p></span></div>
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<span lang="EN-US">I can’t help but naively believe, some
days, that if everyone did art, if everyone lived and breathed art for some
period of their lives, there wouldn’t be killing. Not like this. But maybe I
have to exclude sociopaths, and maybe that’s all this is. (But per psychology
books by and about people defined as “sociopaths,” I have to say that they,
too, are unjustly misrepresented by that name and that it takes something more
to kill in this manner). Poetry, to me, is connection. I feel that when I read.
Someone says something that is so raw, deep, true to my own experience, breath
to page to breath. And the greatest gift is when I have been told that about my
own. It’s true of every art, but I know best that one. My theory falls short
for those who do not connect. Or do not want to. Juliana Spahr wrote the book
of poetry <i>This Connection of Everyone
with Lungs</i>. In part, she writes about 9/11 and how in Hawaii the air she
breathed was also to and from New York. Extrapolate to tsunamis, hurricanes in
Haiti, nuclear plant disasters, kidnappings in Mexico, college kids shot in
Kenya, internal displacements in Syria, shootings and bombings in Paris,
yesterday, and war, war, war. This is reality, it’s reality for too many, and
it has to be incorporated as that. <o:p></o:p></span></div>
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<span lang="EN-US">In the country of my birth, of my first and
native tongue, in whose language I have been told I write the rawest and most
real poems, in a beloved city in which I have lived, no one I know personally
has died or been in the places where people died. Not last night. But my cousin’s
young son marched in his first rally? protest? march, ten months ago, after the
shootings of journalists at <i>Charlie Hebdo</i>.
And eleven months ago, two of my attendings’ young sons were carried in their
first rally, protest, march in the name of Black Lives Matter. Neither has gone
away in either city. (I don’t mean to compare time-delineated terrorist attacks
with systematic, institutionalized, pervasive racism. Only in the sense that
these two are what large groups in each country have recently gathered around).
It takes something truly, truly egregious and outrageous to bring it back. It’s
a state of national emergency, France is in three days of national mourning. I
think that when Les Bleus defeated Brazil 3:0 in the 1998 World Cup, in the
Stade de France, incidentally one site of killing last night, there were three
days of celebration because it was le 14 juillet, Bastille Day. The World Cup victory
had happened just before. This time, it’s just after Veterans’ Day. In New York,
I think I notice flags at half mast on an almost-daily basis, and I’ve stopped
wondering for what. <o:p></o:p></span></div>
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<span lang="EN-US">Should I compare this to medicine, think as
I often do and write of life in those terms?<o:p></o:p></span></div>
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<span lang="EN-US">One thing we do in my residency program is
medical interviews for asylum. Mostly, these are asylum-seekers on the basis of
torture in their native countries. We transcribe their stories. We describe and
photograph their scars. We ascribe the diagnostic criteria of post-traumatic
stress. My first interview was with a man who told me about friends shot around
him in a soccer stadium. Officers had infiltrated and opened fire. He was
kicked and stamped on while pretending to be dead.<o:p></o:p></span></div>
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<span lang="EN-US">I thought of that.<o:p></o:p></span></div>
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<span lang="EN-US">On est ensemble.<o:p></o:p></span></div>
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<!--EndFragment--><br />Jennifer Stellahttp://www.blogger.com/profile/01985168402480341835noreply@blogger.com0tag:blogger.com,1999:blog-5640057601871676179.post-70010260010332802502015-01-10T20:56:00.003-05:002015-03-18T09:53:06.052-04:00All the dangerous things we do with our hands<div align="right" class="MsoNormal" style="text-align: right;">
<span lang="EN-US">le 10
janvier 2015<o:p></o:p></span></div>
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<div class="MsoNormal">
<span lang="EN-US">Wielding pens. Waving swords. Stopping
traffic.<o:p></o:p></span></div>
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<span lang="EN-US"><span style="mso-tab-count: 1;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US">I’ve believed that for a long time, not
just in the old adage that “the pen is mightier than the sword.” As a writer
and a doctor, one of my greatest hopes and exultations in earning my MD was the
power and respect the degree bestows, for better or for worse, deserved or not,
to be a spoken/outspoken advocate, and to be published for it.<o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US">I use writer in the sense of “someone for
whom the act of writing is not an option; someone for whom writing is as necessary
to existence as is oxygen.” I use doctor in the sense of not just the
traditional physician and caretaker for a body and a person, but in the Latin
derivation of “<i style="mso-bidi-font-style: normal;">doceo, docere</i> – to teach.”
<o:p></o:p></span></div>
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<span lang="EN-US">Almost every sentence and every paragraph
here starts with I. There is, too, now, “Je suis Charlie/ I am Charlie,” for
what it’s worth, for belief in and disbelief against the recent attacks in
Paris of freedom of speech.<o:p></o:p></span></div>
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<div class="MsoNormal">
<span lang="EN-US">I have recently felt ill, paralyzed,
galvanized by moment and by turn by the deaths of Ebola, inequalities in Africa
and health systems in Africa, prejudice, hatred, and fear of those of African
descent living in the United States, focus on a few individuals sick in a
country where they can be taken care of versus thousands upon thousands in
countries whose fragile infrastructures are being destroyed; by injustices
perpetrated by institutional racism across the country and most poignantly,
most close to home in New York, a system in which I, physicians in general,
anyone in a hierarchical position of power is complicit, where I weakly, as a
primary care physician, offer flu shots and preventative measures to my
patients who, in the South Bronx, are more likely to go to prison than to
college, who could be stopped and frisked on the basis of nothing, who fear and
are injustly feared on a daily basis. <o:p></o:p></span></div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgB_Nvza95aXxfm7AiNVYhdl3XB7dQpzZq7ZJmaFCjLLESCyb3aByBenN-KUZG-YlQUhMcGhYFELY46l5ifNuioobEQg-Ld4y3ZVrvR0KgVO4IYix_sEVgLyEAL3XyvmzdMBo4uZOmXduih/s1600/5000-personnes-au-rassemblement-lannion.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgB_Nvza95aXxfm7AiNVYhdl3XB7dQpzZq7ZJmaFCjLLESCyb3aByBenN-KUZG-YlQUhMcGhYFELY46l5ifNuioobEQg-Ld4y3ZVrvR0KgVO4IYix_sEVgLyEAL3XyvmzdMBo4uZOmXduih/s1600/5000-personnes-au-rassemblement-lannion.jpg" height="180" width="320" /></a></div>
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<a href="http://www.ouest-france.fr/charlie-5000-personnes-au-rassemblement-lannion-3105561" target="_blank">Lannion, my hometown - where 5000 people is a large percentage of the population</a></div>
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<span lang="EN-US">There is the public health. <o:p></o:p></span></div>
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<span lang="EN-US">There is fear, worry, and helplessness
because my friends in Africa have a higher chance of dying because, well, they
have a higher chance of dying, and in two and a half years I went to
exponentially more funerals, including those of children, than I have ever
attended in the United States. <o:p></o:p></span></div>
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<div class="MsoNormal">
<span lang="EN-US">There is anger, outrage, need for telling
when one of my patients almost died because of his insurance company and the
lack of single payer health care, the lack of a generalized belief in health
care as a human right in this country (article in progress, submission of said
article to be done).<span style="mso-spacerun: yes;"> </span>He’s the first
patient I asked if I could write a story about, a patient I know well, and he
wanted me to publicize his story, to let others know, to try to help this not
happen to anyone else. It was one of the best medical visits we’ve ever had. <o:p></o:p></span></div>
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<div class="MsoNormal">
<span lang="EN-US">I often end up watching the news, being
part of the world, in patients’ rooms. We talk about it. It’s where I’m near
TVs. In the intensive care units, these patients might be comatose, sedated,
intubated, and as I try to remember and still speak to them as people, I become
more part of the world.<o:p></o:p></span></div>
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<span lang="EN-US">I watched the events in Paris, some of,
unfold in such a room. The patient was maybe-dying; a patient we’d had arrive
last week in a similar condition did die. Because the hospital does not have
the capacity it should for patients of this acuity of illness, because systems
and overcrowding and a Bronx that has one of the highest burdens of illness of
anywhere I’ve worked, he had not received an adequate level of care for the two
days since his heart stopped and was restarted. I know little more about him
that what the scant notes told me. I know he immigrated at some point, I know
he mostly speaks Spanish, and I can imagine that due to a paucity of
translators (though the phones are available everywhere), minimal time, and
sometimes a lack of value placed on communication with patients and families in
languages that they fully understand, he had likely not received the highest
level of care or explanation of his condition. He apparently has a primary care
doctor, that’s somewhat lucky. He was able to have a procedure to open the
clogged vessels in his heart, that’s lucky too --- though it shouldn’t be.<o:p></o:p></span></div>
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<span lang="EN-US">So I was standing behind the head of his
bed, increasing his level of sedation as he started to resist us placing a line
in the largest vein in his neck, to give him the medications he needed to
increase his blood pressure to the point of getting sufficient oxygen to his
brain and to the rest of his body. It’s not just because Paris is partly home
(true), or because I was there two months ago (also true), or because so many
people I care about so much are there (true), but I felt more sick and focused
on this, the fear minimally of death compared to the fear and horror of
violence against writing and writers, than by the pain I was inflicting on a human
being for “his own good,” necessity, for his illness that was contributed to by
societal inequalities.<o:p></o:p></span></div>
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<span lang="EN-US">All of the above would be silent, unknown,
if they could not be written of. There is TV now, internet, social media and
the Arab spring, There is the movie held from theaters for political threats.
