Untitled (just call it insomnia.)

During my first year of residency, I cared for a little girl named Z*. She had been on the oncology ward for months, fighting an aggressive blood cancer that hadn’t remitted despite several courses of chemotherapy, each regiment more aggressive than the last. She was on my patient panel for most of my month of heme/onc, and during the entire time she was miserable and in incredible amounts of pain. The only things that seemed to soothe her were sips of water, leg rubs from her mother, and watching Frozen on repeat. By the time I was caring for Z, her mom had a newborn and couldn’t spend nights in the room alongside her daughter anymore. I remember spending a good chunk of my week of night float sitting quietly next to her, watching Elsa sing ‘Let it Go’ over and over and over again, while she cried and asked where her mother was.

Z passed away while I was home one night in between shifts. It was pretty fast - within a few hours of becoming unstable and being transferred to the ICU, she was gone. It was the first time I was up close to a child passing away. I had seen death before, both in medical school and in residency. But I hadn’t seen suffering- not like this, anyway- in such a young and vulnerable child. It was completely heartbreaking. Sometimes you reach a point in caring for a patient when you feel helpless- like your interventions aren’t helping, and maybe by prolonging suffering they are causing more harm to the patient than good. I felt like we had failed her- not because she died, but because she was in terrible pain during much of the end of her life, and maybe instead of fighting her cancer so aggressively, we could have done more to make the end of her life peaceful and less painful.

I didn’t know it at the time, but I was experiencing my first real bout of moral distress. It is broadly defined as a scenario when a healthcare professional feels that they know the morally correct action to take to care for the patient, but are restricted in some way from taking that action (more on the topic of moral distress can be found here, if you’re interested.)

Now all these years later, as I adjusted to working as a pediatrician in a very busy, very high-acuity unit in a low resource setting, I began thinking about this case again. Nearly every day, choices have to be made that bring back those unnerving feelings of discomfort. They don’t all revolve around death, but all revolve around struggling with knowing the right course of action, and not being able to execute it properly. The child we send home who may need a few more days of antibiotics, because there’s no more space in the unit and we need to make room for the next sick child; the infant who goes days without getting the correct antibiotic as the family scrounges together the few resources they have to pay for it; the patient we can’t put on CPAP or oxygen because the only supply available is being shared among several other patients at once. Moreover, when our ability to test and find a cause for a patient’s illness, decision making can become a lot harder (this is related to another type of moral distress related to uncertainty.)

These are challenges I was peripherally aware of during my time in U.S.; they came up rarely, as most of my patients were healthy and resource allocation is not a challenge you have to deal with often. My colleagues here have faced this every day for years. They have incredible knowledge, perseverance and compassion, but underneath the surface is a palpable frustration- a feeling of helplessness, of uncertainty of what exactly needs to be done to tackle some of the systemic challenges we face.

I started writing this in the middle of the night, during a bout of insomnia, but initially struggled to find a satisfactory conclusion, some enlightened wisdom to wrap this thing up in a neat little bow and end on a positive note. A few weeks is not enough time to unpack things, to pick apart the machinery to find the pieces that are broken, and its certainly not enough time to know how to fix them. People who have lived and worked in this environment this every day don’t have all the answers, so how on earth can a Western pediatrician with a few weeks of working here have them in such a short time? I suppose the best I can do is use this feeling of discomfort to keep trying, every day, piece by piece, to understand the fabric, the strengths and the failures of the system here, and support in whatever small ways I can. In the meantime, I suppose I’ll have to get used to this strange discomfort- after all, everyone else here has been dealing with it for years.

*name has been changed.

One day in a Liberian Pediatric ER

I can't believe a month has gone by since I arrived in Monrovia! A month feels like a long time and no time at all with the pace at which things happen here. On the one hand, things move slowly...getting anything done (even something as simple as a blood pressure, and even in an emergency situation) can feel like it takes ages. On the other hand, time flies by as the days that are packed with dozens of sick patients needing various evaluations and interventions.

