Pages from the Philips Seeking God's leading in medical missions

Trauma Surgery is Done…

Only twelve more blocks to go in intern year! What a relief it has been to finish my month of trauma and to start back in the emergency room as of tomorrow. The last two weeks have been very difficult emotionally and have caused me to think again about the type of physician I want to be and to examine what our future life in medicine will look like.

My last night of call was today and I couldn't have been happier to finish this morning at seven so that I could sign out to the new emergency medicine resident coming on to the service. If there has been one consolation for this month it has been the realization that this will probably be the hardest month for me during my intern year and so since this is now done the rest of the rotations should all be easier...or so I hope! This week was particularly a long one because our schedule worked out so that we ended up having three days of call in one week.

In news outside of work, I'm a bachelor again for ten days while Melissa, the kids and Daisy travel to visit family in Nebraska and attend a wedding. Melissa's brother David flew into town last Tuesday to help her drive to Nebraska on Thursday morning. One of Melissa's childhood friends (a friend she has known since the age of three!) got married in Des Moines, IA on Saturday. Melissa tells me that it was fun for her to meet some friends from when they lived in Belmont, IA who she had not seen in almost 25 years! They are planning on being in Nebraska until next Sunday so that they can celebrate her sister, Kris' graduation.

I also got news from Melissa that a sixth member will be added to our family next week since we have now also acquired one of Melissa's parent's kittens who is a couple of weeks old. Karuna is deciding on a name for this new kitten - right now she goes back and forth between Cinderalla and Rosie. We'll let you know what she decides. So even though we have a bigger home in Dallas compared to Minnesota, I feel that we are quickly filling it up with new pets. Daisy also went along with Melissa and the kids and so far she seems to have done great on the trip. She loves being oustide in the country in Nebraska and she has had lots of fun with Melissa's parent's dog, Sarge.

Speaking of bachelor life, I'm definitely not a fan of it. I know there are many people who talk about how they wish they could return to the days when they were single but I have no desire for such a life. I've slept horrible these past few days because Melissa hasn't been around and the house seems eerily quiet without the constant din of Karuna and Luke playing. I've been so blessed to have a wonderful wife and kids who care for me and love me that I just can't imagine going back to a life without them around. Moreover, I'm been realizing with them gone how much I love companionship. Its great to have Melissa with me when I get home because I have some to talk with, to decompress with and to enjoy life together with. Without her around, I just can't seem to get motivated to do things the way that I do when she is here with me. These 10 days that we will be apart will be the longest time we have spent apart in our five years of marriage...but all things considered this was probably a good time for them to go to Nebraska because I've been putting in so many hours at the hospital. Nevertheless, I will be celebrating when they return on Sunday!

These last two weeks on trauma surgery have caused me to think critically about health care, physician responsibility, and our future role in medical missions. One of the biggest frustrations for me on trauma surgery has been the dismal follow-up many of our patients receive once they leave the hospital. I think the hospital I work at provides excellent care to our patients while they are in the hospital but it's a different story when they leave. Case in point - there was a young man who we've been taking care of for several months who finally went home early this week. We had worked hard with him to help him recover from his injuries but when it came time for discharge I was at a loss as to how I could provide him with good follow-up care since he has quite a few chronic problems that still need to be addressed frequently. Most of our trauma patients have no primary care provider let alone a physician they have seen before they come to our emergency room. When our patients get discharged they are followed up in the trauma clinic which is primarily resident run. The problem with such a system is that each time a patient comes back they see a different resident and most of the time that resident has little understanding of what has happened with the patient in the past. Of course the staff at the hospital instruct us to just look through their paper chart to find out what has been done but that is easier said that done. Most of the patients who have been in the hospital for months have charts that are 4-8 inches thick and to expect a resident to review that information before each visit is just not feasible. Besides even if an attempt was made to review the chart, there is often very little organization to these paper charts and so it is next to impossible to find the right information. When this happens the resident bases their decision primarily on what the patient tells them which for most of our patients is incorrect since most of them have little education and have very little understanding of their disease. Thus after a couple of visits these patients start falling through the cracks until they get so sick that they are back in the emergency room and we repeat this cycle yet again.

One of the aspects of medical care that I loved at Mayo was that the patients primarily belonged to an attending physician and the residents helped out rather than the other way around. At Mayo the same attending saw the patients from visit to visit and the residents would assist so that there was someone who had a big picture view of the patient and their illness and could temper decisions based on knowledge they had gained about the patient over time. Because very few of the residents build up long term relationships with these patients there is a general lack of ownership with regard to patients and they are left to fend for themselves. Of course, most of our patients at Mayo had insurance (I think the uninsured rate at Mayo was about 5%) while at Parkland it is close to 70-80%. So I'm not sure what should be done to fix the problem...I just know that it does a poor job of keeping up patients now after they leave the hospital.

The second lesson that this month has taught me has been the need to think critically about systems to provide the best health care to patients. One of the things that has been very difficult for me with working at Parkland has been how inefficient the system here is compared to where I trained. Everything seems to require 2-3 phone calls or filling out the same information on multiple forms before something can be done. There are also many issues with regard to standardizing patient care so that patients receive the most cost effective, high quality care possible. I think in that regard this experience at Parkland will prepare us well for the medical enterprise in India. It seems that much like our experience at Makunda, the needs are so many and the pressures so great that we just go through the motions without ever taking time to evaluate whether what we are doing is the most effective way to do something. As I've thought about that I'm realizing more and more than even though I love patient care, I care just as much about improving systems so that we become more efficient at what we do and provide superior care at the lowest cost. However, being able to do that takes time and being able to step back and reflect. So now we are envisioning that I might spent at least a decent amount of my time at a hospital working to improve processes rather than just doing patient care all the time. We figure that since this has been an interest of mine that it will help to make patient care easier on all the providers while at the same time allowing the hospital to take care of more patients and to do it with the best quality possible.

We are not sure exactly what it will mean for my training after residency but we trust that God will give us greater clarity of vision as the time comes to make that decision. I also wanted to share an interesting series of patients we received in the ER over the last couple of days. First was a man who was transferred to our hospital after being bitten by a rattlesnake on his right hand. After he got bit he captured the snake (live) and then brought it with him in a bag to the ER so that the doctors could identify it to treat him appropriately. He had quite a bit of muscle damage from the venom but after 10 units of CroFab (the snake antivenom we use for North American snake bites) he did fine although his arm looked quite black and blue. I thought this was an unusual event until I went to work yesterday and there was another man who was in the ER also because of a snake bite. This time the snake was a copperhead. After the snake bit him he also picked up the snake by its head and brought it with him in a bag (live again). The EMTs refused to let him get on the ambulance unless the snake was dead and so finally he killed it and in his bed yesterday when I saw him was the copperhead with the head cut off. Again some more CroFab and he did fine. Just in case you might wonder...what do you do when someone is bit by a non-North American snake like a pet cobra? We send the helicopter or police (depending on how quickly we need it) to the nearest zoo (which for us is the Dallas Zoo) because zoos usually keep on stock the antivenom for most of their poisounous snakes in case a zookeeper gets bit.

I also wanted to post some pictures from the end of June and early July. The first is a series of pictures we took when our friends Eric and Kristy came up from College Station and our friends Brett and Meghan came down from Rochester. There are also some pictures in that set of our friends the Warrens who we have know from church for almost 15 years. You can view them as a slide show by clicking on this link: Friends from CS & Rochester or just click on the pictures below. The second set of pictures are from Karuna's fourth birthday party and 4th of July celebrations. You can view them as a slide show by clicking on this link: Karuna's Birthday Party & 4th of July or just click the pictures below.