But first, foremost, and still (yes, a picture may be worth a thousand words),
there are writers, there are pens, there is finding the exact expression of
something that is not for and by one but that is for and by a collective.<o:p></o:p></span></div>
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<span lang="EN-US">Plato banned poets from the Republic. They
were too dangerous.<o:p></o:p></span></div>
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<span lang="EN-US">It’s not just that they were writers and
artists. It’s that an editorial board meeting was targeted (and what, more than
that, proves the power of words?) In France, political satire is an integral
part of the culture. The political cartoonists were, are famous, before their
violent deaths for writing. Not every country would hold a national day of
mourning for writers. In few countries are major streets and squares, and so,
so many other public and critical things, named for writers and philosophers.
Writers are venerated. Artists are venerated. There are TV shows, many, solely
of political cartoons and sketches. There are more newspapers than this one.
Growing up in the United States, spending much but far too little time in my
native country, in my first language, even I knew their names. <o:p></o:p></span></div>
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<span lang="EN-US">With everything wrong and injust and
indignifying and terrifying and almost to be believed in the world (what else
makes the news?), the largest piece of meaning, what I personally (and everyone
is making this personal. Freedom of speech, freedom of expression is not just a
societal but a personal human right granted to every individual – or should
be—Je suis Charlie, I am Charlie) want to make a major part of my life is to
write about it. There is arrogance in that too, in the need and want for
publication. But it is tapping into a collective conscience, conscious and
unconscious, Poetry is, anyway. Many of the writers in Paris wrote under
assumed names, partly because that, too, in political satire there, is part of
the culture. They were still known as people. Any attack on writers is not just
an attack on writers but on everyone with a mouth, a tongue, a hand, an ear. <o:p></o:p></span></div>
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<span lang="EN-US">In Cameroon, I know people afraid to speak
of politics in taxi cabs. On presidential election day in 2007, my friends didn’t
want me to leave my house for fear of what I would see and what could,
potentially, happen to me. The same year, I spent six months trying to master
the bureaucracy of the French embassy in order to register to vote as a citizen
abroad, I traveled (four times) one hundred miles in fourteen hours in order to
vote. In the United States, I have campaigned in every presidential election
since 2000. And I have been grateful for the accident of birth that gave me two
passports in two countries that honor, that promote the right to speak and
write freely. This shouldn’t happen in my first, my native country and language
or in the country I am also from and where I’ve spent most of my life. <o:p></o:p></span></div>
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<div class="MsoNormal">
<span lang="EN-US">There is nothing left to say, there is
nothing left to write but to speak. And to write.<o:p></o:p></span></div>
Jennifer Stellahttp://www.blogger.com/profile/01985168402480341835noreply@blogger.com1tag:blogger.com,1999:blog-5640057601871676179.post-88144616476614212422015-01-10T20:50:00.001-05:002015-03-18T09:53:06.057-04:00Toutes les choses dangereuses qu'on fait avec nos mains<div align="right" class="MsoNormal" style="text-align: right;">
<span lang="FR" style="font-family: Times; mso-ansi-language: FR;">le 10 janvier 2015<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="FR" style="font-family: Times; mso-ansi-language: FR;">Manier le stylo. Brandir l’épée. Arrêter les voitures.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="FR" style="font-family: Times; mso-ansi-language: FR;">J’y ai cru pour longtemps, pas seulement dans le vieil adage que « le
stylo est plus puissant que l’épée. » Ecrivain et médecin,<span style="mso-spacerun: yes;"> </span>un de mes plus grands espoirs et joies dans
l’acquisition de mon doctorat était la foie dans le pouvoir et le respect qui
vient avec, pour le meilleur ou pour le pire, méritée ou pas, d’être défenseur
a haute voix, et d’avoir mes écrits publi</span><span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">é</span><span lang="FR" style="font-family: Times; mso-ansi-language: FR;">s.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="FR" style="font-family: Times; mso-ansi-language: FR;">J’utilise « écrivain » dans le sens de « quelqu’un pour qui
l’acte d’écrire n’est pan une option ; quelqu’un pour qui l’écriture est
aussi nécessaire a la vie que l’oxygène. » J’utilise « médecin »
non seulement dans le sens du médecin traditionnel, celui qui s’occupe du corps
et de l’humain, mais dans le signifiant originel en Latin, « doceo,
docere » - enseigner. » <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="FR" style="font-family: Times; mso-ansi-language: FR;">Pratiquement chaque phrase et chaque paragraphe ici commence avec
« je. » Il y’a aussi, maintenant, « Je suis Charlie, » dans
tout ce que cela représente, pour la croyance et l’incrédulité envers les
attentats récents a Paris contre la liberté de l’expression.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="FR" style="font-family: Times; mso-ansi-language: FR;">Récemment, je me suis sentie malade, paralysée, pousse a agir par moment et
par tour autour des morts d’Ebola, les inégalités en Afrique et dans les systèmes
de sante en Afrique, la préjudice, la haine, et la peur de ceux d’origine
Africaine vivant aux Etats-Unis, la focalisation sur quelques malades dans un
pays où on peut s’occuper d’eux, contre mille et des milliers dans des pays où
les infrastructures neuves et fragiles sont en train d’</span><span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">ê</span><span lang="FR" style="font-family: Times; mso-ansi-language: FR;">tre d</span><span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">é</span><span lang="FR" style="font-family: Times; mso-ansi-language: FR;">truites ; par les
injustices perpétr</span><span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">é</span><span lang="FR" style="font-family: Times; mso-ansi-language: FR;">es par le racisme institutionnel </span><span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">à</span><span lang="FR" style="font-family: Times; mso-ansi-language: FR;"> travers le pays et,
plus poignant pour moi, </span><span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">à</span><span lang="FR" style="font-family: Times; mso-ansi-language: FR;"> New York, dans un syst</span><span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">ème dans lequel je,
et les médecins en général, tout le monde qui fait partie de l’hiérarchie est
impliqué, où je impuissante, comme médecin généraliste/des soins primaires,
offre des vaccins contre la grippe et d’autres mesures préventifs à mes
patients qui, dans le sud du Bronx, ont plus de chance d’aller en prison que
d’aller à l’université, qui pourraient être arrêtés dans la rue sur la base de
rien, qui ont peur et qui font peur, injustement, chaque jour.</span><br />
<span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;"><br /></span>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgB_Nvza95aXxfm7AiNVYhdl3XB7dQpzZq7ZJmaFCjLLESCyb3aByBenN-KUZG-YlQUhMcGhYFELY46l5ifNuioobEQg-Ld4y3ZVrvR0KgVO4IYix_sEVgLyEAL3XyvmzdMBo4uZOmXduih/s1600/5000-personnes-au-rassemblement-lannion.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgB_Nvza95aXxfm7AiNVYhdl3XB7dQpzZq7ZJmaFCjLLESCyb3aByBenN-KUZG-YlQUhMcGhYFELY46l5ifNuioobEQg-Ld4y3ZVrvR0KgVO4IYix_sEVgLyEAL3XyvmzdMBo4uZOmXduih/s1600/5000-personnes-au-rassemblement-lannion.jpg" height="180" width="320" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="http://www.ouest-france.fr/charlie-5000-personnes-au-rassemblement-lannion-3105561" target="_blank">Lannion, lieu de ma naissance--5000 personnes, c'est une grande partie de la ville</a></div>
<br /></div>
<a name='more'></a><o:p></o:p><br />
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<br /></div>
<div class="MsoNormal">
<span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">Voilà la santé publique.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">Il y a la peur, le souci, la faiblesse sans défense parce
que mes amis en Afrique ont une plus haute chance de mourir car, que cela, ils
ont une plus haute chance de mourir, et dans deux ans et demi j’ai participé à
un nombre impossible de deuils, y parmi ceux des enfants, auxquels j’ai jamais
participé aux Etats-Unis.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">Il y a la colère, l’indignation, le besoin de raconter
quand un des patients a presque perdu la vie à cause de sa compagnie
d’assurance santé et à cause du non-existence d’un système de santé organisé et
national aux Etats-Unis, le manque de croyance générale dans la santé et les
soins de santé comme un droit humain (mon article est en progrès, et après le
dépôt de mon article en progrès). Il est le premier patient auquel j’ai demandé
la permission d’écrire un article sur son histoire, un patient que je connais
bien, et il veut que je publie son histoire, pour que les autres puissent
savoir, pour essayer que cela n’arrive pas à personne d’autre. C’était une des
meilleurs rendez-vous que nous n’avions jamais eu. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">Souvent, je regarde les infos dans les chambres des patients
hospitalisés. Nous en parlions. C’est quand je suis auprès des télés. Dans les
unités de soins intensifs, ces patients peuvent être dans le coma, sous
sédatifs, intubés. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">J’ai regardé les événements à Paris, quelques uns, se
dérouler dans une de ces chambres. Le patient était peut-être mourant ; un
patient qu’on a reçu la semaine avant dans de conditions similaires est décédé.
