Archive | March, 2012

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International Elective in Argentina

Posted on 23 March 2012 by Keegan Selby (Meds 2014)

The following is an excerpt from my Journal Entry taken during the summer of 2011 on an international elective in Argentina.

Wednesday July 20th 2011:
Our bus rambled its way down the dirt road and finally pulled into the bus stop at 9 pm. Outside, our host was waiting to direct us to what would be our living quarters for the next few nights. We jumped into some cabs and drove in darkness to the former hospital, which had been converted into dormitories for Argentinian clerks. I say in darkness, because the power to this part of town was currently out, an occurrence that was actually commonplace in this area.

We had seen the rich tourist areas of the ski resort city, Bariloche, and the provincial oil-rich capital of Neuquen…but this was rural Argentina. The town endures predictable rolling blackouts and only the main couple of streets are paved. Most houses have their own rain barrels for water and fire stoves for heating and cooking.

We dropped our backpacks off on our bunk beds, formerly an old surgical or examination room, and walked over to the current hospital to get some dinner. All our meals were provided by this small hospital and made by a group of elderly woman who treated us like their grandchildren. The staple of their meals was usually cheevo meat (a small goat-like animal), and the food they prepared was delicious and plentiful.

Thursday July 21st 2011:
Our first day in the rural hospital…apparently people don’t eat breakfast down here, just white bread and matte (a strange green tea like drink). Oh well, we will have to take leftovers from dinner tonight!

Mauricio, the paediatrician here, is hosting us and he has been very hospitable and a superb tutor. His motto is, “I show you the first time, you do it the next time”. Under his guidance I observed 12 pediatric cases today. He taught me how to do some basic dosing calculations as well as well-baby checks on kids that were less than 24 hours old. This included checking all reflexes and the normal anatomy of each child.

The absolute highlight of the day, even of the two-month trip, was when Mauricio told me there was a woman in labour and I would be catching the child. What happened to the “I show you first, you do it next time”?? But, there comes a time early on in each medical student’s education where one must step up to the plate, even though it is their debut game in the Majors versus the Yankees. Plus, I had to learn at some point.

I scrubbed in a little shakily, and was rushed by the nurses because it appeared the delivery was coming quicker than initially expected. Sure enough, I ripped the first pair of gloves because they were too small and the nurse didn’t speak English so she didn’t understand my request. Yes, I should have asked in Spanish but with all that was going on I could hardly begin to translate. I was given a larger sterile pair again. “Vamos,” they pleaded, ”Vamos!”. I pulled on the new pair of gloves and in my haste ripped my right glove as well…no time for another pair though. We ran into the delivery room just as the baby decided it was time to poke his little head out.

This was the first time I had witnessed a birth of any type. What an incredible experience it was and to have it occur in Argentina will ensure that I never ever forget this place and what happened here. I can’t overstate how incredible it is to see a new life brought into this world. When the child was pulled from his mother, I must confess, there was a moment of shock and fright. What if there is something wrong with the child? Will I be in the way? Is it supposed to look that way?

I kept the towel pressed warm up against my scrubs as I waited…and then caught little baby Abraham from the gynaecologist. The child was completely bluish-grey when it first came out and didn’t make a noise…wasn’t it supposed to be pink and angry at the world for being so bright?! The baby and I were rushed into a small heated area beside the delivery room where I proceeded to rub little Abraham all over to stimulate breathing. A few gurgles later and the first cries of life miraculously emerged from his tiny mouth. He simultaneously turned from bluish-grey, to pink and healthy looking. He was beautiful.

 

The new father watched through a tiny square window and I could see the pride on his face. He took photos as I clamped and cut the remaining umbilical cord and gave an injection of vitamin K and other needles into each of his squirming legs. He was a beautiful little kid and perfectly healthy. I ran my hands over his head and clavicles, ribs and abdomen for broken bones or tumours. His perfusion was normal and anatomy from head to toe was as it was meant to be. I picked him back up and he weighed in at 3360 grams, and we also checked his length. There was some blood on him from when I had cut the umbilical cord so I next bathed him in the sink beside the pediatric station before giving him back to his mother to be held lovingly. The mother wept as this new life from her womb was pressed against her cheek.

