King Teddy, Part II

For those of you who think I only blog about "the cat," please stop any eye-rolling at the sight of this blog and see the many previous blogs NOT about Teddy.

If you are part of the cult-following that likes my cat better than me - enjoy!  :-)

 I want to be a cat when I grow up.....

Some of us are now too good to drink from a water bowl....

Learning Points

It seems to be the same whether it happens in the United States or Kenya.

You step in front of a group of your peers and consultants/attendings.  The Power Point is queued to your presentation.  You look around the room.  All the necessary characters are present - the medical student or intern who sleeps through ALL the lectures.  The consultant/attending who brings his computer/i Phone to everything is already tapping away.  The attending who hasn't picked up a book or journal in 20 years is ready with some jaunty comment. 

So, you take a deep breath and begin.  And afterwards, you wait for the onslaught of questions that you KNOW will come.  It is the sword of Damacles above your head, the day of judgement in the medical community.  It is the M&M Conference. 

M&M - or Morbidity and Mortality Conference - is something that most hospitals with educational programs (residency programs) hold periodically to review case of patients in which the outcome or care was poor or unfavorable.  The goals of M&M are to learn from patient complication or medical errors, so that medical professionals can prevent future bad outcomes.  These conferences are confidential and focus on improving patient care, physician judgement or hospital protocols. 

Apparently M&M Conferences have long been a part of the medical education.  In the early 1900s, Dr. Ernest Codman at Mass General Hospital in Boston lost his hospital privileges after suggesting that surgeon competence be formally evaluated.  However, his ideas contributed to the development of a case reporting system that designated culpability for poor outcomes.  This system was adapted by the American College of Surgeons in 1916.  In 1983, the requirement that all residency programs hold routine M&M Conferences was issued.

Well.  That seems honorable right?  Physicans getting together and talking, in order to learn through mistakes.

HA! M&M Conferences are the scurge of every resident on earth!  Here's a few reasons why:

1. The person who presents the case is responsible for all things done, not done, or done poorly for the patient during the hospitalization. 
Problem: Behind every patient is a team of multiple interns/residents and consultant/attendings.

2. Sometimes the person presenting the case has never even met the patient that he/she is presenting!

Problem: Obvious.  But it's a good case, so you take one for the team.

3. The consultant/attending is never in attendance to support you on the case, or if they are, they forget they were involved with the case and ask disparaging questions.

Problem: Refer to number 1

4. There are always at least 1-2 hecklers in the audience. The heckler is someone who - because of their vast medical training - feels it is necessary to point out all your mental deficiences by asking such questions as, "Did you compare the patient's rectal temperature to his oral temperature?"  and "Did you check a sodium: chloride ratio?" OR "Does the patient have a history of recent space travel."
Problem: The heckler's questions are always polite and well-posed, they are not-relevent are, in fact, retarded.  They add stress because you are not allowed to say, "Who cares?!"  Instead, you must muster such diplomatic responses as: "No." or "That's a good question, but I don't recall that being in the case file."

5. You have to tell "what you learned."    

Problem 1:  Sometimes the learning point of a case is vague and not helpful to the audience.  It is also unfair to the presenter.  For example,  "You should have diagnosed X condition sooner."  How is that a learning point?  I should be smarter?  Why should I have diagnosed it sooner?  Was it because obvious symptoms were ignored?  More often, here in Kenya, it is a combination of the patient presents late, there are too few nurses to care for so many patients and labs/imaging can take 24 hours or longer.  This is really about constructive criticism - and doctors are not very good at that.  "You should do better," is not constructive criticism.  Sometimes it is as simple as changing to: "If you have a patient with A, B, C, consider X." 
One memory from my residency:  I remember taking care of a patient who was 24 weeks with triplets who was hospitalized for preterm labor.  One night on my watch, early in my second year of residency, she went into labor and delivered.  The attending later said that the deaths of all three babies were on my shoulders because I should have diagnosed her labor sooner.  I've never regained the respect that I lost for that attending.  For those of us who are in a position to teach, be careful with your words - they can create long-lasting memories.

Problem 2: Do you even need to have a learning point?  I say no.  Sometimes there are poor outcomes - not because anybody did anything wrong - but because there are risks with surgery, there are limitations to testing and medicines does still have boundaries.  These cases are still worthwhile as teaching tools - not every M&M needs to feel like a meeting with the firing squad.

6. Sometimes the M&M involves other specialties.
Problem:  You may have to rush to "claim" the case before the rival specialty gets it or you may have to present it in retaliation.  If the case has a particularly bad outcome and people are upset, it would be beneficial if were the other "team's" fault.