Parce que l’hôpital n’a pas la capacité qu’il devrait pour autant de patients
avec cette acuité de maladie, à cause des systèmes, parce que le Bronx a un des
taux plus élevé de maladie que j’ai jamais vu aux Etats-Unis, il n’avait pas
reçu un niveau adéquat de soins pour les deux jours depuis que son cœur s’est
arrêté et qu’il s’est remis à battre. Je connais très peu sur lui, pas plus que
ce qui contient les notes courtes. Je sais qu’il a immigré à un moment de
quelque part, je sais qu’il parle principalement espagnole, et je peux imaginer
qu’à cause de l’insuffisance des traducteurs (pourtant, il y a des téléphones
avec services de traduction partout), peu de temps, et parfois un manque de
valeur placée sur la communication avec les patients et leurs familles dans des
langages qu’ils comprennent, il n’a probablement pas reçu les meilleurs soins
ou une explication de sa condition. Il a, apparemment, un médecin
primaire ; c’est un peu chanceux (et ça ne devrait pas l’être). Il a pu
avoir une procédure pour ouvrir les artères bloquées dans son cœur, c’est aussi
chanceux. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">Alors j’étais debout derrière la tête de son lit,
j’augmentais son niveau de sédatifs parce qu’il commençait à nous résister dans
le placement d’une ligne dans la veine la plus grande don son cou, pour lui
donner les médicaments ce dont il avait besoin pour soutenir sa tension
artérielle<span style="mso-spacerun: yes;"> </span>au point de circuler le sang
et l’oxygène à son cerveau et au reste de son corps. Ce n’est pas seulement
parce que Paris, c’est en partie le chez moi (vrai), ou parce que j’y étais il
y a deux mois (aussi vrai), ou parce que tant de gens que j’aiment tellement y
sont, mais je me sentais plus malade et focalisée sur cela, la peur de la mort
minime comparée à la peur et à l’horreur de la violence contre l’écriture et
contre les écrivains, que par la douleur que j’infligeais à un être humain pour
« son propre bien, » la nécessité, pour la maladie avec grande
contribution des inégalités sociales.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">Tout cela serait silencieux, pas connu, si on ne pouvait
pas en écrire. Il y a la télé maintenant, l’internet, les médias sociales et le
printemps Arabe. Il y a le filme caché des théâtres à cause des menaces
politiques. Mais en première place, au début (et oui, une photo peut valoir
mille mots), il y a les écrivains, il y a les stylos, il y a la trouvaille de
l’expression exacte de quelque chose qui n’est pas pour et par une personne
mais qui est pour et par la collective. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">Platon a exclu les poètes de la République. Ils étaient
trop dangereux.<o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">Ce n’est pas seulement qu’ils étaient écrivains et
artistes. C’est qu’un rendez-vous éditoriale à été ciblé (et quoi plus prouve
le pouvoir des mots ?) En France, où la satire politique fait tellement
partie de la culture. Ce n’est pas tous les pays qui déclareraient une journée
nationale de deuil pour des journalistes. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">Avec tout ce qui est mal, injuste, terrifiant et presque
ne pas à croire dans le monde (qu’est-ce qu’il y a d’autre dans les
infos ?), la partie la plus signifiante, ce que je personnellement (et
tout le monde fait de cela le personnel. La liberté de la parole, la liberté de
l’expression n’est pas seulement un droit des populations mais un droit humain
et personnel accordé—ou que ça devrait l’être—à chaque individu—Je suis
Charlie) veux faire une grande partie de ma vie, c’est d’en écrire. Il y a
l’arrogance dans cela aussi, dans le besoin et le souhait d’être publié. Et
connu. Mais en vérité, c’est accéder à la connaissance collective. Au moins, c’est
ça, la poésie. Un attaque sur les écrivains, c’est non seulement une attaque
sur les écrivains mais sur chacun avec une bouche, une langue, une oreille.<o:p></o:p></span></div>
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<br /></div>
<div class="MsoNormal">
<span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">Au Cameroun, j’en connais qui ont peur de parler de la
politique dans les taxis. Le jour des présidentielles camerounaises en 2007,
mes amis m’ont défendu de quitter ma maison pour la peur de ce que je verrais
et de ce qui, potentiellement, pourrait m’arriver. La même année, j’ai passé
six mois à naviguer la bureaucratie de l’Ambassade de France pour m’inscrire
aux listes électorales. J’ai voyagé (quatre fois) deux cent bornes en quatorze
heures pour voter. Aux Etats-Unis, j’ai fait de la campagne politique pour
chaque élection depuis l’an 2000. Et je suis énormément reconnaissante de l’accident
chanceux de ma naissance qui m’a donné deux passeports dans deux pays qui
soutiennent, qui protègent (à priori) le droit de parler et d’écrire librement.
Ces événements, ces attaques, ces actes ne devraient pas se passer dans mon
premier, mon pays natale et ma première langue, ou dans le pays duquel je viens
aussi et où j’ai passé la majorité de ma vie.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="FR" style="font-family: "Times New Roman"; mso-ansi-language: FR;">Il n’y a rien d’autre à dire, il n’y a rien d’autre à
écrire que de parler. Et d’écrire. <o:p></o:p></span></div>
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Jennifer Stellahttp://www.blogger.com/profile/01985168402480341835noreply@blogger.com0tag:blogger.com,1999:blog-5640057601871676179.post-61864911919575291872014-12-14T23:01:00.002-05:002015-02-17T23:32:45.595-05:00The Whiter Coat<div align="right" class="MsoNormal" style="line-height: 150%; text-align: right;">
<span lang="EN-US">14 December 2014<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">The Whiter Coat<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<br /></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US"><span style="mso-tab-count: 1;"> </span>I hadn’t worn it in a year.<span style="mso-spacerun: yes;"> </span>Halfway through internal medicine residency,
I’ve lost two of my allotted four. But yesterday, for the <a href="http://www.theguardian.com/us-news/2014/dec/13/marchers-protest-police-brutality-new-york-washington-boston" target="_blank">Millions March</a> in
NYC, I donned my white coat under the banner of “<a href="http://www.pnhp.org/news/2014/december/medical-students-to-hold-nationwide-%E2%80%98die-ins%E2%80%99-and-protests-wednesday-because-blac" target="_blank">White Coats for Black Lives,</a>”
over jeans, under scarf and knit hat. Doctors worldwide wear stethoscopes—a
necessary tool, used for heart-lungs-belly-neck. A patient feels taken care of
if you’ve listened to her heart and lungs. We have the laying on of hands and
the laying on of stethoscope diaphragm and bell. Doctors worldwide wear white
coats, a tool of nothing but repository for tools, a signifier of
identification, power, an instrument of implementing hierarchy, and whatever
else (including the positive) that is associated with the profession. With
power comes implied responsibility, a mandate to earn the given trust.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US"><span style="mso-tab-count: 1;"> </span>Before even my first day of medical
school, we received our white coats in a ceremony, parents came and took
pictures, and we solemnly recited the Hippocratic oath, months before touching
our first patients. A symbol of induction into the lifelong guild. For students,
the white coat is short, still symbolizing power to patients perhaps oblivious
to the length, but clearly showing the lowest rank to other doctors. It takes
so many years to arrive at medical school. We had made it. Quickly, I learned
to hate the coat, resent it, except for its many practical pockets, and I
relished the rotations—pediatrics and psychiatry—that didn’t require and even
discouraged its use. In my social medicine program, there is something vaguely
uncool about the white coat, the long white coat we worked so hard to achieve.
I wore it for the protest, yesterday, faint ink marks still visible after
hospital dry cleaning, in a contingent of many others---to show we know We are
an institution, We are implicit and complicit, and We, in positions of power,
are here in solidarity because, among other things, racism is bad for health.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US"><span style="mso-tab-count: 1;"> </span>But to reject the whiteness of the
coat requires whiteness, no need for cloth that soon shows sweat stains to
confer that final privilege.<b style="mso-bidi-font-weight: normal;"> </b></span><br />
<a name='more'></a><span lang="EN-US">How are
non-white-coated doctors of color seen in comparison to those in white coats? I’ve
never thought or asked. It is the white doctors who can reclaim the coat in
this particular era of protest (…partly because doctors are, still, majority
white), to say fuck the institution, to say lie down, pretend to die, and fuck
them, one minute of silence (eleven) for every “I can’t breathe.” Too, at a
medical school, administration having heard vague rumblings of a coming
protest, emailed a few vocal students of color to ask what was happening, assuming
this issue and its demonstrations were divided by color lines. Elsewhere, faculty and administration were in visible support.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US"><span style="mso-tab-count: 1;"> </span>Shortness of breath is a common
chief complaint in offices and then ERs. The white-coated have algorithms
memorized to diagnose and treat that. “I can’t breathe” generally means heart
or lung. And for how long. Are the lungs closing up at any level (either no
sound or whistles), or is the heart unable to move blood and thus oxygen
through the body effectively, fluid backing up to legs (pitted like play
dough), lungs (sound like crumpling tissue paper or the sound it makes if you
pour milk over puffed rice), or the neck announcing every heart beat (anxious
or arrogant in columns directed to the brain). History and physical lead to
different paths, different etiologies, and different treatments. There is also
the anatomic. If your chest wall is constrained and cannot move for force
applied. If your neck is in a noose. This is easy to diagnose. You are unable
to breathe.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US"><span style="mso-tab-count: 1;"> </span>It takes privilege to reject privilege.
And maybe in reality a black doctor should keep a white coat in his car in case
he gets stopped at a non-roadblock, coupled with “MD” ID and stethoscope to toe
past doubt. And maybe in reality a black med student should wear the coat at
all times, because even in a tie he might be confused for any other worker. <b style="mso-bidi-font-weight: normal;"><o:p></o:p></b></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US"><span style="mso-tab-count: 1;"> </span>There is nothing inanimate about an
institution. Medicine is not the prison-industrial complex. But in some places,
a nurse is a warden is a prison medical director. In some places, doctors (<i style="mso-bidi-font-style: normal;">docere</i>, Latin, to teach) supervised
executions. In every place in this country, pronouncing death requires doctors,
as if anyone could not know by focused observation. If someone dies and no
white-coated human passes by, did they really die? <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US"><span style="mso-tab-count: 1;"> </span>Each white coat is full of pockets,
full of tools to fix things in theory. The four pillars of medicine are:
Non-maleficence (do no harm), Beneficence (do good), Autonomy, and Justice. Too
often, the fourth is missing. The injunction to save every life, regardless, is
legacy from ancient Greece. It is so much harder to <i style="mso-bidi-font-style: normal;">do good</i> than to <i style="mso-bidi-font-style: normal;">do no harm</i>
(in which we are often also paralyzed). Many times, it is not possible.<o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US"><span style="mso-tab-count: 1;"> </span>After the protest, I removed my
coat. I replaced it in my closet, haphazard and somewhat folded. At this rate,
I’ll end residency with zero coats, but my next job will likely give me one the
next step up, embroidered with my name. Sewn on and into privilege. White Coats
for Black Lives is from <a href="http://www.pnhp.org/" target="_blank">Physicians for a National Health Program (PNHP)</a>: health
care, equal access for all, health care as a human right. White Coats for Black
Lives, because every doctor gets at least minutes to be white. I can reject the
coat. I should not reject the privilege and power implied (earned and un-) to speak.