I thought a month was enough time to share a bit about what my day looks like here. Because there is a residency program, a lot of aspects of the day are familiar, with a Liberian twist :) No days are exactly alike but they tend to have a general pattern, something that goes like this:

6:10 am: alarm goes off. Depending on how late I stayed up worrying about this or that sick patient, I either hop out of bed to do a quick home workout or scroll through my phone a bit. I drink a ton of water as there's no clean water to refill my nalgene bottle with at work and take my anti-malarial pill. I usually listen to a podcast or audiobook while getting dressed ready to go. Liberian doctors tend to dress pretty formally (and have great style) so unless you're on call no one wears scrubs- they will typically dress in business attire with a lot of beautifully patterned custom-made dresses and suits sewn from lappa fabric (more on that another day.) I usually wear business attire and a white coat with a small notebook, pen and the WHO blue book (basically a global health pediatric bible) in the pockets.

7:00 am: the sun has started rising just enough that its safe to walk to work (as someone who is obviously Western you can't really blend in here, and petty crimes aren't uncommon.) I usually bring my breakfast to work- a banana, coffee and peanut butter smoothie that I may have become slightly addicted to. The hospital is 15 minutes away and if the weather is nice I get to catch a beautiful sunrise through the Sahara dust that blankets the atmosphere during the dry season.

Beautiful mural at the hospital's main entrance. It depicts the history of medicine in Liberia, including the traditional healers all the way up to the present day. 

7:15 am: I arrive in the pediatric emergency room to pre-round. The room is shaped like a T- the base of the T has a a row of chairs on one side where patients who have been triaged wait to be seen, and a large desk and chairs on the the other side where the docs can sit and review charts, interview patients and document. Unless there is an active resuscitation going on (which isn't that uncommon,) I sit down here and review the charts.

The top horizontal bar of the T contains 8 patient beds (there's also two doors to the left- one leading to the outpatient department, one to another room for patients who will have shorter admissions.) These are the sickest and/or newest patients. After reviewing the vitals, notes, diagnosis and medications served, my goal is to examine all of these kiddos before 8 am. Because of the aforementioned codes/high acuity (new sick patients arrive all the time, or I may get caught up addressing a patient who is getting worse right in front of me), this doesn't happen as much as I'd like. You just kind of have to take things as they come here.

8:00 am: morning meeting occurs on the wards in the main hospital, meaning I am usually dashing upstairs at 7:55 am to grab my white coat and make it in time (some things never change; I will forever be afraid of lateness, even when it isn't uncommon here.) Similar to the U.S. system, the overnight team presents all admissions from the last 24 hours, as well as any deaths. The consultants (attendings) and specialists (board eligible pediatricians in the process of becoming attendings) will comment and highlight teaching points on various cases. The West African medical teaching and lecture style is pretty formal compared to American training, but I try to weigh in occasionally if I feel I have a useful or unique perspective to add. Residents and attendings can also share announcements, concerns and issues at the end of morning meeting so they can be discussed in an open forum where everyone can have their say.

9:30 am (ish): this is where the day becomes more fluid. After morning meeting I head back to the peds ER for rounds. Depending on the specialists, rounds can either involve significant teaching, be rapid fire/brief, or not happen at all if the ER is very chaotic with a large volume of patients to see. We usually have several medical students, an intern and 1-2 residents around to present each patient, discuss the current medications and plan, and decide what the next steps in care are.

Something that's been a fascinating adjustment for me is patient ownership. In the U.S., as a resident I'd arrive on the wards each morning with a neat list of 5-10 patients I was primarily responsible for that day. Here, every patient is under the care of all of us as a team; the resident presenting the patient is arbitrarily chosen and the third year, specialist and consultant all agree on the plan together (though the most senior person has the final say.) Its been a fascinating deviation from what I am used to that is a better fit for the Liberian culture and practice style.