It would be an understatement to say I was amazed…even though this child was not mine, even though I had never spoken a word to this mother and did not know her life or her story. Even though I wasn’t her family, her friend, or even her doctor…a tear came down my cheek and in no way was I embarrassed.

When we leave this small Argentinian town I will be taking with me the highlight of my medical school career thus far. This highlight was not a rare disease or case presentation, nor an intricately complex surgical procedure in a posh operating room. It was an event that occurs almost 250 times per minute around the world, but being a part of just one has made me more aware of the miracle of life.

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My Summer Elective experience

Posted on 23 March 2012 by Dan Myran (Meds 2014)

This summer I spent one month in Northern Ontario on a medical elective. Over the month I was given considerable autonomy to practice my clinical skills and interviewing, and was granted a unique view of complexly foreign part of the country. The following patient encounter was one of the most shocking and influential events of my elective.

My preceptor for the day had assigned me one examining room and given me a third of the patients. After seeing each patient I would give her a summary, discuss a management plan, and we would then go in to see the patient together. I grabbed my first chart of the afternoon, a 16 year old female patient was presenting to the clinic with what she suspected was a Chlamydia infection.

I knocked on the door, walked in and introduced myself to a nervous looking girl who seemed far to young to be worrying about STIs. We started talking, she had a previous episode of Chlamydia 6 months ago (the reason why she was so certain it was Chlamydia again) which another doctor at the clinic had treated. She had been sexually active since 13, used the birth control pill for two months when she was 14 (she stopped because she could never remember to take the pill) and had since used no forms of contraceptives. At this point alarm bells were ringing in my head and I asked her when her last period was. The answer was informative to say the least: over 7 weeks, and it had not occurred to her that she could be pregnant. To complicate matters, the patient normally drank several drinks a day, and I was seeing her the Monday after Canada Day Weekend, where she had been drunk for most of the weekend. At this point I obtained her consent to test her for STIs and pregnancy, and then made a beeline for the doctor’s office.

I summarized the patient for my preceptor and to my surprise didn’t bat an eye – it was a fairly standard story I guess. One urine dip later and my preceptor turned to me and said, “Ever told someone that they are pregnant?” I replied with a shaky no and then injected slightly more confidence into my voice and said that I would like to be the one to tell her. So tasked with relaying this all-important news, I went next door, with my parting instructions to break the news and find out if she wanted to have the baby.

I entered the room, and said, “I have some big new. You’re pregnant.” I gave her a moment, and then asked her how she was feeling. She said she was shocked. Now the tricky part – the key would definitely be in the phrasing. I cleared my throat, collected my thoughts and blurted out something wonderfully awkward along the lines of “Do you want to carry this baby to term?” She beamed back at me – the answer was a definite yes. The rationale was certainly not to my liking: Dad was in jail, not speaking to the young girl, and she wanted the baby to remember him. But it was her choice. The clinical encounter wrapped up quickly: my preceptor came into the room, we treated her Chlamydia infection (a single dose of 1 gram of Azithroymycin given orally, for those who are curious), gave her some general prenatal recommendations, and set up a follow up appointment.

The patient left the office happy, but I was left with some serious doubts. Aside from being concerned about her prospects for the future, two nagging issues stood out to me. First, this young girl was a high risk pregnancy with significant risk to both mother and fetus (mainly Fetal Alcohol Syndrome). I was aware of it as was my preceptor, but it is unclear how adequately we relayed that message to the patient. It is possible that the patient was unaware of her risk. Should we have directly laid out the risks for the patient before asking about having an abortion? Would it still have been appropriate to discuss risks and offer alternatives after her expressed desire to have the baby? Does pregnancy count as a “medical procedure” for which complications, and alternatives must always be discussed and then offered to the patient?

I was also struck both by how preventable the situation had been and the clear signs that this patient needed help before she showed up at the clinic pregnant. After this “routine” event, there was no discussion of how to adapt or alter the practice, and I am quite positive that similar outcomes will continue to occur. I learned considerably from this encounter, and even more from my time up north, but left my elective cognizant of enormous gaps in our health care system, which unfortunately have no easy solution.

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Reflections on Chinese Healthcare

Posted on 15 March 2012 by Kenneth Lam

When my friends ask me how medical school is, I explain to them that the human body has been written about with zeal for millennia and that I’m spending a paltry four years catching up on as many stories about the body as I can. In every scientific paper and report and publication I read, I ask myself: what did this researcher observe? How did she come to terms with what she observed? What story is she trying to tell me, and how is she wrapping her head around what she saw?