We are given the coats from before the beginning. From this position, not just
to the individual patients, we owe: Doing Good, Not Doing Harm, Respecting
Autonomy, and Advocating and Fighting for Justice. <o:p></o:p></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal" style="line-height: 150%;">
<span lang="EN-US">Jennifer Stella, MD</span></div>
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Jennifer Stellahttp://www.blogger.com/profile/01985168402480341835noreply@blogger.com0tag:blogger.com,1999:blog-5640057601871676179.post-51505241202902500292014-02-17T00:32:00.000-05:002015-02-25T01:32:27.737-05:00Let there be equatorial light<div class="MsoNormal">
<span lang="EN-US"><br class="Apple-interchange-newline" />le 27 mars 2013</span></div>
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<br /></div>
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<span lang="EN-US">I used to think of writing (or doing anything inside) by headlamp as spelunking. It was certainly more practical than my first year PCV strategy of candles and kerosene lamp propped on various books and papers—before I had a table—and sitting hunched over to the in the right part of the penumbra.</span></div>
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<br /></div>
<div class="MsoNormal">
<span lang="EN-US">It’s a funny thing about light.</span></div>
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<br /></div>
<div class="MsoNormal">
<i><span lang="EN-US">The Constant Gardener</span></i><span lang="EN-US"> came out weeks before I left for Peace Corps in Cameroon. Without mention anything else I love about the movie (which was great for terrifying many parents of about-to-be PCVs about to move to Africa), the light struck me. The quality of it. I’d noticed years before that Paris has its own quality of light. Some photos, movies capture it (<i>Amélie</i> does). I don’t think you can successfully pretend that something is filmed in Paris.</span></div>
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<span lang="EN-US">This light, though, the Kenya-in-the-movie light, was unlike anything I’d ever seen.</span></div>
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<span lang="EN-US">And then I moved to Cameroon.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">It’s the same light. Gazing across the city at very familiar views this morning (Yaoundé, like Rome or San Francisco, is a city of hills), I remembered it. I have photos of the same view, and in the US they look—faded. Light-stained. But that’s how things actually look.</span></div>
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<span lang="EN-US">The forest almost never comes out, either. I think it’s more greens than the human eye can discern (we can see sixteen shades of gray, I recently learned, on CT scans).</span><br />
<span lang="EN-US"></span><br />
<a name='more'></a></div>
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<span lang="EN-US">**</span></div>
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<span lang="EN-US">I was reminded of <i>why</i> the old Snickers ad (<a href="http://jenny-and-cameroon.blogspot.com/2006/08/not-going-anywhere-for-awhile.html">Not going anywhere for awhile?</a>) and Green Day (“I’ve been…waiting a long time….) used to enter my head so often. It took almost three hours to print and copy one document, for various reasons. On the way to the second printing place, though, I heard someone call my name. I turned. And it was a friend I hadn’t seen in 4 years. Now, he’s at the hospital where I will be this time, Centre Hospitalier et Universitaire de Yaoundé, a different one from where we were previously (he’s a resident). Currently, he’s working in the ICU, which is <i>reanimation</i> here. It’s about coding. (“Code blue”). Come back from the dead, make something alive or lively. Resuscitation, they call it, instead of our Intensive Care. Shortened, it’s “<i>Réa</i>” – it sounds flip in a hopeful way.</span></div>
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<span lang="EN-US">This—the chance meeting—is something that happens. In Ebolowa, my provincial capital, I couldn’t go anywhere without seeing people I knew; it was amazing and heartening a year and a half after I’d initially left. And it used to happen in Yaoundé, occasionally. When I had my first chance run-in in NYC, I knew I really lived there. And here? Apparently, I still do.</span></div>
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<span lang="EN-US">I’m waiting for the chief medical officer of the hospital to meet me and certify that I can be here. All I know thus far about the hospital is from the two French nurses who just left. They saw an upper GI bleeder come in. Died. They didn’t know exactly what was done or what happened.</span></div>
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<span lang="EN-US">This time, I’ll learn about the medical management here—what’s the same, what’s different, and what doesn’t exist. I learned some of that, before. And that you have to buy everything down to the IV tubing.</span></div>
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<span lang="EN-US">ER. Six weeks ago, I was in an ER in Guatemala (working, not sick). Small rural hospital compared to one of the top four in Cameroon, a major teaching hospital. There, they were oddly over-staffed. Here, I am the functional sub-I, or intern to the residents, or whatever approximated role.</span></div>
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<span lang="EN-US">Here, I walked in to see the repair of a scalp laceration, and by scalp lac I mean the cut penetrated to the dura mater, through the skull. Assault by machete. I’ve seen that, but the one I remember was due to a machete accidentally dropped from a tree. That kid looked like he was partly scalped. (And that was one of Doc’s gleeful moments, showing anatomy on monkey bones). Now, I wonder if, in the US, we’d put a JP brain in before closing the laceration. The kid is going to CT. Don’t know.</span></div>
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<span lang="EN-US">Next case. Moto accident led to a comminuted tibial fracture and a shattered fibula. We waited while the patient’s brother bought all the supplies requested. (Were I not there, would they still have had him buy two pairs of sterile gloves….? How to reconcile “teaching hospital” with patients paying for everything you use on them?</span></div>
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<span lang="EN-US">It was the first time I’d sutured in over two years. The light is weak and far away, we can’t raise the bed, the patient’s ankle is a mess with visible bones, he hasn’t had any pain killers and crying/screaming…(we did use local anesthetic)… But medicine is already (re)baptism by fire. Everywhere. This is nothing new. It’s vaguely remembering hand tying and instrument ties (it slowly returns), correctly angling the crescent-shaped needle, with the surgery resident showing me where to close because in that erratic wound with jagged layers, I have no idea.</span></div>
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<span lang="EN-US">Later in the day, I go to Hôpital Centrale to meet Dr. Bwelle for his medical student teaching rounds. He shows me the tall, modern glass-and-brick structure that looks like an added-on center to the other, spoked buildings. It was a Swiss project, he says, supposed to be dedicated to neurosurgery. But the people building it forgot that they were building a hospital. The floors are all completely flat—in ORs, this means nowhere to direct water. It’s all stairwells, for four stories. No elevators. The building has been empty for the past four years.</span></div>
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<span lang="EN-US">This is all too common a story.</span></div>
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<span lang="EN-US">As always, every day is every emotion. Aggravating (the personal level—dérangements, harassment, etc), but then also the men speaking in Bulu about me this morning led to “<i>mintangen a wôk”</i> – you know, the white woman understands you. And then I sat down with my spaghetti omelet and bread and “coffee,” (I’d forgotten about the sweetened condensed milk) and we chatted over their morning beer. (or, it’s evening for at least the one who drives trucks overnight).</span></div>
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<span lang="EN-US">But running from hospital to hospital (and angry when the taximan who <i>had</i> accepted my negotiated price then refused it and wanted more money), an exquisitely-peeled (not a good enough word. It’s beautiful, geometric) green-fleshed orange is just perfect to raise blood sugar back to awake-enough levels.</span></div>
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<span lang="EN-US">63 year-old woman. Altered mental status, sudden onset. Fever. Tachycardic. (and immunocompromised…) My mind starts racing through differentials, I try to rule out meningitis, I start to think about how to work up…and, wait, what we can work up, and I go talk to the attending. “It’s probably neuro-malaria.”</span></div>
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<span lang="EN-US">Oh. Right.</span></div>
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<span lang="EN-US">~j</span></div>
Jennifer Stellahttp://www.blogger.com/profile/01985168402480341835noreply@blogger.com0tag:blogger.com,1999:blog-5640057601871676179.post-86783137801107528602013-12-19T01:50:00.000-05:002014-09-18T00:29:16.429-04:00On Love and MedicinePart old, part new. <a href="http://jenny-and-cameroon.blogspot.com/2010/11/on-love-and-medicine.html">The first part was originally posted November 15, 2010</a>, about halfway through my third year of medical school (edited for length). It takes place during my anesthesia and integrated medicine/neuro/psych rotations. Rereading, though I have changed many descriptors and diseases, I can picture the patients again. Still. What remains is what matters. Then, I had many fewer patients and many fewer responsibilities; in some ways, it was easier to really care. There was more space and time.<br />
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And the second part was written tonight.<br />
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<i>November 15, 2010</i></div>
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<i>Fresno and San Francisco, California</i></div>
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<i>MSIII</i></div>
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<span style="background-color: white;"><i>I think a lot about “for better or for worse” these days. In medicine, you see a lot of “worse” and “worse”, and I see a lot of partners who are there for both. For anything. Siblings, children, grandchildren, nieces, nephews, friends. I guess these would be the ‘chicken soup’ or whatever stories (are they even still publishing those?) But it’s true – rushing around, where so many things are difficult and sad – it’s something to stop and think about. Or try to remember to stop and think about. With the sickest patients, it’s their loved ones that I know. The ICU patients, the altered mental status patients, dementia, kids…whatever. I’ve spoken with a lot of family members. In anesthesia, wheeling people into surgery, you leave Loved Ones at the corner. (They call it the ‘kissing corner.’ Really). And you see them into the waiting room, point it out, say go get coffee or whatever, we’ll be ____ hours, and don’t worry, we’ll take really good care of X. Your X. I’ve seen the wide eyes when we push through the doors again, X is barely waking up from surgery, likely has an oxygen mask over her face, and we’re rushing into the PACU. It doesn’t mean anything’s wrong. It’s normal, and it means the surgery’s over, and if people don’t look like they’re freaking out (The doctors), everything is probably fine. It’s a vulnerable position to see someone in. And in the OR, they’re alone.</i></span></div>
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<span style="background-color: white;"><i>There’s the couple who came in with the wife’s entire medical history typed out – each had their own version – with a list of questions. She suddenly went blind, no one has any idea why, no one has any idea if it’s part of something more progressive – probably. So they’re searching. And with each doctor, they get more frustrated at not having answers. But the other point, to me, is that it’s always both, it’s really about their health, and the patient is – almost – both. Making sure you do speak to both.</i></span></div>
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<span style="background-color: white;"><i>There was the man whose wife died of ALS (Lou Gehrig’s disease). She lived with it for twelve years, far longer than the average prognosis. At the end she was, as they are, completely paralyzed, ventilator-dependent, and could not speak or do anything independently. He ran marathons with her – there were photos of the special chair he ran with. For ALS research. There were vacations…. everything you can imagine that is so hard to imagine in thosecircumstances. So when she died, he wanted to donate all of her special equipment (hundreds of thousands of dollars, I think), some of which he had designed or modified, to other patients. He drove across the country with this. He’s still working with ALS.</i></span></div>
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<span style="background-color: white;"><i>And there’s the patient who had a second stroke on top of her first one and was almost comatose. Before the second one, she and her husband had been living with their daughter, just while she was doing rehab. He kept trying to convince us – again, again, again – that she was fine, that they could go back to their own home. They’d been together over 60 years. All he wanted was to take her home. And then there was the second stroke, and she wasn’t talking but I saw him every day, the daughter, the granddaughters. He left to get food sometimes, when his daughter was around. Otherwise.</i></span></div>