We see a lot of very sick patients; birth asphyxia (when the baby is deprived of oxygen and comes out critically ill with neurologic damage,) sepsis and other infections, and severe malnutrition are incredibly common and come with very high mortality rate.

One factor we consider in decision-making that I didn't expect was the cost to families; apart from a limited selection of medicines, everything we choose to do costs money. From a CBC to an x-ray, to selection of the correct antibiotic, parents have to scrounge up what little money they have to buy sometimes life-saving treatments for their kids. For a parent who makes only a dollar a day, even spending five dollars on a lab test or medication can be close to impossible.

Noon- 2 pm (ish): after rounds I tend to stick around for a bit to see how I can help without impeding work flow. This could mean I am writing in the chart, following up on a blood pressure or discussing a complex case a bit further with the residents and specialists. Eventually I make my way upstairs to work on research, helping the residents gain uptodate access, and looking up papers and articles on various interesting cases we've had to share with the team.

2 pm- 5 pm (ish): Depending on the day, there's loads of things going on during this time. Like any residency program, various lectures are given, either by the residents or by a local or visiting consultant or specialist. There are also various official exams at any given time of year; currently the first years are preparing for their exams (something between a Step 1 and Step 2-type of test) and we meeting regularly to review topics and go over questions. I also spend time with our research nurse entering data, tracking down missing information and troubleshooting whatever issues may be arising in the ongoing research work on a given week.

While the clinical work is a great learning experience for me, I find my work in the afternoon to be more rewarding; because of resource limitations there's not a whole lot I can do to improve outcomes on the level of individual patients. It can be incredibly emotionally draining to see your third newborn in 24 hours die from the same preventable illness (true story. More on that later.) But with collaborative research, and with actionable, big-picture policy changes, slowly over over time you can start to enact meaningful changes, and hopefully over time see improved outcomes.

5 pm-6 pm (ish): I check in with the peds ER 1 last time before heading home. If things are quiet, this could just be hanging out with the specialist, or reviewing patients of concern (watchers) with the overnight resident team to come up with contingency plans. Its not unusual for an actively crashing patient to be rushed in though, requiring resuscitation of some kind. These cases are the hardest because if I don't leave before dark it isn't safe to walk home, and because of recent gas shortages its not always easy to find a cab to drive you. So much of this job causes scenarios like this, of moral discomfort. I can't say that leaving feels like the right thing to do, but I can't help anyone if something bad happens to me. There's way more to unpack there than I feel up to sharing at the moment, but it is definitely an uncomfortable conundrum I encounter pretty regularly, so it would feel odd not to at least acknowledge it.

My favorite fruit stand...its bananas how good the bananas here are (pun intended)

6 pm: If I don't stop at the supermarket or fruit stand by the hospital to grab more bananas, I arrive home, usually covered in sweat. I tend to immediately throw on my swimsuit and jump in the pool to cool off if I have time. Taking a couple minutes to swim some easy laps and unpack what I've seen/heard/felt throughout the day helps me to transition from the "everything is on fire and everyone is sick" mode into a more relaxed and reflective state. I tend to cook something easy and quick, maybe watch 20 minutes of a show while having dinner, then read on a few topics I jotted down throughout the day or get some research work done, depending on what's on my to-do list.

9 -9:30 pm: wind-down time before bed. One thing I really appreciate here is a consistent schedule; not working evening and overnight shifts like I do in the U.S. is one of the nicer luxuries of my time over here. The overnight team can call me any time but usually don't unless there's something they feel I can specifically help them with. I usually read a novel, listen to a podcast, watch something or whatsapp call family before going to bed around 10 pm.

And that's a typical day as a clinical pediatric fellow in an urban Liberian referral hospital! In the future I may share more of the specific types of cases we see, or how the health system works, and hopefully introduce some of the incredible doctors I have been working with, but for now I just wanted to share what happens on a day-to-day basis. Hope its interesting to someone :) Feel free to share any particular questions or thoughts in the comments. PS- You can also follow along on instagram if to see more of the day to day things, if you are curious.