All in all, M&M Conference was and is a great tool for learning and improving patient care.  But it can also be one of the most hated parts of medical training where the focus becomes to defer blame to other specialties or to gloss over mistakes.  The product of M&M conference is dictated largely by the environment in which it is hosted.  Perhaps with an enviorment of purpose and objectivity, without finger pointing or self-elevation, these conferences can foster the type of learning and reform that is still needed in medicine.

An Update on Teddy....a little about Me, Too

June marks my sixth month working in Kenya.  The types of surgeries here and the challenge of taking care of such complicated patients is becoming more familiar and is definitely the best part of my job.

This is a patient (Janet) that I wrote about in "Ruptured Uterus."  After her C-hyst, she developed a horrible pelvic abcess that required 5 trips to the OR for wash-outs.  She was intubated and extubated multiple times.  We had her on TPN (very expensive in Kenya) and Lovenox in hopes that she would remain strong nutritionally and not develop a DVT.  Miraculously, Janet has pulled through and has recovered from an obstructed labor with ruptured uterus / pelvic abscess and anterior abdominal wall wound breakdown, to just having an area of 6x3 inches that is yet to heal.  Through it all, she has been smiling and lovely person to take care of.  Her bill is very great for her family to have to pay; please pray for them as they try to find the funding to take her home.

This is a solid ovarian tumor ~ 15 cm that was chronically torsed.  If you look in the picture - center - you can see the point of torsion.  The lady presented with a complain of an abdominal mass for 3 weeks.  Time is always a questionable thing in Kenya.

An amazing 12 fetus that I removed today from a lady who presented with an ectopic pregnancy at the fibria of the tube.  On ultrasound, I saw this little guy happily kicking away against the back drop of about 2 liters of blood that was in the abdomen.

Outside the OR, I have been pleasantly surprised at how much I enjoy being involved with the education of the interns.

As I have mentioned in previous blogs, the interns in Kenya have finished a general medical school training program and now must complete a one year internship.  The intern year is comprised of 4 rotations: medicine, peds, surgery and ob - 3 months on each service.  Then each intern is expected to be able to work indepently at a district hospital as a generalist.  So, in 3 months, I must teach the interns to do C sections, D&Cs, tubal ligations and to work up ob patients.  To me, it is a daunting system and I am AMAZED at how sharp some of these young people are!

I have become very interested in trying to improve education in Ob and also, to make some resources more available to the interns.  For example, many of them do not have proper eye protection to wear in the OR for cases.  The OB triage does not stock supplies to do nitrazine or ferning to check for rupture of membranes (only a speculum exam to check for pooling or ultrasound to check AFI).  So, I coordinated efforts with the nursing supervisor to get an OB intern "locker" on the ward.  It is stocked with various goodies: masks with face shields, nitrazine paper, microscope slides, sterile swabs, extra ultrasound gel, extra KY jelly --- and I hide my good forceps in there!  All of you who have sent me supplies - chances are - it is now in the intern locker!

I have also had a lot of fun with the interns by having "knot-tying" parties at my house.  Many are not given any formal instruction on suturing or knot-tying - they are just expected to watch and learn.  We have had a few evenings of "practice" with expired suture, tying knots on my couch cushions and suturing lacerations I cut into towels.  Then, after all the hard work - we have cake or cookies!

I think they are saying,"Yes, we DO love Dr. Huber!"

All grown up....and operating with me......*sniffle*

I recently learned that the interns are not provided with an OB textbook for their rotation.  Many have some sort of text left over from their studies in medical school, but nothing formal is recommended.  My partner, OtherDoc, made a booklet of all or Tenwek guidelines - new this year - which is a great reference material when doing admissions or needing quick facts.  I am in the process of looking at the possibility of purchasing 4-6 OB textbooks for the interns.  Something with details, but also not so dense that it will prohibit being carried easily.  The books will be the property of the rotation and will be passed from one group to the next every 3 months. 

Please remember me as I strive to be a role model (scary, I know!) and a teacher to these great young people.  There are many things I could use in my educational endeavors that are difficult to get here in Kenya so I am trying to be creative AND comprehensive.


Now, while I have been busy teaching and surgerizing at the hospital, Teddy has been busy....well....being TEDDY. 

 Here he is playing with what I like to call "the most expensive cat toy EVER," otherwise known as my iPod headphones.  While I was on vacay in Ireland, he decided to chew on them and now they don't work.  Now they belong to him.  Thanks, Ted.

 He has also been busy getting into things around the house.  He got into something that caused a big snarly knot in his fur.  I couldn't brush it out, so I cut it out.  Hence the little bald spot seen above.  Pay back for the headphones!!!