Sometimes the stories affirm one another, and other times the stories conflict. Here’s an example: in the past, Western medicine used to say that peptic ulcers were caused by stress and excessive acid production. But when Barry Marshall and Robin Warren entered the scene in 1982, they told a different story: peptic ulcers are largely caused by an organism known as Helicobacter pylori. I absolutely believe it to be true, but I also understand that the story they tell is about a small creature that few will ever have the privilege of seeing first hand and that doctors recommend their infected patients to vanquish this little beast by consuming small yellow pills.

The point here is that I take information on faith by the authority of those teaching me, which is the same way my teachers learned from their teachers and how they continue to learn from their colleagues. And so I need to make a disclaimer before I begin this article: I know precious little about medicine of the Western variety and even less of the traditional Chinese variety– only what I have been told and what I have seen.

I spent the past summer in China with four friends on a very non-systematic tour of hospitals and other care facilities in five different cities. On three or four occasions, we saw traditional Chinese medicine (TCM) being practiced. Sometimes, it was in TCM hospitals: six story complexes divided into departments with teaching faculty and nurses and the same aura of legitimacy of any hospital, but devoted to a system of medicine that I had been told lacked evidence. Other times, we visited the TCM department nestled within a larger public hospital or community care centre. These departments seemed just as busy as the outpatient departments providing Western medicine.

The presence of these well-funded and well-visited complexes was evidence with which I grappled. The first thing I conceded was that traditional Chinese medicine was doing something. At the very least, it did enough to get people to change their behavior and spend money. Some patients traveled hours by train to see a doctor. Others were following through on doctor’s recommendations to live closer to the hospital so that the doctor could provide more regular care and update their herbal regiment more closely. And every TCM patient we asked gave us a testimony of how it really worked for them: their asthma was better, their cheeks were less flushed, their hematuria lab results came back negative, their diarrhea was relieved. We had a case where a patient reported having Duchenne’s muscular dystrophy (an irreversible genetic condition) improved with TCM.

Confused, I wanted to learn more about the principles behind TCM, and the opportunity came in our last week. We were shadowing Dr. Sun in his clinic at the Shanghai Children’s Medical Centre and his students brought in some bilingual textbooks on Chinese medicine. They were a series of four books published by the Nanjing University of Traditional Chinese Medicine and translated in Shanghai and they covered the basic theory, diagnostics, science of prescription, and science of curative properties. So in between patients, we each read a little.

Two theories govern Traditional Chinese Medicine, but before I get into them, I need to expose the underlying premises in Western medicine. Western medicine is generally built on a theory of reductionism and causality: we break the body up into systems and then the systems down into organs, tissues, and cells, and we then find out what everything causes in order to predict how we can change things. I’ll give you an example: if someone comes in looking jaundiced (yellowish in colour), our explanation is based on how abnormal function of the smaller parts of the body add up to this overall appearance. Jaundice is caused by the excess build up of bilirubin in the skin, and bilirubin is cleared by the liver and produced when red blood cells are broken down, and so the problem must be with the liver or with the break down of red blood cells. It’s a remarkably systematic and rigorous approach to the body.

By contrast, the theories in Chinese medicine are primarily theories of dynamic equilibrium– that the whole body is in a state of balance that’s established by conflicting forces. That balance is thrown off if one side becomes deficient or too strong. One theory asserts that the balance is always between two forces; the second theory asserts that the balance is a complicated web between five forces. Note that these ways of thinking aren’t foreign to one another. The Western notion of water balance (homeostasis) in the body has the same philosophical underpinning– you’re not drinking enough or you’re sweating too much. Similarly, Chinese medicine does break the body down into different functional systems. But in Chinese medicine, the concept of balance comes first, and the concepts of reductionism and causality occur WITHIN the framework of these forces that need to be balanced.