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<span style="background-color: white;"><i>There is love in medicine. And it’s the patients who don’t seem to have that support who are the hardest, for me. Almost doesn’t matter what the diagnosis is. When you can’t send a patient home because there’s no one to help, there, or the people there will not help… it’s hard. And it does change the medical plan. It’s been gratifying to me to realize how much this is taken into account. Teams don’t – or try not to, anyway – discharge patients without knowing where they’re going, and how. (and yes, then they pawn the patient off onto a social worker. but that’s why everyone is expert at different things).</i></span></div>
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<span style="background-color: white;"><i>But medicine has to be a little bit about love. It has to be about healing. When we’re in surgery waiting for pathology to call back – cancer or not cancer – everyone is holding their breaths, a little bit. Everyone wants to know what is finally said. And yes, people get jaded when they are overworked and overtired and it’s overwhelming to care individually about every single person in a day that you’re caring for, and if you’re in the hospital, some of them will die. I’ve heard people comment about the annoying paperwork of death certificates, rolling up the sheets (like we do with everything else) and sticking them into a pocket. Everyone’s job has lots of paperwork and bureaucracy. In this job, the papers can say things like “full code/do not resuscitate/ do not intubate.” A progress note can describe a scene of death, at what time, what exactly happened, who was there. And it can also describe a birth – clinically, the first moments of someone’s life, and not just that but exactly what happened before. And who was there. And what happened. It’s a little bit of personal history before the lungs are even shocked into expanding and the fetal vessel connections close, and, and….</i></span></div>
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<span style="background-color: white;"><i>This is our bureaucracy. This is our paperwork. Birth, death, prescriptions, and “orders.” And “progress notes.” And more “orders.”</i></span></div>
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December 18, 2013</div>
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Bronx, NY</div>
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PGY-1</div>
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Stably sick. Many patients, many families, might not appreciate our divisions between "sick" and "not sick." It's common enough to be in the hospital, yes, but "not sick." The sick ones take more time. The crashing ones - <i>crumping</i> is more common in parlance, but I still prefer the latter - take more time. More time in the room, more time on the phone or face-to-face with the family and with other providers, more time on documentation and reading old records. I've worked in places where people were poor. Yet somehow, in the Bronx, so many are that - and so many are sicker (than in other parts of the US<i>)</i>. I'm not in the ICU, but I may as well be. Many of them should be. </div>
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But this means that so many of my patients are tied to their beds, literally and/or figuratively. Lines and tubes. The breath capacity to cross just half a room before collapsing. Amputated toes and feet and legs. Should-be-amputated limbs. So it's hospital gowns, oxygen prongs or masks, IVs, feeding tubes, breathing tubes, continuous electrodes (and the stickers we absentmindedly leave on), sequential compression devices to prevent blood clots, fluorescent 'FALL RISK' bracelets. An isolation room for whatever infection or risk of infection. They are bedbound, identically dressed, tired, covered in stuck-on gauze for infinitessimal blood draws, barcoded by bracelets. The nurses identify them by room number. I forget those and identify them by name. And because of our ordering system's algorithm, I automatically combine first initial, last initial, age, and sex. The sicker you are, the better I know how old you are. A descriptor, for lack of a more meaningful one to standardize. (The sick-not-sick patient this morning, with biting wit in his jokes, couldn't remember what his birthday was. Or his last name). </div>
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The patients who've had strokes and now can't talk, who've contracted illness-after-illness for years and are now defined by a sick role, wasted away limbs, and a nighttime cry, who are literally being kept alive by machines, or who can now do nothing but breathe and cough--I don't know them. I haven't met them, and I never will. So I define those patients by the people who love them, and how.</div>
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Today, Ms. M, one of my stably-sick (and completely non-responsive) patients began to actively die. Die actively. It has been a long, passive process for her. Every night, I've drawn labs from a central line (one of my favorite activities, every night. <a href="http://scalpelwithwords.blogspot.com/2013/08/peripheral.html">It was the one thing I was sure to get right)</a>. I greet her - it's habit - it's 3 am, and it's like I'm miming a conversation, outloud. Blood out, chemicals back in to balance it. The mathematics of medicine. Eyes open or closed, light always on, a soothing channel on the TV, a sporadic and strong cough to prove a will to live, arms so full of extravasated fluid that the thought of regaining IV access after removing the central line seemed impossible. She caught a cold, it infected her heart, her heart's rhythm mimicked experimental jazz rather than a metronome, a clot snaked or flew up to her brain, she had a stroke and was okay but then there was bleeding after and that pushed part of her brain down into her skull...etc. Etc. But she could still open her eyes (but not follow anything with them, not track like greyhounds on a cheetah track), she could still breath, and she could still spit and cough. She remained. Last night, running in to check oxygen levels in her blood, again (the fingertip monitor), I ran into her sister. And I asked - not just because I cared, partly to make small talk, and partly to make myself care - who my patient was. Who she had been, "before." Someone who helped her twin sons study for the SATs...and then took the test herself, for the first time. Someone who was almost a national track star. Whose first grandson was just born.</div>
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And today, Ms. M began to actively die. She had a fever, all of a sudden. She was breathing twice as fast, all of a sudden. Her oxygen was going down. And her heart had tripled its speed. We knew that her family had decided - for sure - to not intubate her. No machines were going to breathe for her (not again). No chest compressions. But "everything else." I tripped over my words as I called her oldest daughter (now next of kin. Husband died ten years ago). "I'll be there in half an hour," she said. I paused. "Good. We'll talk when you get here." And when she did, I presented the options for testing - why test if the decision will be to not treat - in an unsensitive list, trying to just remember what to say and to be factually correct. She was horrified. Why was testing a question? "Aren't you here to save people's lives??" Pause. "We want to make sure we respect your wishes." "Why aren't you helping her??" </div>
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I am. I will. And as I sat to draw blood for bacterial cultures from her right radial artery, turning over her wrist and watching her arm, full of fluid, settle in place, I had a few minutes to ask who she is. or was. or is. How and why she'd moved to the neighborhood at sixteen, inflating her age on IDs, picking up part-time jobs at the zoo for her to-be-first husband. How she practically collected three-legged cats. The daughter rummaged through receipts in her wallet. "Here. and here." Her mother - my patient - on her own wedding day. And then the daughter, twenty years later, in the same dress. What she looked like. The face they see and that I would never recognize. Later, a large family is hunched in prayer around a breathing-with-difficulty body in a bed. How much love can fit, cliched, in a fluorescent-lit room.</div>
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Another patient's wife. "I know you can't get too attached. You have too many patients. I know. If you cared too much, it would be too hard, you wouldn't be able to stand it. I know. You can't care too much." Right and wrong. But unusual, because for others, <i>their</i> patient is (should be) <i>our</i> only. The partner. "One in a million. Forty years. There aren't any others like her..." paranoia, crippling illness, weakness and dependency. In the hospital, they renewed their vows. (The only other person I know who's done that? One of my clinic patients). The best friend who paused. "This...isn't her. This sick. This wasted. After the last time, she went right back to work." "What was her job?" "Dental assistant. She practically ran the place." I consider the patient I've never seen sit up. We wore the same thing to work - but I can picture her scrubs, the stereotype, brightly colored and pastel. She must have closets-ful. Here, she's surrounded by the same clothes, but more uniform. I'm overwhelmed by the trust people put in me, every day, and I'm overwhelmed by the devotion others show. The son who stayed up all night, every single night, by his father's bed. The daughters with endless containers of chicken soup. The niece of the visibly-dying woman who arrived with purple nail polish and hairspray. When there's little else to go on, when the patients are dressed drably and identically in drab and identical rooms, they become distinguishable by visitors and visiting patterns. </div>
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When I walked into Ms. M's room this morning, I had a nagging thought that something was wrong. There's little to go on. I rechecked. Oxygen, perfect. Lungs, fine. Or rather, the same. Every reaction. The same. I managed to convince myself that I was wrong, using data. Later in the day, as she transitioned from passively to actively dying, I sinkingly remembered the morning. It was something. I had known. A slight color change, a slight grimace, maybe. I was developing an instinct, morbid or not, practical or not, to trust. Had I said so to the team, nothing would have been different. Nothing would have been done differently. She would have started to die at exactly the same rate. That, Ms. M could tell me herself. </div>
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I've written reams about K, <a href="http://jenny-and-cameroon.blogspot.com/2011/04/a-year-for-patients.html">my first patient who died</a>. I have two pictures of her in my head. The emaciated body sinking back into the bed that I encountered upon opening the door to room 782. And the one I found when I looked for her obituary. I never met her family or any friends. Somewhere in the gulf between those pictures, the volume she used to take up, was a life, I like to imagine, well-lived. And loved. I wish every chart was emblazoned with a "before." I was too afraid of K's pain, death, and slow dying to ask enough about who she was---I didn't admit her to the hospital, and I didn't think of asking until she really was too tired for questions. I counted her platelets. I got mad at her oncologists. Back then, I was younger than her. Now, I'm older than she'll ever be. My job includes more counting of more platelets/ particles and chemicals of blood than I might have understood, then. If that was most of what mattered, medicine would be a science. It isn't. </div>
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Jennifer Stellahttp://www.blogger.com/profile/01985168402480341835noreply@blogger.com0tag:blogger.com,1999:blog-5640057601871676179.post-69382349228643510392013-09-09T22:50:00.001-04:002014-02-17T00:34:30.117-05:00Communion<i><span style="background: white; color: #222222; font-family: Times, Times New Roman, serif; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";">Yaoundé, Cameroun</span></i><br />
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Universitaire (CHU)</span></i></div>
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<span style="background: white; color: #222222; font-family: Times, Times New Roman, serif; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";"><i>Last
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<div class="MsoNormal">
<span style="background: white; color: #222222; font-family: Times, Times New Roman, serif; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";">I
flipped open my patient’s blue cardboard folder. <i style="mso-bidi-font-style: normal;">Groupe sanguin. </i>Blood type. ---<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><span style="background: white; color: #222222; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";">***</span><span style="color: #222222; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";"><br />
</span></span><br />
<span style="font-family: Times, Times New Roman, serif;"><span style="color: #222222; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";"><br /></span><span style="color: #222222; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";"><span style="background: white;">The day before, I'd gone to the blood bank at CHU.</span></span></span><br />
<br /></div>
<div class="MsoNormal">
<span style="background: white; color: #222222; font-family: Times, Times New Roman, serif; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";">It
was the first time I'd ever donated – my more than 6 months straight in Western
Europe since 1980 disqualify me by Red Cross standards (mad cow disease/CJD).
