11 January 2015

All the dangerous things we do with our hands

le 10 janvier 2015

Wielding pens. Waving swords. Stopping traffic.
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.
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 “doceo, docere – to teach.”

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.

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.

Toutes les choses dangereuses qu'on fait avec nos mains

le 10 janvier 2015

Manier le stylo. Brandir l’épée. Arrêter les voitures.

J’y ai cru pour longtemps, pas seulement dans le vieil adage que « le stylo est plus puissant que l’épée. » Ecrivain et médecin,  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 publiés.

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. »

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.

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’être détruites ; par les injustices perpétrées par le racisme institutionnel à travers le pays et, plus poignant pour moi, à New York, dans un système 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.

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.

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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.