Togo Week 4: Bringing it home

Last week, I stocked up on Vitamin D at the pool, did a lot of spinal blocks, saw a lot of patients in clinic, and said my goodbyes. One day, I saw thirty patients in six hours, which averages out to one patient every twelve minutes! I also performed two Caesarian deliveries and a tubal ligation, and helped on a hysterectomy and a couple inguinal herniorraphies. Finally being able to get in the OR my last couple of days felt like a reward for all the hard work I'd done the previous month.

I wanted to come away from my time in Togo with new tangible skills, and I did. I'm comfortable doing spinal blocks on my own now, and a lot more comfortable with Caesarians now than I was before I went. To reinforce what I've mentioned in prior posts, I also feel much better about taking care of sick or potentially sick newborns, as well as malaria, typhoid, TB, parasites, HIV, schistosomiasis, and snake envenomations.

I also had a lot of time to reflect over the past week on larger learning points from the trip. An important one is that it's basically impossible to meaningfully connect to people with whom you do not share a language. This motivates me to continue to learn French, but also to try more to learn the local language of whatever place or places I spend more time working in the future. My gains in French over 3.5 weeks were fairly good, but would have been much more if I had had the head-space available that was taken up by medicine. In the future, I would like some dedicated time for just language learning, 24/7 for at least a couple months. Right after residency or fellowship would be the best time to do this, though I'll have to see what my life looks like at that time.

A related musing was how we should approach everything in life as a challenge, a puzzle, a problem, a question to be answered, solved, and overcome. This perspective is so empowering. When I was hot, I did not succumb to the temptation to dwell on how I wasn't meant to be in Togo or how I could never work at a mission hospital in Africa; I borrowed some thinner pants from Brett and took short breaks in air-conditioned areas, and felt just fine after that. Similarly, when I didn't understand what people were saying in French, I decided to make more of an effort to study and try to speak what little of the language I knew, and could at least understand bits and pieces of what people were saying by the end of the trip. When I wasn't sure how to get something done in the hospital, I would try to ask more questions rather than resign to futility. The list goes on. I'm frequently struck by how so many people resign themselves to being bad at something rather than approaching their weaknesses as solvable problems. Sure, not all of us are wired to be math whizzes or golf champions or social butterflies, but unless you have a personality disorder, a physical disability, or a below-average IQ, you can become decent at just about anything. We should all strive to be Renaissance men or women, not only to increase our antifragility but also so that our lives may be enriched. That's been my goal for a long time, and it's made my life immeasurably richer. But I still have a long way to go!

In addition to medical experiences, I was also able to connect to most of the English-speaking staff members of the hospital. I really enjoyed getting to know the CRNA's in the OR, who were all my age and spoke decent English. One guy even gave me an invitation to his wedding! During my down time, I watched Frozen with some other short-termers and the first half of the expanded The Hobbit 1: An Unexpected Journey with my house parents Mark and Donna Thompson. Church also offered a chance to engage with Togolese culture in a different venue, and the dancing and music did not disappoint! I also got my first djembe lesson by the long-term surgeon, Eric Miller, and am excited to play more and maybe get some drum circles going in the future.

My trip to the airport in Lome on Friday was eventful, as our first driver drove away with the keys to our van after we switched drivers halfway. Brett took off down the road waving his hands in the air, but she didn't see him. I'm sure it was quite entertaining to all the locals. Fortunately, the driver picked up when our driver gave her a call on her cell phone. Thank God for cell phones. We had a good time chatting with Koffi, the second driver, as well as a neat guy named Serge we met at a pizza place where we ate before heading to the airport.

The twenty-four hour series of three flights home was about what you'd expect; a never-ending stream of customs agents and airline clerks, movies and podcasts, carb-heavy food and cramped seating, naps and attempted blog posts that got lost multiple times. I finally gave up on the blog post, but think the added few days of perspective has helped things.

I already posted my photos from last week on Facebook, but will put up a few of the same here for posterity. Another post is coming where I will reflect on how well I met February's goals and what March is looking like. Until then, stay on the rise.

Togo Week 3: Pushing farther

This week, Brett, Felisha, and I met with a number of challenges, but today offers a chance to reflect on how we are overcoming them. Firstly, Brett got malaria (we think) on Thursday, and had about 48 hours of flu-like symptoms. But after taking a 6-drug cocktail last night and getting some good rest and prayer, he is back in the saddle today and taking Medicine call. Apparently not even malaria can keep that guy down for long! Compared to him, I haven't had any major challenges, but had to work through another couple days of low motivation and fatigue after taking two call shifts back-to-back earlier this week. But I'm back in the saddle today, too, thinking and learning and working, and taking OB call.