Global Health Careers: Part II

Ok, so here’s part 2 for global health career paths… I am a physician so this is pretty physician-geared, but I want to re-emphasize that there are tons of areas of work in global health, many of which don’t require any sort of clinical degree. I just wanted to share some of the resources I’ve accrued in case anyone else is interested in this kind of work. These ideas are by no means an exhaustive list. I sorted these out chronologically/by career stage so it should feel like a sort of pathway into global health from start to finish, but if I’ve learned anything in the last couple of years its that there are probably dozens of ways you could go about doing this and there’s no ‘right’ way to pursue a career in global health. Hopefully its helpful to someone interested in getting involved in this field :)

Undergraduate/pre-med. With some exceptions, I would not rush into field work at this stage. Unless you have something concrete to offer such as EMS skills or language proficiency, I really would spend this time learning, reading, and absorbing everything you can from the field of global health. Work experience overseas is great, but be selective about the programs you choose to become involved with. You never want to be in a position where your presence is causing more harm than good. For me working through a Fulbright grant offered a great opportunity to work overseas doing research without becoming involved in direct medical care. It was easily one of the coolest things I’ve ever done. For more information on how to apply for a Fulbright Grant, see their website here. 

In the meantime there are plenty of great resources you can explore to continue learning about the field- you can follow mailing lists such as NPR’s Goats and Soda, Johns Hopkins’ Global Health NOW and the Center for Global Development. There are also many great books- too many to list, but Mountains Beyond Mountains and The Spirit Catches You and You Fall Down are two that I was recommended again and again.

Right after undergrad is also not a bad time to pursue an MPH, especially if you’re still not sure if clinical medicine is for you, or you’re not sure your application for medical school is strong enough yet. If this isn’t you, I’d strongly consider waiting until during or after medical school. The reason for this is twofold: one, if you hold off on getting your MPH until residency or fellowship, there’s a good chance someone will pay for it for you- yay! Secondly, a master’s degree in public health is the kind of graduate training where it kind of does matter where you go. While you don’t have to go to a top 10 program, you should definitely aim to go somewhere with a robust global health curriculum and reputation, as networking is one of the key reasons to get an MPH. Here’s a list of some of the top master’s programs when it comes to global health. 

Medical School. Ok so first off, just learn how to survive and thrive in the insanely rigorous environment that is medical school. If you plan to practice clinical medicine, the best thing you can do to prepare yourself for a job in global health is to learn great clinical medicine. Once you feel you’ve found your footing in medical school, you can start to seek out opportunities and experiences in global health. This may take the form of a rotation overseas or online, an interest group, a spring break trip or lecture series. Whatever you do, I still think you should prioritize quality over quantity- make sure if you are going to work overseas your have adequate supervision, and your presence is not causing more harm than good. This may mean an ‘away’ rotation with a medical school that has a well-established, positive relationship with a hospital overseas rather than an experience with your own school.

Medical School is also a great time to consider an MPH; some people take time to do it before clinical medicine rotations begin, or before they apply for residencies. You’re already going into a ton of debt so it will be a balance of finding the best program for global health you can get accepted into and the program that won’t cost you an arm and a leg (this is key! It’s a lot harder to work in this field if you accrue a ton of loans.) On that note, while virtually everyone takes on loans for medical school, if you truly want to pursue a career in global health, you want to know all your options, and consider things like scholarships and the public service loan forgiveness programs.

Residency. Again, step 1 is focusing on becoming a strong clinician. But before you submit your rank order list, if you are considering a career in global health, I would strongly, strongly recommend ranking programs with global health tracks. These tracks vary widely, from a few courses with a short project assignment to an entire extra year sent at a site overseas. In pediatrics the programs doing the most in global health are generally Boston Children’s, CHOP, UCSF and Baylor School of Medicine, but there are plenty of small and mid-sized programs with great opportunities as well. A quick google search will give you pages and pages of info, and the ABP guide (linked here) is also a great resource and guide for trainees interested in global health tracks and pathways.