And so the balance between two forces is known as the Yin-Yang theory, while the balance between five forces is known as the Five Elements theory. All disease always goes back to Yin-Yang or the Five Elements. These are abstract concepts: yin-ness is exemplified by the moon, the shade, the internal, the cold, downward directions, etc. while yang-ness is exemplified by the sun, heat, the external, upwards-ness, etc. So, if you’re too hot and feverish, it goes back to either too much yang or too little yin. And the treatment (whether herbal or pharmaceutical) is, by definition, a yin-strengthener or a yang-inhibitor. The Five Elements are also abstract concepts: fire, water, metal, wood, and earth, and they have a relationship of either strengthening or restraining another element. This is where things got strange for me.

TCM believes that the Five Elements get mapped to five systems in the body based on traditional abstraction. The Fire element is mapped to the Heart– but not just the anatomical heart. The Heart includes the blood, the vessels, and the tongue. So perhaps it is better to say that the Fire inside the body is manifested in the blood, the vessels and the tongue. Metal in the body is mapped to the Lungs: but the Lungs also include the hair, the skin, the nose, and sweat. So far so good– maybe TCM simply regroups organ systems along different categories. But I balked when the book made an assertion about the relationships between these categories. Why should Fire necessarily restrain Metal? Sure, I could interpret the sweating from a heart attack as Metal becoming overactive once Fire failed to restrain it, but it didn’t seem like a particularly rigorous or well-founded association.

I tried to put my skepticism aside as I watched Dr. Sun apply these theories to his practice. Like a primary care physician during a routine checkup, he’d ask questions about how the patient was doing and whether there have been any changes recently. But I wondered about the credibility of his diagnoses when I saw that his physical exam consisted chiefly of inspecting a patient’s tongue. The reasoning goes as follows: childhood illnesses tend to be problems of too much yang, the Heart is a yang organ, and the tongue is a window into the Heart. From there, he’d make a conclusion (many of which were lost in translation and understanding), and then he’d tailor a herbal recipe based on each herb’s yin or yang property and its elemental attribute. After that, the next patient.

So over this backdrop of a very unfamiliar medical system and cultural and language barriers, I watched as patients poured into Dr. Sun’s office and sometimes paid a little extra to get a bit more time and attention from him. I mean, what was he doing for them? Was he improving their health? Or if not their health, was he improving their wellness? Was he offering the reassurance of his white coat? And if so, was the reassurance powerful enough to make them well? I grappled with the possibility that he was a charlatan and a quack, selling them the promise of better health but being unable to deliver it.

Calling Dr. Sun a quack is a heavy criticism on both the integrity of his character and his beliefs, and there are a few things that keep me from laying down such a pronouncement on him and by extension, TCM practitioners in general:

Firstly, as squeamish as I am about the theories behind TCM, it could be a working medicine of inaccurate theory but accurate associations. There is some evidence where traditional remedies outperform placebo: Chinese herbal medicine works for irritable bowel syndrome (Bensoussan 1998), and acupuncture is indicated for chronic pain (Manheimer 2005). In this situation, it may be that certain treatments were documented to have a positive effect on certain conditions and out of a desire to create a unified system of thinking, TCM used opposing elemental categories to record which treatment was effective against which condition. And when I reflect on the history of Western medicine, I concede that oftentimes, we are also a medicine based on association rather than bulletproof theory, but still we practice.

Secondly, I found that the TCM students were just as motivated by altruism as I was, and putting myself in their shoes, I couldn’t accuse them of any insincerity or quackery. They gave the same response that I would give if I were asked why I wanted to study medicine– they want to help people. And it’s hard for me to fault them for what they believe: the same way I usually don’t question whether clarithromycin works against H. pylori so long as my professor tells me it works, I imagine they don’t question the usefulness of a herbal remedy when Dr. Sun tells them it works. My convictions regarding the efficacy of Western medicine are founded on the trust I have for my teachers. If Western medicine is superior to TCM, then isn’t the validity of my belief only the result of my privilege to be told true stories about what makes people healthy and sick?

Thirdly, TCM is neither a small nor static field of study. Dr. Sun’s students will be learning TCM for the next four years. Just as they respectfully acknowledged that their field is complementary to the massive body of knowledge that is Western medicine, I have to admit that there is so much about TCM that I don’t know and never will. The total index of herbs is in the thousands (though less than a hundred are used regularly). They pick up new techniques from other naturopathic schools. And they are starting to use Western diagnostics to quantify their practice.