The challenging, sometimes sad, but always interesting cases continued this week. I got my wish and saw my first snakebite. A young man came in on Monday after being bitten on his foot by a snake 3 days prior. His leg was swollen and painful and he was having some bleeding from his mouth as well as from numerous little cuts a traditional medicine man had made on his body. He identified the saw- scaled viper in our handy-dandy Snakebite Guide as the one that got him (and got away), and we gave the appropriate antivenin along with antibiotics, the tetanus vaccine, tetanus antiglobulin, and Benadryl for a mild reaction to the antivenin. And he got better, which is always nice!

Look closely and you can see two fang marks just anterior to the abrasion near his heel.

On my call shift on Thursday morning, an elderly lady was brought in shortly after being struck by a moto. With her decreased level of consciousness, blood coming from her mouth, blood (which turned out to be a bloody CSF leak) pouring out her ear, and her Cushing's response (hypertension and bradycardia), it was clear she had sustained a basilar skull fracture and had a major head bleed. She remains unresponsive with fixed pupils this morning, and as there is no neurosurgery here, we are planning on withdrawing care in the next day.

We also saw a couple children with cerebral malaria complicated by meningitis Those kids have not done well; if they ever wake up, they will be permanently disabled. 

The ICU-- one of the cerebral malaria patients is in the corner bed

I diagnosed several patients with metastatic breast cancer in clinic this week, along with a couple others with intranasal masses. It can be frustrating and heartbreaking having so little to offer. I did start the breast cancer patients on tamoxifen in hopes they would get some palliation. One 22-year-old patient came in with obvious TB, but because his sputum smears were negative for TB the government had refused to treat him. I prescribed him quadruple therapy from our dispensary, but it turns out the pharmacy is currently out of pyrimethamine. Ultimately, after talking to one of the long-term missionaries, we decided to wait on starting him on treatment. Not starting him on treatment and not knowing whether he will ever get treated has been the most frustrating case of the whole rotation.

No C-sections for me this week, though I did place three spinal blocks and first assisted on an inguinal herniorraphy on a 2-year old. I should be able to get some more spinals and OR time this coming week, and I'm also hoping to primary a Caesarian on a transverse-breech set of twins scheduled for Thursday, if she doesn't go into labor before then. Like many patients, she is staying in the Cuisine, which is a building on the grounds where patients who need to be followed closely can stay for free. 

The Cuisine on the left and OB ward on the right

OR 2

My "NICU rotation" continues-- after some reading and discussion with the Pfennigers, I feel good about how to evaluate and make decisions on babies at risk for sepsis. I can see this knowledge being put to use both back in Wichita and also in my future practice. I'm very appreciative.

Maternity

My pleasant diversion this week was this morning's solo hike up the mountain road behind the hospital-- about a 45 minute walk each way, although the road was still ascending at a modest grade when I turned around. It was fairly peaceful at times, affording some moments for reflection, but also offered many opportunities to practice the situational awareness of Jason Bourne by staying out of the way of a steady stream of motos, trucks, and cars.

I would never trust a Togolese parachute.

Not much change in certain other areas: I continue to miss Mindy as well as other familiar comforts of home, The Book Of Daily Readings and Celebration of Discipline continue to inspire, and I'm still slowly learning French. My final session with Professor Tupo yesterday was excellent as usual. My nurse translator Maman Cherie continues to share the gospel like a boss and rock out an average of 2 conversions a day. It's amazing to watch.

Mindy and snow

Tupo

Maman Cherie

I'm thankful for the margin I've had during my time here to set fresh new goals for the year and consider the pros and cons of my various post-residency options. I'm sure I will return home inspired. Until next week!

Togo Week 2- Working Hard

Today marks the halfway point of my rotation here in Togo. Appropriately, Dr. Gayle (a long-term family doc here) and his wife Cheryl took several of us on an outing to the largest town in this region of Togo, Kpalime. We toured the local school for the blind ("The Village of Light"), checked out their nifty aquaponics set-up, shopped at their artisan boutique and the larger local artisanal market, dined at a nice local restaurant, and shopped in the town's outdoor market. All of the experiences-- as well as the drives there and back-- were eye-opening and enjoyable. I continue to derive pleasure from spending time with all the folks here, and am coming to appreciate more how truly wonderful most of the Togolese people are.

Yes, that is a goat on top of the van and two pigs on the back of a motorcycle. Not all that surprising when you think about it (how else are poor people going to transport their livestock?), but entertaining nonetheless given the novelty.