I was lucky enough to trade in my previous couch for a different one.  This one is more comfortable and it came with a loveseat, too.  Of course, Teddy has claimed both pieces of furniture as new napping spots!

Moving to Africa Made Simple?

Over one year ago, I began the very long process of packing/moving/selling/organizing that ultimately brought me here to Tenwek.  For those of you who may be contemplating a similiar endeavor, here's a few things to check off your "to do" list:

• De-clutter:  Moving out of the US is the ultimate de-cluttering experience.  Everything should go into one of three categories: Store It, Take It, or Get Rid of It.  I got accounts at consignment stores and used Craigs List online to get rid of many household items, furniture and clothes that I didn't want to take or store.  I was amazed at the money other people paid for my junk! (See my blog: Adventures in CraigsListing)
• Get a contact at your destination for info on things to take:  Months before departure, I contacted people a Tenwek to start finding out what things I need to bring and what things could be bought in and around Tenwek.  It's nice if your contact can relate to you and anticipate your needs: for example, if you are single, try to find a single person or if you have young children, find someone with kids. Then shop smart!  I began stockpiling the things I would need to take with me so I wasn't stuck buying everything in the month before departure. I hit the Sunday papers for coupons to help stock up on personal care items that I preferred but weren't available/or were expensive in Kenya.  By combining my local grocer's double coupon days with their sales, I ended up getting items very cheap over time.  I also took advantage of the Back To School sales and stocked up on ink pens, markers and extra household items.

• Get a power of attorney: Someone has to be your legal advocate in the US for banking, tax or legal issues that may arise while you are gone.  I made a binder for my POA with copies of all my important documents in it: passport, birth certificate, credit cards, info regarding mortgage, disability insurance, health insurance - basically EVERYTHING she needs to know about me legally and finalcially.  The binder is carefully organized so if she has a question about anything - she can just look it up versus trying to email me.
• Disability Insurance:  Many insurance companies will maintain your insurance overseas but will not allow you to increase your coverage while you live outside the US.  Plan ahead and increase your benefits - if possible- before you move.
•  Get a permanent address:  all your mail should be sent to this address.  You may advise this person to periodically pack up non-junk items and mail them to you (ie... cards, medical journals).
• Get online: Any accounts that will persist after your big move should be able to be paid online.  Get in the habit now of paying credit cards, managing bank accounts, etc.. online.

• Get an international credit card: This is a credit card that does not charge any international fees; I have a Capital One Visa that doesn't charge any fees.  I also opened a Capital One checking account that doesn't charge any ATM fees AND pays interest!
• Call credit card companies and let them know you will be outside the US so you will be able to use your card.
• Stock up on prescription drugs and contacts: For me, 2 years worth of contacts!  I also explained to my eye doctor what I was doing and she made a note in my chart that will extend my prescription in case I need to order extra contacts (via the help of someone in the US) and I will not be required to come in for an eye exam.
• Visit a travel clinic to check what vaccines are recommended for the area  you are moving to. 
• Stock up on electronics: flashdrives, portables hard drive, CDs, camera & computer accessories, printer cartidges (expensive and difficult to find in Kenya)

• Scrapbook or make photoalbums of family photos - your "new" neighbors will love seeing pictures of your family and you will like having these memories to share.
• Packing supplies: I used large/sturdy duffles from WalMart that were only $15 each.  I labelled them using paint pens - no worries about lost luggage tags!  I also bought 2 Rubbermaid Action Packers from Wal-Mart.  They are also available on Amazon with free shipping, but I found them cheaper at WalMart.  They are sturdy for fragile items, but heavier than duffles, so watch your weight limits carefull!  They are great to have for storage once you reach the field, too.
• Hire an Accountant:  During my Ob/Gyn Residency, I had an accountant do my taxes.  When I decided to move to Kenya, I had a special meeting with him to make sure he was comfortable to continue doing my taxes via my POA, and with the added complication of me living outside the country.  He agreed and is awesome to work with.  He is accessible by email and phone and my experience this tax season was flawless.  My advice - lots of communication before you go and someone who is accessible via email.
• Renew Passport/Driver's license if it will expires during your time abroad - usually the passport agency is aggreable if you post a letter with your application explaining why you are applying for a renewal early.  I applied for a passport renewal 9 months early with no problem.
• Place valuable paperwork/jewelry in safe deposit box, safe place, etc...in the US.
• Don't be afraid to take a few nice clothes - just because you are a missionary doesn't mean you have to look like you are from 1978.
• Take your favorite textbooks.  There are no well stocked libraries on the mission field.

