15 December 2014

The Whiter Coat

14 December 2014

            I hadn’t worn it in a year.  Halfway through internal medicine residency, I’ve lost two of my allotted four. But yesterday, for the Millions March in NYC, I donned my white coat under the banner of “White Coats for Black Lives,” 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.
            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.
            But to reject the whiteness of the coat requires whiteness, no need for cloth that soon shows sweat stains to confer that final privilege.

10 September 2013


Yaoundé, Cameroun
Centre Hospitalière Universitaire (CHU)
April 2013

Last day at CHU

I flipped open my patient’s blue cardboard folder. Groupe sanguin. Blood type. ---


The day before, I'd gone to the blood bank at CHU.
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.

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”).

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.

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).

The public health self gave mebendazole.
The doctor self gave blood.

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.
“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.

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.


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.

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.

Description: http://2.bp.blogspot.com/-f7EUQJHmkFU/Ui6IyuIJcTI/AAAAAAAADzo/0SmAvoEYl4k/s320/2013-04-16+03.07.29.jpg

Mr. C needed blood within 24 hours of its donation.

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.


Last day at CHU

I opened Mr. C’s blue folder. Groupe sanguin. Blood type.

A positive.

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.
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.

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.
Just hours before. Would it have been too personal? Too martyr or savior-role, anyway?


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.

We asked. We were given. We gave it.

Yaoundé, Cameroun

There is not enough blood here, or water.

26 August 2013


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  (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.

We are vampires not only at night.

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.
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…

Or carry blood.

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.  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.

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.

“Patient refused the dose.” And sometimes, this is followed by documentation of “Dr—notified.” And sometimes not.
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.
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.

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.

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.

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.

And my patient and I can talk.