The workweek was also varied and productive. Since my last post, I have performed two more Caesarian deliveries (both of which went well from a surgical perspective, although one was on a known fetal demise), gotten pretty comfortable in both inpatient and outpatient OB and Medicine, and seen a lot of neat cases. There are too many stories to tell and cases to review. In rough order of frequency, on inpatient medicine we see malaria, typhoid, new HIV, anemia, schistosomiasis, acute kidney injury, osteomyelitis, and pneumonia most commonly. Common outpatient issues include dyspepsia, parasites, other infections, back and hip pain, infertility, diabetes, hypertension, orthopedic issues, HIV, and new TB. Yesterday, I was finishing up clinic when I heard a commotion in the waiting room, and a support staff person burst in the room, grabbed a fistful of gloves, and rushed out. Shortly later, I followed him out and discovered two motorcycle accident victims being rushed in on stretchers. I also discovered I was the only doc around. I instructed a nurse to get me some help from one of the local PA's, and began to run through the ABCDE's for each patient. Turns out both had head injuries (hopefully superficial only) and one had an open tib-fib fracture. Fortunately, both were protecting their airway and didn't show any obvious signs of imminent shock. After I got them exposed, I had them moved over to the hospital triage area, where we got IV's started and I was able to promptly obtain a surgery consult. That was fairly exciting.

Kristi, me, Chantal, Amanda, bowel gas, and Chuck

Alcoholic GI bleed in hemorrhagic shock

Peds ward at night

Bronchiolitis-- would have been intubated in the US, but still survived with non- invasive positive pressure ventilation

Myelomeningocele

Sundowning in same baby who really needs a VP shunt

In regards to surgery, I have not pursued getting in the OR (aside from C sections) because of my workload on Medicine and OB and the presence of five surgeons here for the past two weeks. I do still hope to get a few intubations, as well as a few spinals and some General Surgery cases if I can find time. 

Tomorrow, I'm back on OB call, then on Medicine call Monday. We have some people leaving so it will be busy, but hopefully in a good way. I also hope Brett, Felisha, and I can find some time in the afternoon to repeat our Sunday Swim! 

Though it's been a busy week, I've been encouraged by reading Celebration of Discipline by Richard J. Foster and following via group text the experiences of my house church brothers and sisters as they have sought to make meditation (the topic of this week's chapter) a meaningful part of their lives. Being a part of a group of people committed to strengthening and encouraging each other is a key to making spiritual progress, and I've come to appreciate that more this week.

I also had an African feast on Wednesday, which was the first time I had knowingly eaten cassava. It was super bland. The rest of the food was ok. Though I knew cassava wasn't paleo, after reading the Wikipedia article on it, I realized it ranks somewhere near Little Debbie Cakes in its un-paleoness, consisting of almost 100% carbohydrates and requiring extensive processing to remove toxic levels of cyanide. And it's not even native to Africa, having been transplanted here from Brazil by the Portuguese in the 16th Century. Next time, I think I'll pass.

Cassava (agbeli) balls, third bowls from the front

I also had my second French session with Professor Tupo yesterday, and have made some good progress in vocabulary and verb conjugations this week. I'm hoping to practice more each day as I become able to articulate a few things and understand more. Brett has studied with me a couple times, which has been good. I have one more lesson to finish learning the rest of the language!

Though it's been a good two weeks and I'm looking forward to another couple good ones, I'll get to see my girls when I get home! And other people too, I guess. I miss you!

That's Mindy and Molive. I'll never be a cat person, but do have a special place in my heart for Molive. Mindy's ok, too.

Togo Week 1- Growth

To those of you who don't know, I've been working at a mission hospital in Togo, Africa for the past week. I'm here with my friend and colleague Brett Hoffecker and his lovely wife Felisha. 

The first four days I was here, I was hot and exhausted all the time, didn't know how the hospital system worked, and somewhat anxious about how the month would go because I had so little energy. The last two days, I have felt like my normal self and been a lot more comfortable rounding on patients in the hospital. I'm not sure what changed, but for whatever it was I am thankful. Brett and I are alternating medicine and OB coverage every two days, which corresponds to each of us taking calls every other night (q2 call) either on medicine or OB. The other night, Brett was up literally all night delivering four babies, all of which were complicated by some combination of prematurity, pre-eclampsia, chorioamnionitis, and fetal distress. Fortunately, I haven't had a night like that yet.