If you aren’t at a program with a strong global health track or presence, don’t worry. There are definitely still options to stay involved in global health. Baylor’s International Pediatric AIDS Initiative offers 4-6 week rotations to outside residents. I also did nearly all my mandatory presentations on global health topics, from journal clubs on hand-held echo use in diagnosis rheumatic heart disease to resident as teacher talks on HIV/TB. Staying involved in global health societies, such as the Consortium of Universities in Global Health, and the AAP’s SOICH (if you are in pediatrics) other ways to continue to network as you complete your training.

Everything else. Once you’re an attending, the world really is your oyster. If you are truly passionate about a subspecialty field, now is a great time to become involved in global health as a fellow, as there’s huge need for specialty care in low and middle-income countries worldwide. ID, critical care, neonatology and emergency medicine tend to be subspecialties with a decent amount of overlap with global health, but it does vary A LOT from program to program.

I was somewhat undecided about subspecialties, and wanted more on the ground clinical experience, so I went for a global health fellowship. Only a handful of pediatric programs offer an entire fellowship for global health (At the time that I was researching options last year it was UCSF’s HEAL program, Utah, CHOP and Boston Children’s Hospital.) Some are more research driven and require NIH K-grant funding, while others (like mine) are funded through the fellows working as gen peds clinicians in community hospitals for half the year to fund the other half of your time being spent working abroad. A big driver for me was that I am getting part of my MPH funded (yep! Another reason waiting to get your MPH isn’t always a bad idea) but I also feel very, very lucky to be able to work with and learn from the network of people here who are doing amazing things in global health.

I will also say many people just get out there and practice global health. This may be through a U.S.-based program (BIPAI hires general pediatricians for their HIV clinics, and Seed Global Health hires physicians to teach Helping Babies Breathe Curricula in resource-poor settings) or through an international NGO (MSF is very competitive and offers only longer stints unless you work in certain specialties, but there are many smaller organizations looking for physicians to assist with various projects.)

One extra option I’ll throw out there- the CDC has a field epidemiologist training program that basically trains both physicians and non-physicians to address epidemics in the field and is another great way to get on the ground experience and training. The UK and EU also have a similar track.

Hope this has been a helpful guide to anyone who is interested :) Feel free to message me or comment if there's anything you're particularly curious about. 

  

Maintaining Sanity on Night Float.

My sister recently started her sub-internship on night float (side bar: my sister is in her last year of medical school?! Cue the quarter life crisis) and it brought me back to those good old days when I was a wee intern….

And didn’t sleep, froze my butt off every night, and jumped out of my skin with every page, even the ones that were just asking for a Tylenol order. 4 years later, I have a weird appreciation for working in hospitals at night- the quiet hallways, being able to chat with patients and their families uninterrupted, and getting so tired you start laughing at the most nonsensical things with your senior resident. I figured I’d write this out for my sister (if she reads this blog, she might be too cool for this kind of thing. LOL) and any other new interns or almost-interns about to dive into their first experience working nights at hospitals.

Get comfy. Night float shifts are often long, lasting anywhere from 10 to 14 hours. Many nights you’ll be on your feet a lot, and won’t be spending a ton of time sitting or resting, so good shoes are key. Many healthcare workers swear by Danskos; a well-fitting pair will last you for ages ( one nurse I work with has had hers for 7 years,) but make sure to try them on before you purchase, as each pair is handmade and therefore will fit slightly differently. I personally have loved wearing my Allbirds and have also used my running shoes in the past; both worked fine for me.