And even if that ever changes, after living in Africa, there's no way I'll ever
be able to donate blood in the States. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="background: white; color: #222222; font-family: Times, Times New Roman, serif; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";">The
irony. I can donate in Cameroun. I explained to the phlebotomist that I can't donate
blood in the US, trying hard to make my explanation make sense, without the
questionable undertones of the Red Cross rules rejecting African or
"African-ized" blood. It was my last day at CHU. In a month, I had
watched people die, and I had maybe, minutely, helped. I had spent a night on call learning about how
overstaffed the hospital really is, when compared to the resources they have
for patients. Compared on that alone. The nursing censuses are lower. The
doctor censuses, even, are lower. There were so many eager med students (their
education, not mine), working zealously on med student-thorough, handwritten
H&Ps in French or in English, that they sent me to the resident call room
for an hour or two of sleep. The GI fellow was in there, and she woke up enough
to kick off her shoes, move over, and give me part of the twin bed. I felt
hesitant and unnerved; they were treating me like a doctor (and four months
later, firmly enmeshed in my intern year, I finally don’t jump to attention at the appellation “med student”). <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="background: white; color: #222222; font-family: Times, Times New Roman, serif; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";">The
transition from dark to dawn is the same in every hospital. There are the early
evenings hours. There are the middle ones that stretch forever—nothing good
happens, then. Either people are asleep. Or they are very sick. It's the slight
undertone to complacency on a quiet night. In the US, we have pagers; if you
lie down, you will be awoken. In Cameroon, there are cell phones, of course,
but there is almost no reception in the hospital. And no one knows who is there.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"></span><br />
<a name='more'></a><span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<span style="font-family: Times, Times New Roman, serif;">
</span>
<br />
<div class="MsoNormal">
<span style="background: white; color: #222222; font-family: Times, Times New Roman, serif; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";">I
learned—and taught—chest compressions. I helped “consult” 140 patients in two
hours by kerosene lamp in a cement block school room after a 21 hour trip and
sleeping in a field. I gave hundreds of shots. Hundreds of deworming pills
(mebendazole). (That, the last, is the only thing that rivals blood in real
utility, real helpfulness).<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="background: white; color: #222222; font-family: Times, Times New Roman, serif; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";">The
public health self gave mebendazole.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="background: white; color: #222222; font-family: Times, Times New Roman, serif; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";">The
doctor self gave blood.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="background: white; color: #222222; font-family: Times, Times New Roman, serif; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";">And
it was only one unit of blood. One g/dl hemoglobin. And it’s not type O. I’m no
universal donor. I’m A negative. The phlebotomist exclaimed over and over how rare
it is. A raw moment of guilt. My blood type.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="background: white; color: #222222; font-family: Times, Times New Roman, serif; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";">“Will
it help, anyway?” I asked. Hesitant. A real question. How long does it keep. To
whom do you give the units. How well do the generators work that maintain the
freezers. Let this not be mainly to make myself feel better. I don’t know the
epidemiology of A or AB in Cameroon. In brief genetic terms, I can donate to A
pos or A neg and AB pos or AB neg. And I can only receive A neg or O neg. But
it also means that in emergency situations—when you don’t know the person’s
blood type and don’t have time or lab availability (and the lab closed or out
of reagents or on strike about one third to one half of that month)—you can
only use type O. Not mine.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="background: white; color: #222222; font-family: Times, Times New Roman, serif; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";">Let
there be a point to this. Rather than just calling it an early day and going to
lie down on a table, arm out-stretched, awaiting a quick sugar reward. Tired,
on my second-to-last shift of a long month; days in the hospital and weekends on health
campaigns in villages. A congratulatory and regretful marker—why did I not
think of this years ago. There are useful ways to leave pieces of yourself where you do, regardless.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="background: white; color: #222222; font-family: Times, Times New Roman, serif; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";">***<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="background: white; color: #222222; font-family: Times, Times New Roman, serif; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";">Mr.
C needed whole blood. He needed fresh blood. I don’t remember the medicine of
why or if I understood it in the first place. Fifty-two, seemingly healthy for
the ICU, had some sort of job, I think, and he was weak but awake enough to
talk, and he had a wife, and there was a cousin with a moto or a friend’s moto
taxi who was going to the other hospital’s blood bank or to find someone else
to donate or to find money to pay for the materials to transfuse.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><span style="background: white; color: #222222; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";">Those
were the ICU days. Sylvie (ER resident from Belgium) and I had decided to go
downstairs from the ER (every other emergency department I've known is on the ground
floor or near enough). Maybe it would feel less futile. Patients there had
gloves and beds. Some had blood draws. They had family. They had windows, near
the open air conference balconies.</span><span style="color: #222222; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";"><o:p></o:p></span></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyQ3dYhzwfIsjuL081tZhyphenhyphenr6KRNkjJMiEOiPB75L27aUjXzptqKqRqQsLRNsnLiHNuLa2P65pJ28NwEBxTi0dluesZ8wwHFZ84oq-uVu3yCKm7pTD0qNZr14a7ibjjF6rmU70E3pBjFOTw/s1600/2013-04-16+03.07.29.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><span style="font-family: Times, Times New Roman, serif;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiyQ3dYhzwfIsjuL081tZhyphenhyphenr6KRNkjJMiEOiPB75L27aUjXzptqKqRqQsLRNsnLiHNuLa2P65pJ28NwEBxTi0dluesZ8wwHFZ84oq-uVu3yCKm7pTD0qNZr14a7ibjjF6rmU70E3pBjFOTw/s320/2013-04-16+03.07.29.jpg" height="240" width="320" /></span></a></div>
<div class="MsoNormal">
<span style="color: #222222; font-family: Times, Times New Roman, serif; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";"><br />
<br />
<span style="background: white;">Mr. C needed blood within 24 hours of its donation.
<o:p></o:p></span></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="background: white; color: #222222; font-family: Times, Times New Roman, serif; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";">What
did I bring on that trip but a suitcase of scrubs. Another medical implement to
leave. Concrete. Gauze pads, tape, saline, alcohol, needles, suture, scissors,
gloves, and a small cache of medication I imported directly from Mexico.
Everything suddenly feels small, that one can bring in regulation-sized checked
bags. Sub-Saharan Africa, unlike most of the world, still allows two.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Times, Times New Roman, serif;">***<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Times, Times New Roman, serif;"><i>Last
day at CHU</i><o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Times, Times New Roman, serif;">I
opened Mr. C’s blue folder. Groupe sanguin. Blood type.<o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Times, Times New Roman, serif;">A
positive.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="background: white; color: #222222; font-family: Times, Times New Roman, serif; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";"><o:p><br /></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="background: white; color: #222222; font-family: Times, Times New Roman, serif; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";">I
had waited until the late afternoon. No one thought I should return to work
minus a pint of blood. So, it was the last act of my second-to-last day. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><span style="background: white; color: #222222; mso-ansi-language: ES-TRAD; mso-fareast-font-family: "Times New Roman";">My
A negative and I, my exclaimedly difficult venous access and I, requiring the
head blood bank nurse and her no-nonsense deliberation and needle (I'm
accustomed to apologizing for my veins. I'm accustomed to directing the one
holding the phlebotomy tray) were hours too late. </span><span lang="EN-US"><o:p></o:p></span></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Times, Times New Roman, serif;">I set
this up as a too obvious story. But it was a too obvious omission, that day,
that I hadn’t looked first. Had I read his chart the day before. Had anyone
asked. It was a pat irony, or an obvious one. This is the way the story goes.