My medical goals are to get lots of procedural experience and learn how to take care of some tropical diseases. This week, I did one C-section and two lumbar punctures and saw a few cases of malaria. The topic I actually learned the most about this week was taking care of newborns. My second day here, I performed a difficult neonatal resuscitation on a baby that ended up dying later that day. Although I did the resuscitation with another doctor, I felt like I could've done an equally good job on my own with the training I have received at Via Christi, which was reassuring. But I still learned a few things. The few other resuscitations I've been in on have been uneventful. But I'm also rounding on babies that would be in the neonatal intensive care unit in the United States, a setting in which I have never worked. So I am getting comfortable with treating babies who possibly have sepsis, premature babies who are not yet feeding well, and babies who aren't breathing well. It's been good. Since there are a lot of surgeons here my first two or three weeks, my only real time in the operating room was for the C-section I did and a couple neonatal resuscitations. I hope to get some more time in the OR my final couple weeks of the rotation.

Another goal of mine is to learn lots of French, which is the primary language of the staff here. Yesterday, I had my first of three hour-long French lessons with a local dude who comes here every Friday to provide lessons to the missionaries. His name escapes me, but he has a close-criopped white beard and is a pleasant guy. I'm starting to learn, which is exciting as it represents the start of a new journey.

My interactions with the short- termers, intermediate-termers, and long-term missionaries have all been positive. I'm enjoying their company and learning a lot from them. Some of them are truly inspiring. Today, a few of us short-termers went for a three-hour hike to a nearby cascade and back, which was pleasant. I'm also getting to know the national staff pretty well, and played with a bunch of kids on my run yesterday and ended up with a good story I'll perhaps share another time. I'm particularly looking forward to learning from an OB who just arrived yesterday and continuing to learn from the two Family Medicine and OB fellowship-trained missionaries here with World Medical Mission's 2- year post residency program.

Things are pretty good for me spiritually too. God is teaching me how big He is, how to live more other-directedly, and what walking by faith looks like for me, being a critical and very analytical dude. I'm going through literally the best devotional I've ever come across, a gem of a book I was given by Mindy entitled A Book of Daily Readings. It's basically a bunch of the best quotes you've never heard, some of which are religious but most of which are simply very thought-provoking and heart-pricking. Mindy found it second-hand somewhere and it blows my mind every day. I'm also starting to go through Richard J. Foster's Celebration of Discipline, which has been good so far.

Last but certainly not least, my first week of engagement with Mindy and our first Valentine's Day have been wonderful. Though we have been separated by oceans, mountains, and many miles of flatness, we have had time to process together in a way that would not have been possible if we had been in the same location, partly thanks to the power of the internet and partly thanks to journalling. I'm growing more excited and thankful for her each day as October 4th (our tentative date... not yet set in stone) approaches. 

Thanks for all your thoughts and prayers. A lot has gone into making this trip happen, and it's encouraging to look back over the past week and see some real gains in all the areas I've mentioned. If you'd like, pray that the growth continues.

January

      My vision of structuring my clinic along the lines of a Direct Primary Care (DPC) practice this month was partly successful. Before describing the changes I've made, I must first give a bit of background. For most of last year, I simply tried to see as many patients as possible each half-day in order to make the quickest progress toward the 1650 patient visits required for graduation. Often, than meant feeling rushed and not fully addressing some of the more peripheral concerns patients would bring up during the course of an encounter. As I reflected on this and became exposed to the DPC model, I came to realize I was practicing sub-optimal medicine, which unfortunately cannot be labeled sub-par because it is the norm in our current third-party payer fee-for-service model.

       This month, however, I've been taking as much time as I feel I need with each patient in order to do a good job, and have resisted the urge to feel rushed at any point or even check how many patients are waiting as I interact with each patient. Sometimes, this has meant spending the better part of an hour with a patient who presents with multiple conditions and complaints.  Fortunately, these visits are often balanced out by quick 5 to 10 minutes encounters, many of which are prenatal visits or well-child checks. My rock-star nursing staff helped me at the few points where I did fall very behind, for example when I did a circumcision in the clinic on a patient who turned out to have mild hypospadias.

       Two crucial recent modifications of my schedule are that I have asked to only be scheduled to see 7 patients per 3.5-hour half-day (which seems to be my sweet spot) and having the first slot of the half-day always double-booked. Only once did one of the two patients scheduled for the first slot have to wait more than 30 minutes; all the other times the first visit was fairly brief or one of the patients did not show up. Though this is not something I plan to do in my own practice, double-booking is a necessary evil given the waiting room wait times and significant time needed for nurses to room each patient in my clinic, neither of which can I change. In my future practice, it will likely take no more than a minute for a patient to be roomed by my nurse (if they are roomed by a nurse at all), and I will likely have a much lower no-show rate, obviating the need for any double-booking.