So, as China continues to grow economically, it will be interesting to see how their medical system negotiates between TCM and Western medicine. If patients substantially switch over to Western medicine as the medicine of preference, perhaps it suggests that traditional medicines were a compassionate cushion for those who couldn’t afford better care. But at present, I’m more inclined to withhold passing judgment on TCM. I think it is easy to pick on alternative medicines from within a North American medical fortress, to come to a rash conclusion, and to develop a hostile us versus them mentality and in doing so, create conflicts where there are none.

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Why Medicine

Posted on 13 March 2012 by Saurabh Gupta (Meds 2015)

I remember wanting to be just like Woody and Buzz from Toy Story. I was six years old when I first watched the movie and decided just then that I would grow up to be a Space Cowboy; the best of both worlds! However, as I progressed through all the remaining developmental milestones of my childhood and hit adolescence, one thing appeared obvious – the job market was not (and is not) very receptive of aspiring space cowboys. And so, I entered high school with a broken dream.
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Golden Key – An Organization Dedicated to the Education of the Visually Impaired in China

Posted on 02 March 2012 by Jonathan Fairbairn (Meds 2014)

This summer, four classmates and I visited several non-governmental organizations (NGOs) during our five-week trip to China as part of the Medical Student’s Initiative in China (MSIC). These NGOs were often faced with many challenges including difficulty in securing funding, entrenched cultural attitudes, and problems faced by the sheer size of the population they wish to serve. Indeed from what we saw, it seemed NGOs as a whole in China tend to be generally less well off than those in Canada. However even among other Chinese NGOs, one NGO stood out from the rest in terms of the disproportionate need they sought to address and the resources with which they were equipped to do so. Nonetheless I was encouraged by the optimistic and passionate attitudes of its members in the face of such a challenge. I choose to write this article about Golden Key Research Center of Education for the Visually Impaired for such reasons.

Golden key focuses on education for the blind and low vision population in China. The organization was established in 1988. Their eventual aim is to have every blind or visually impaired child in China have access to education. China has a total population of 1.3 billion, 50% of which are classified as rural, and 15.9% of which earn less than $1.25USD per day. The liaison we spoke with, May, mentioned that Golden Key is the only domestic organization dedicated to promoting education for blind and low vision children in China. The headquarters in Beijing currently employs eight full-time workers, including May. To put it lightly, Golden Key has set a very ambitious goal for itself.
Indeed the state of education for blind and low vision individuals in China is lamentable. This problem is more severe in rural areas. In these areas, families of blind or low vision children are often poorly educated and do not have the knowledge or resources to handle the special needs of these children. To further exacerbate the problem, there is a wide-spread belief in many rural Chinese communities that disabled children are born as a result of the parents’ wrong-doings.

This can include wrong-doings related to directly to maternal or fetal health, or to acts which many Westerners would see as unrelated e.g. not abiding by Confucian social order. An example of the former, May reported, is when some parents try to abort a fetus by ingesting chemicals. This may be done for a variety of reasons, for example sex-selective abortions, attempting to abide by the one-child policy, born out of wedlock, and so on. The efforts of the parents may not always be successful, and can sometimes pose risks to the fetus. Thus, fearing shame and rejection from the community, parents often keep disabled children at home, and subsequently these children do not receive education.

The minority of blind and low-vision children who do manage to receive education are often faced by discrimination and stigma in the work force. For example, May brought up the example of a low sighted person who, when attempting to find employment, was consistently confronted by the belief that blind or low-vision worker would require more work on the part of the company. Part of the discrimination stems from Chinese culture, in which a large value is placed on conformity, and with a low tolerance for unorthodox or abnormal behaviour. Since blind or low vision individuals often have special needs or cannot fulfill roles in the same way that other non-disabled people can, these make them obvious outliers compared to the otherwise healthy and uniform population.

Overall, the current state of blind and low-vision support in China is one that lags behind the standards of many developed countries. However, as China’s economic progress approaches that of developed countries, there will be increased material wealth and likely increased access to education. Increased material wealth will hopefully lead to increased funding for domestic NGOs. Overall increase in access to education will hopefully make education more obtainable for the disabled, and help to soften some of the social and cultural beliefs held by the population at large, which poses such a substantial barrier to a disabled person’s education.

For more information please visit: http://www.goldenkey.org.cn/en/intro/intro_en.html

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