• Purchase an electronic reader - Kindle, Nook, etc... - you can't read textbooks all the time!  And this is a great way to cut down on your packing!
• Don't forget entertainment: CD's, movies, games.  I downloaded all my CDs into my iTunes library, then backed them up on a portable hard drive.  My movies I put into a CD book to cut down on storage space.   I brought a few blank CDs and empty CD cases in case I wanted to burn something or in case someone wanted to borrow a movie.
• Organize your bags: Keep a packing list for each bag that you pack so you know where everything is and how much of each thing you have packed - and if something gets lost - you know what items were inside.  I also numbered the outside of my bags - 1, 2, 3, etc.... so at the airport I could easily look and tell which one was missing.
• Make your ministry a Team Effort:  Working on the mission field is not a solo act.  You need a POA to help with finances, but you also need people to support in other ways.  Consider choosing 4-6 people to form a Social Support system for you.  They can support you by remembering birthdays, anniversaries and periodically sending care packages.  One person may head up the group effort, but this show of support can really help maintain your spirit on the field.  It may also be helpful to have a team of Prayer Warriors: this is a group of people that you correspond with on a routine basis to discuss prayer requests and praises.  This approach allows your family and friends to show their love and support for you and truly become a "part" of your ministry team.

Gifts from Home

Over the past weeks, I have received some gifts for my patients from friends and family at home.  This past Sunday, I packed up some baby hats, socks, onesies and adult-sized socks and handed them out on maternity.  Thanks to my friend Amy RN and my lovely cousin Amanda for their contributions.  The ladies enjoyed your generosity!  Check out the smiles!

Seriously?!

If you ask me what I like the best about doing Ob/GYN, I usually say: "The unpredictability."

Today I was a victim of my own cliche answer.

We admitted Susan to the ward ~ 1 week ago.  She came to Casualty complaining of a low abdominal pain and an ultrasound from an outside clinic citing a pelvic abscess.  She said the problem started four weeks prior after a d&c at a nearby hospital for a miscarriage.  She complained of pain, but no bleeding or vaginal discharge. 

She was afebrile.  Her white count was normal, Hb was 13 and her pregnancy was negative.  I repeated an ultrasound at our facility: there was a thickened stripe in the uterus and a large mass in the pouch of douglas consistent with an abscess.

So, I thought, great - this poor lady had a miscarriage, somebody did a d&c and perforated her uterus and now she has an abcess and maybe retained products!

We get alot of chronically botched abortions/retained products here in Kenya.  Because of the high rates of infection and sepsis, if the patient is stable and no signs of SIRS, I prefer to get 24 hours of antibiotics in before a d&c.  For pelvic abscessed related to PID, I usually try 48 hours of IV antibiotics before turning to ex lap - there's a lot of pelvic TB and PID here, so ex lap is not also a successful option for those desiring fertility.

For Susan, I decided to start with a d&c and Culdocentesis.  During the d&c, I discovered that her cervix was very stenotic and upon dilatation, a fair amount of old blood poured out!  I was surprised!  The person who performed the d&c had perf'd her uterus AND injured her cervix to the point of stenosis, causing pyometrium.  Complicated!  On my culdocentesis, I got no return: no clear fluid, no blood, no pus - nada.  Weird, I thought.

Anyway, the next day Susan felt better.  She had a discharge now, but overall she was happy.  Great!  I thought.  Now, we will just continue the antibiotics.

Post op day 2: Susan felt worse again with pelvic pain and vomitting.  Another ultrasound showed the abcess just as before, now with a normal uterus.  Still she was afebrile.  We discussed what to do.  She wasn't too keen on the idea of an exploratory laporatomy, so we decided to try the culdoscentesis once more.

Still nada on the culdocentesis.  I was starting to feel like a culdocentesis-failure.  Moreover, I felt like it was time to throw in the towel and just go to the OR.  My Kenyan colleague helped convince Susan of the same.

Today we did the ex lap.  I could not believe it.  We opened up her abdomen and there in the stupid pouch of Douglas was 350 mL of old, clotted blood (I'm NOT a culdosentesis failure!).  Her left tube was dilated to 4 cm distally with old clot spilling out.  It was adherent to the posterior side of the uterus and into the POD. 

It was a CHRONIC ruptured ectopic!  If you had asked me about such a thing last week...I wwould have said such a thing could never exist!  But it can in Kenya!  SO, the guy at the other hospital DIDN'T perf her uterus during the d&c, he just MISDIAGNOSED an ectopic pregnancy! 

Meanwhile.....I came along....un-stenosised her cervix from the unnecessary d&c, drained her pyometrium, did two unnecessary culdocentesises, all in the face of a NEGATIVE pregnancy test and Hb of 13!

Seriously?! 

Susan, the woman who survived a chronic ruptured ectopic pregnancy...

This job is crazy.