       A final piece I have made progress on is my and Brandon Alleman's longitudinal project for the year, the Paleo Health Group. I recruited a few patients in the course of my clinic and have started to solidify the structure the meetings will likely take. Brandon and I just discussed our plans with a few attending physicians today at a Research Meeting, and they essentially reinforced our plan. Also, I booked the space for the first meeting and started a GroupMe text messaging group for us to start using in a few months. I was also able to hit two birds with one stone by making this my Practice Management project, which was nice.

      As I peer into February (and early March), I am re-motivated to pursue my goals of 21 intubations, 21 surgeries, 21 French words a day, and 21 blogged cases from my trip to Togo. I will probably type the cases up on my computer and post them all sometime in March, as internet and time will be limited. But we'll see; I'll try to post at least something on this blog while I'm there!

      I'd like to end this post, and every future post this year, with a reminder for you to quantify your goals and put them out there for the world to see, whether it be on a blog, a facebook post, in a small group meeting, or on your front door. In what specific way do you plan to better your life during the month of February? What skill set can you master or project can you complete that will make you healthier, wealthier, happier, or more filled with love? Seriously-- give this some thought. You grow old fast and Old Man Time is not your friend.

N of 1: 21 Days to Expert Enough

      What I am about to describe is next year's plan of self-experimentation, which has its origins in the things I've been reading and thinking about this year. A foray into the quantified self movement this year using the AskMeEvery service and numerous articles on methods of becoming "expert enough" have convinced me of the need for a structured program for self-improvement. A blog is perhaps the most useful tool to keep the self-experimenter on task; I first experienced the power of this motivation at the end of medical school, when I reflected on a number of William Osler's quotes during the first half of April. I still carry in me the lessons I learned from that time.

     Specifically, I am laying out a calendar of 12 21-day self-improvement projects I plan to accomplish over the next year. I chose 21 days because it takes at least that long to ingrain a habit (recent research actually puts the number at 66 days), and because it gives me wiggle room to miss a few days each month. This blog will be the site for my reflections on each project. The specifics will probably change, but as of now, my plan is as follows:

21 Days to Expert Enough

January: Approximate a direct pay primary care clinic in my clinic 

February: Blog about 21 cases in Togo, learn 21 French words a day, intubate 21 patients, and perform 21 surgeries (Caesarian deliveries, D & C's, exploratory laparotomies, etc.)

March: Teach medical students or interns about 21 different topics

April: Read 21 books

May: Build my website

June: Go through 21 medical journals (including back-issues of NEJM, AFP, JAMA)

July: Establish 21 new professional contacts

August: Quantify 21 areas of my life using the Apple Watch 

September: Establish a long-term financial plan   

October: Update my website or blog 21 times

November: Start a YouTube channel

December: Re-pursue one of the above projects, and do it better.

     A longitudinal project I'm pursing this year is a monthly Paleo Health Class (set to start in April and run for one year) for patients, staff, and faculty of Via Christi. The website and Youtube projects are even more long-term projects I've been hoping to start for the better part of the past year. My longest-term project will be the establishment of my own (or partnered) Direct Primary Care practice after residency, location TBD. Perhaps I'll be able to expand to multiple locations after a few years, as the Atlas MD folks are starting to envision.

     Rather than list out a bunch of resolutions you vaguely hope to accomplish but probably won't, why don't you consider committing to a more structured program of self-improvement? As 2015 begins, I hope I can inspire you to begin the process of quantifying yourself with the goal of becoming more effective, efficient, healthy, wealthy, wise, and happy.

     Be well.

     Dan

Jany Moussa

Twelve reasons why Dr. Jany Moussa is the man:

-He listens

-He is genuine

-He is warm

-He cares deeply about his patients and residents

-When he is upset, it is for a good reason

-He doesn't pull any punches

-He challenges us residents to be better

-He expects us to be good

-He encourages us when we do things right

-He believes in us

-He is a superb clinician

-He is always seeking to improve himself and others

For these reasons and others, everyone loves Dr. Moussa. I had the privilege of spending two weeks with him in June and seeing first-hand how he operates, and it was the most transformative two weeks of my first year of residency. I've since been trying to emulate many of the things I've listed above, and although it is slow going, hopefully I'm making some progress. These qualities fall under the three components of charisma that I learned from The Art of Manliness and am seeking to exemplify in my own life: Presence, Power, and Warmth. My new mantra.