Some people give patients bus fare or metrocards. Some people give blood,
marrow, and organs to friends, family, or strangers. I could have given my
blood to my patient. <o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Times, Times New Roman, serif;">Just
hours before. Would it have been too personal? Too martyr or savior-role,
anyway? <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Times, Times New Roman, serif;">***<o:p></o:p></span></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="font-family: Times, Times New Roman, serif;">NYC<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Times, Times New Roman, serif;">Mr. D
came back from surgery. Mr. D was bleeding. Mr. D was losing so much blood that
he was getting dizzy. Mr. D needed blood. I put in the order, printed a label
and stuck it to my hand, and walked quickly, the way doctors do, to the blood
bank. “I need blood for Mr. D. We already called.” Here, only physicians can
sign for blood. Sign out blood. Blood, plucked from freezer to fridge to a
brown paper bag clutched in my hand, with implements for transfusion. The most
useful thing I did that day was to walk to the blood bank and walk back. But
here there’s no shortage, and here no one in Mr. D’s family had to donate in
kind.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Times, Times New Roman, serif;">We
asked. We were given. We gave it.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Times, Times New Roman, serif;">***<o:p></o:p></span></div>
<div class="MsoNormal">
<i style="mso-bidi-font-style: normal;"><span lang="EN-US" style="font-family: Times, Times New Roman, serif;">Yaoundé, Cameroun<o:p></o:p></span></i></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Times, Times New Roman, serif;">There
is not enough blood here, or water.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Times, Times New Roman, serif;"><br /></span></div>
<div class="MsoNormal">
<span style="font-size: large;"><br /></span></div>
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Jennifer Stellahttp://www.blogger.com/profile/01985168402480341835noreply@blogger.com0tag:blogger.com,1999:blog-5640057601871676179.post-62863091928588800682013-08-25T23:49:00.001-04:002015-02-25T01:32:42.800-05:00Peripheral<div class="MsoNormal">
<span lang="EN-US" style="font-size: large;"><i>NYC</i></span><br />
<span lang="EN-US"><br /></span>
<span lang="EN-US"><br /></span>
<span lang="EN-US">I look idly at the hand grasping the
laundry basket. “That’s a beautiful vein,” I think. “Someone would be lucky to
get to slip an IV into that.” And like everything that gets accidentally
carried back from the hospital—venipuncture kits, 4cm x 4cm gauze (think:
measures I am learning), alcohol swabs, tape, fecal occult blood cards and
guiac solution, gloves—I have the materials to do it. But I’m not the one I
would need practice on. It’s the patients with scarred veins<span style="mso-spacerun: yes;"> </span>(drugs, fistulas, too many hospital visits)
or overloaded with fluid—the “vasculopaths”— that take skill. A patient with
good veins is a good patient. Ones that don’t roll or slip away from you. Ones
that leap to attention under tourniquets and alcohol. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">We are vampires not only at night.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">It’s using your hands (not trusting your
head), taking ownership of each step of the process, delegating tasks (most)
that don’t take a medical degree to yourself.<o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Georgia, Times New Roman, serif; font-size: large;">I’ve caught myself thinking “I wish I had a
med student for this.” To get patients’ weights while standing (find the heavy
scale, wheel and weave it through the hallway, support the hesitant frame). To
get orthostatic vital signs (vital. Life. Here, to check the difference in how
fast and how hard the heart beats, how much the veins and arteries contract and
relax, when equilibrating between lying down and standing up). It takes
minutes. Five. Or more. I picture third year of med school, two hours per
patients, an afternoon to sit and talk…<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Georgia, Times New Roman, serif; font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Georgia, Times New Roman, serif; font-size: large;">Or carry blood.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Georgia, Times New Roman, serif; font-size: large;"><br /></span>
<a name='more'></a><span style="font-family: Georgia, Times New Roman, serif; font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Georgia, Times New Roman, serif; font-size: large;">It’s the beginning and the end of the day’s
menial tasks. I learned to relish the quiet moments, years ago—coffee and
morning labs. Keeping track of numbers. Comforting shapes (mean: which value is
this. Which electrolyte, element, atom. Which part of your blood) scattered
across the paper—it used to be the pride, the insider-ness of using them and
starting to understand what they meant. Now, it’s the morning labs. And in the
evening, it’s entering orders for the next day’s labs. (What do I need to know
about the inside of you. What am I following). It’s still trying to be careful
and responsible with language, when entering notes into the permanent medical
record. For example: patient refused the dose.<span style="mso-spacerun: yes;">
</span>Or, patient declined the dose. Patient refused the exam. Or, patient
declined to participate in the exam. Participate in the exam. Or follow
commands. Or not.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Georgia, Times New Roman, serif; font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Georgia, Times New Roman, serif; font-size: large;">For so much of the day, it’s numbers.
Numbers correlated with symptoms. Refusing the medication lactulose, for
example, means Ms. A’s liver disease will cloud her mind. I picture a shroud of
permanent damage (cirrhosis. Hepatic encephalopathy). Septic flood waters
rising into the brain. We have a medication for that. And we’ll titrate it,
we’ll base our decisions upon how many bowel movements recorded in a day. The
septic systems pulled down from the brain, down, down, and out. It’s one of the
most important medications. It’s critical.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Georgia, Times New Roman, serif; font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Georgia, Times New Roman, serif; font-size: large;">“Patient refused the dose.” And sometimes,
this is followed by documentation of “Dr—notified.” And sometimes not.<o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Georgia, Times New Roman, serif; font-size: large;">The patient’s mental status is a
temporarily soluble problem. There are so few problems we can fix. This one. We
can help. But she refuses.<o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Georgia, Times New Roman, serif; font-size: large;">Because a 57 year old woman who brought up
her (I found out today) 28-year-old severely autistic niece, who used to draw
caricatures of tourists on the street, whose house slippers are red, does not
actually want to soil herself and the bed (how many do I want) four times per
day. When I read the “1”, “2” in the morning I’m disappointed. So I increase
the dosage. It’s not working. It’s not working. And she can barely move to get
up, and when she does, it’s certainly not swift enough for something this
powerful. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Georgia, Times New Roman, serif; font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Georgia, Times New Roman, serif; font-size: large;">In the middle of the day, I know this. At
the end of the day, I finish my progress notes. “Ms A was cloudy today because
she declined two doses.” But, I think, upbeat, she has a PICC line
(peripherally inserted central catheter). It’s an IV inserted through the arm
into the heart. It’s a longer-term and deeper-inserted IV, which is so easy to
use and consistently get abundant blood flow for labs that it’s equivalent to a
sigh of relief anytime I realize I need more information about my patients’
insides. Patients with PICCs are the sicker ones, whomever will need that many
blood draws and that many days, weeks of IV medications.<o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Georgia, Times New Roman, serif; font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Georgia, Times New Roman, serif; font-size: large;">I want blood from a sick patient. These
labs will be quick. I’ll draw them myself. This is the one easy moment of the
day. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Georgia, Times New Roman, serif; font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Georgia, Times New Roman, serif; font-size: large;">I sit down, on the bed or in a chair pulled
close, with the labeled, carefully colored-tubes beside me, and biohazard bag, two
syringes full of sterile saline, gauze, alcohol swabs, and vacutainer adaptor.