Another thing people don’t realize off the bat is that hospitals are cold, and they get even colder at night. I would walk into work wearing fleece leggings pretty much from August through mid-June. A fleece or zip-up jacket plus cozy socks and you have a semi-tolerable work environment. Some of my colleagues even had a hospital blanket stowed in their lockers.

Have a sleep strategy. I have never been a good sleeper. I am one of those people whose brain likes to play the game of ‘lets dive into your most cringe-worthy memory or deepest regret!’ as soon as my eyes shut, and breaking routine can really exacerbate my insomnia. I generally had two approaches to sleeping on call- I would prioritize trying to get REM sleep in at least once; at my hospital I had to follow up on midnight and 4 am vital signs, which meant I could sleep for 4 hours in between if my brain would settle down or I was tired enough. If sleep wasn’t coming easily, though (like, say, if I was having the recurring nightmare of the code pager going off and my legs turning to jelly. That was a fun one.) I would hammer out some work- either easy readings, life stuff that I’ve been procrastinating on, or mindlessly running through a few board prep questions. About half of the time these activities were boring enough that I’d eventually nod off.  

There were definitely nights I wasn’t going to be able to sleep; you just have to accept that you’re being paid to work no matter what, and that being paid to sleep is a kind of bonus perk that happens once in a while, but isn’t guaranteed. This mentality helped keep me from getting too stressed out if my grand plans didn’t work out.

Another semi-related tip for interns: do your own night rounds. You certainly don’t have to see every patient, but walk through each unit shortly after nursing sign out to check in, see what’s going on, provide updates and change or correct orders as needed. I would even bring a computer around with me to change orders in real time. This does two things: first, it shows the nurses that you are attentive and care about their contribution to the patient’s care plan. Getting friendly, recognizing names and faces and even engaging in small talk really does go a long way. Second, it reduces the number of pages you will get at 2 am to change that Tylenol from round the clock to as needed, or other non-urgent matters. 😊

Time your caffeine boluses. I tended to be sensitive to caffeine. It made me jittery and jumpy, and would occasionally exacerbate an essential tremor that came out of nowhere in residency. I would usually drink a half cup of coffee before work, then, depending on how the night was going, either plan to lie down and sleep and have another coffee or tea before signout, or on PICU nights when I knew I’d be up, time an 11 pm- midnight coffee to keep me going until signout.

Maximize your home rest. I think of this as two parts- creating a cozy environment to sleep in regardless of time of day, and balancing the need for sleep with the need to maintain a normal circadian rhythm. For me this usually meant blackout curtains and ear plugs (you’d be surprised how noisy it can get during daytime hours at home) plus a 3-4 hour nap, then getting up to do errands or enjoy some sunshine, have dinner, and go to bed early so I was rested enough for the next day. I always found days that I slept much longer than 4 hours led to trouble sleeping later in the evening that could worsen my insomnia for days.

Others I’ve worked with have used working out right after call to ensure they get really good sleep, taking melatonin, or just pushing through the day and going to bed early in the evening. The bottom line is you have to figure out what works for you, but in general if you go into REM sleep for too long, your brain is going to be confused and think you need to be awake every night.

New Year's 2016, celebrating with sparkling grape juice in the pediatric ICU

Have fun. No, really. While there are definitely plenty of rough nights to be had in residency, there's also some true camaraderie to be had on night shifts. Some of my deepest conversations with colleagues and coworkers occurred on night float. Some of us had ‘family dinners’ where all 9 people on the floor teams at night would order Thai food and hang out/chat for half an hour. Sometimes we got together and watched Harry Potter marathons on the fuzzy-screened box of a TV in the heme/onc signout room. A curmudgeonly older nurse would break character on Saturday mornings and make French toast at 4 am for anyone passing by. For one intern’s birthday, we raided the supply closet, made her a birthday crown out of the weirdest supplies we could find, and celebrated with ginger ale mocktails served in plastic pink cups at midnight.

Hope this is at all helpful to someone, and best of luck to all the new interns who started this summer and the sub-interns trying on this role for the first time!