And gloves. For the one minute I’m here, knowing that I’m not causing any pain
or discomfort, and doing something almost effortless and overflowing with
potential, I am completely relaxed. I am accomplishing something – to check off
– necessary. <o:p></o:p></span></div>
<div class="MsoNormal">
<span style="font-family: Georgia, Times New Roman, serif; font-size: large;"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US" style="font-family: Georgia, Times New Roman, serif; font-size: large;">And my patient and I can talk.<o:p></o:p></span></div>
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Jennifer Stellahttp://www.blogger.com/profile/01985168402480341835noreply@blogger.com0tag:blogger.com,1999:blog-5640057601871676179.post-52653191044388716062013-07-28T14:06:00.001-04:002013-09-09T22:51:43.080-04:00When Patients Care About Doctors...<div class="p1">
http://primarycareprogress.org/blogs/16/276</div>
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Jennifer Stellahttp://www.blogger.com/profile/01985168402480341835noreply@blogger.com0tag:blogger.com,1999:blog-5640057601871676179.post-47300498799627378622013-06-30T23:13:00.002-04:002013-06-30T23:59:05.286-04:00And now introducingI'm starting residency. Tomorrow is the first day I will introduce myself as "Doctor" to patients.<br />
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I'm in the Primary Care/ Social Internal Medicine program at Montefiore Medical Center, in the Bronx. More on that later. In essense, public health + internal medicine + primary care.<br />
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Two years ago, I was taking a leave of absence from medical school to pursue an MFA in poetry at Brooklyn College. I had started my fourth year prior to leaving, and had thus spent close to three months in the "sub" intern role, with a greater degree of autonomy and individual work with patients than during my third year.<br />
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Prior to leaving, I wrote a blog post called "<a href="http://jenny-and-cameroon.blogspot.com/2011/08/luckiest.html">The Luckiest</a>," referring to (at the time) medical students, poised on the path of an incredible career. (Reposted below)<br />
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This is something to recall, and something that, even on the bad days, is still true.<br />
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Today, tomorrow is the first day, but it's also the nth day of a path I've been on for a long time. Steep learning curve, steps you learn how to barely jump or grasp with determined fingertips. I'm still convinced--and I hope to remain convinced, most of the time--that, for me, this is one of the best things, and it is absolutely the right thing. Right now.<br />
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<br />Jennifer Stellahttp://www.blogger.com/profile/01985168402480341835noreply@blogger.com0tag:blogger.com,1999:blog-5640057601871676179.post-4407359971575145932013-06-30T23:10:00.000-04:002013-09-09T22:52:28.484-04:00The Luckiest<div class="MsoNormal">
I wrote this in the middle of my fourth year of medical school, before taking a year off to go to New York for an MFA in poetry.<br />
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<b><span style="font-size: large;">August 2011</span></b><br />
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It’s said in many ways.</div>
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Absence makes the heart grow fonder.</div>
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Nostalgia in looking back.</div>
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Selective memory.</div>
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And, per Ben Folds, “The Luckiest.”</div>
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This usually refers to, I think, people/place/thing. Certainly people. Certainly place. Time period. Self at a different stage of life.</div>
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It’s not usually used in reference to career.</div>
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It’s now been three days since I was an active medical student.</div>
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And I miss it. A significant lot.</div>
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I can’t wait to be a doctor.<br />
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Before I started med school, I couldn’t believe how lucky I was to <i style="mso-bidi-font-style: normal;">get</i> to go to medical school. I’ve had a lot of privilege in my life. This is one of the greatest, most amazing, most incredulous ones.</div>
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What I’ve done, what I’m doing, what I will be doing.</div>
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I was let into this hallowed profession – in some places, hallowed, darkened halls – in which I <i style="mso-bidi-font-style: normal;">get</i> to learn all about the body. Get to. And I <i style="mso-bidi-font-style: normal;">get</i> to interact with people in the most intimate way, at their most vulnerable – they trust me, let me in. I have to earn that trust.</div>
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Starting, and before starting, I didn’t understand that sacred trust. It’s something I continue to learn, every day. And I am amazed.<br />
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After a day with patients, last week – any day – I left the hospital exhilarated. Exhausted. Beaten down, burnt out at times. But exhilarated.</div>
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I will have no days this amazing as a writer. Or as anything else.</div>
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I am unbelievably, incredibly lucky. I <i style="mso-bidi-font-style: normal;">get</i> to do this. They let me in.</div>
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When I graduate from medical school, I will have been thinking about becoming a doctor for about 17 years.</div>
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I am the luckiest.</div>
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When I hear about people studying for the MCAT, my first question – reaction – is <i style="mso-bidi-font-style: normal;">why.</i> It’s partly that I’m still not sure if I would do this again; there are other things I could have been very happy doing, and I wouldn’t have known, exactly, what becoming a physician means. <i style="mso-bidi-font-style: normal;">Why. </i>This is too damn hard if you don’t love it. Too hard. Not worth it. Become a lawyer, go into business, science, anything, anything, anything that is intellectually challenging/prestigious/hard/will make you money. Whatever the motivation is. This is too much work if you don’t love what you’re doing.</div>
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Perhaps I’m already nostalgic, but that’s why it’s important to write this now – so I remember, have it to read again, on the inevitable terrible days and nights.</div>
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I <i style="mso-bidi-font-style: normal;">get</i> to be a physician. I get to have patients.</div>
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When doing procedures that are <i style="mso-bidi-font-style: normal;">uncomfortable</i>/ painful. . . I give patients license to do whatever they want. Whatever helps, I say. Swearing. Call me names, I say – it’s nothing I haven’t heard before. And it won’t hurt my feelings - promise. It’s definitely not personal. You can talk on the phone. Whatever. . . If I’m holding a patient’s hand during a procedure that someone else is performing, I joke about breaking my hand. Go ahead, I say.</div>
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The unbelievable, unbelievable, incredible privilege.</div>
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It began with cadavers.</div>
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No, before that. It began with getting in. Before that. The opportunity to do pre-med at a ‘very good’ university, with a lot of support, and enough liberty to really have time to focus on classes. Which goes back to high school, etc.</div>
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I was in the school bookstore today and I almost started tearing up, looking at the stethoscopes. Mine is coming with me to writing school. It’s part of me, at this point – it’s an extension of my ears, another way to augment my senses. And it hangs so naturally around my neck that I once picked up someone else’s stethoscope – same color – thinking it was mine, and didn’t notice I was wearing two until someone pointed it out.</div>
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I get to have a stethoscope. Mine. I get to listen to the inside of the body. And with this training, I learn to interpret what I hear. Sounds and silences. The natural unwinding of this caduceus. At one point, I thought I’d lost it – left it in a clinic, somewhere. (I know people who have lost them/had them stolen). And it wasn’t just the frustration/annoyance of having to spend money on another one.</div>
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It was the thought of losing <i style="mso-bidi-font-style: normal;">mine</i>. I can keep this one for the rest of my career. I’ve gotten to know it. In mine, there are still a few grains of sand around the bell from the time I put it in a bag I’d just taken to the beach…</div>
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If I don’t use it, as a writer, it’ll hang on the wall.</div>
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The early med students walk around in clean white coats (I remember being told that was how we were recognizable), and the stethoscopes look a little awkward. The scrubs are almost a status thing, at that point – a little bit in awe of getting to wear them. (<i style="mso-bidi-font-style: normal;">Getting</i> to). And now… well, nothing used in that context stays white, and bleach barely works. The stethoscope that I used to wind carefully into a little bag, the one my sphygmomanometer (blood pressure cuff) came in – now goes around my neck, winds into a pocket, gets dropped into my bag. It isn’t fragile. And it’s mine.</div>
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I get to be a doctor.</div>
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I can’t imagine any job as incredible as this one.</div>
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This morning, talking about this with a med school friend –I, starry-eyed, was waxing poetic. I know it. And I’m trying to not forget the hours of exhaustion, “scut” (busy + mundane + worse at times) work, being grilled on the spot and judged on absolutely everything you do in a day, subjectively. And being graded just on that. And test scores. I got into this business for my patients. I want to be a <i style="mso-bidi-font-style: normal;">good</i> doctor for my patients. That’s the point and it comes back to that, it should always come down to that.</div>
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No matter what else is going on in the day – getting yelled at by an attending for something out of your control that you had no idea about – you <i style="mso-bidi-font-style: normal;">get</i> to be alone in a room with a patient. I do. And there are the patients who scream and throw things (more often, on psychiatry). There are the patients whose affects are so disturbing that you really hope the drug test comes back positive, to give you an explanation…There are the patients perseverating on things you really don’t need to know about and you have limited time and the story isn’t making sense and they’re ranting about things in the clinic or the health care system or life in general that are out of your control but they’re somehow being put on you. . .</div>
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There’s that.</div>
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There isn’t anything that doesn’t happen.</div>
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There isn’t a person, or a “type” of person, who doesn’t get sick and need to go to the doctor at some point. (Or they show up in the county hospital ER, or they need primary care but are marginally housed. . .) Or needs primary care/preventative medicine, which is generally not covered at all.</div>
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In the room with a patient, I am focused on that patient, and – the point is what the point is. I want to be a good doctor for my patients. And that’s most of what I have to think about, in those moments. That’s what I’m doing.</div>
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And I do it every day. Now, it could be a dozen times in a day. Different people, different stories, different ways lives are affected by the exact same pathophysiologic disease. But I have to do something different. The treatment might be the same, the procedure might be the same, but the way in which I approach it, talk about it, take time explaining (or not, as patient preference dictates) changes. The way I sit. The way I talk. What I talk about. Tone, volume, rhythm, posture, eye contact/facial expression – it’s not an act, it’s a mirror, and it’s finding how to be what your patient needs in that moment. Learning how to do that. You’re not changing yourself – you’re accessing all of yourself in different ways. You use the patient’s language and metaphors.</div>
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And then there is the science, some of which is supposed to become second nature. Pattern recognition and understanding the underlying conditions, the physiology, what is going on in this body at this time.</div>
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I get to do all of this.</div>
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I am trusted by the physicians around me – my colleagues – and by my patients. I get to go in, alone, and do all of this. And it’s the trust on both sides that helps me need to do it <i style="mso-bidi-font-style: normal;">right</i>, or as “right” as I can with the training I have.</div>
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There are the times I’m frustrated with the <i style="mso-bidi-font-style: normal;">thing</i> (or the patient). The vein is rolling or they have no veins left… the cervix is wayyy anterior and it’s hard to find/access. The tonsils are large and obstructing the intubation. The heart sounds are muffled. The patient <i style="mso-bidi-font-style: normal;">will not</i> get the concept of taking a deep breath (“in through your mouth, out through your mouth). And I still have difficulty (a lot) finding the optic disk…</div>
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For now, I get to take time as a writer – a writer who misses medicine and patients and remains involved, in ways –</div>
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But I still can’t imagine a job as good as this one (perspective).</div>
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There are days I left my internal medicine clinic almost skipping across the parking lot. My patient’s blood pressure was better. Another one’s insomnia was improving. Another was seriously keeping track of his blood sugars. Another brought his three-year-old in to meet me (not all the same day).</div>
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My job. My future job, my future, and the present/future job of so many wonderful people I know. We – no, they – no, we – are going to be incredible doctors <i style="mso-bidi-font-style: normal;">for</i> these patients, because that’s the “why” in this privileged position.</div>
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Lucky, lucky patients?</div>
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Luckiest – us.</div>
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~j</div>
Jennifer Stellahttp://www.blogger.com/profile/01985168402480341835noreply@blogger.com0