Interesting Article

Doctor Hotspots (One MD's project for Health Care Reform)

Highlights:

(Taken from http://www.pbs.org/wgbh/pages/frontline/doctor-hotspot/)

..."What I knew from my office is that I'm paid to go from room to room to room as fast as I can, and the faster I go from room to room to room, the more money I make. When I slow down and I get involved in a complex case, I may as well hand money over the patient. I lose money. So that's a terrible model of care… You can't do good care in 10 minutes".

"Essentially what's happened over time is that we built a specialty care and hospital system on steroids ... We have shrunk and shriveled our primary care base".

"We have inflated a capacity bubble in our country to do expensive, high-tech, hospital-based care... At some point you inflate a bubble past its true need in society"...

... "So we went back and asked each hospital for all their claims data for a full-year period, ... and began to find buildings in the city that were hot-spot buildings, where there were a lot of elderly and disabled people living in the building that were generating enormous amounts of costs, going to the emergency room and hospital over and over; that there were specific patients in the city that were going over and over to the hospital".

"1 percent of the patients [that] are costing about 30 percent of the health care resources".

"His team is a nurse practitioner, community health worker and a social worker. It's our outreach team, and every week they do internal case conferences, and they run all the cases, and they talk about what the barriers to care are, the challenges, and brainstorm solutions. And every month the whole city comes together -- front-line providers, social workers -- and we do anonymous case discussions at the city level. And what we do is try and pull out common barriers and themes that we're seeing over and over among the patients, and then elevate that up to my board and think in an organizational level, how can we be solving systematically the barriers to care"?

"We think that we're pointing the way with this team to better care at lower costs by bringing care to patients in the community". (Reducing hospital visits/ costs).

February 2010 Trip to Kenya

Below are several journal entries from my clinical externship to Kenya as a student intern. Myself and three of my colleagues spent a month in Kenya, in order to supply medical care to under-serviced communities and tribes in the northern Laikipia region. There we were volunteering with a charitable organization called FIMAfrica (Foundation for Integrated Medicine).

Through FIMAfrica we administered mobile clinics to provide free medical services such as physical exams, medicines, conventional and holistic health care education to the people. The goal of the organization is to provide unprejudiced and sustainable care to poor rural communities in Kenya. Ultimately the hope is to collaborate the skills of students and health practitioners around the world with local health care workers, where there is a transfer of medical knowledge that remains in the hands of these local people.

First day in surgery- Kenyan Highlands

Michelle and I went to do rounds with Dr. David and Josephine (the intern) in orthopedics. It was a much more jovial atmosphere. Despite serious injuries, the doctors would joke with the patients, we laughed a lot, and everyone knew they were on the mend and would be out and back to work soon. There were so many road traffic injuries- broken hips and femurs- mostly men b/c they're more aggressive and risk takers. One guy had a broken tibia and fibula with crazy edema, b/c he had been attacked. Another 19 year old guy had been knifed in the low left abdomen at 11:30 at night, and only came in to the hospital midday the next day- with his intestines hanging out- had gangrene and had to have a portion removed. He was so tough, and had recovered so well, he was eating whole foods and passing normal stool soon after his surgery! The docs all seemed interested in our suggestions for integrative care- such as remedies for postnatal hemorrhage, acupuncture or pressure to induce labour, hydrotherapy to reduce edema and speed healing, plus strategies to reduce scar tissue or strictures. The only possible obstacle being policy.
In the pediatrics wing, so many children were there with 3rd degree burns. A fire safety rural education program for kids would probably be useful here.
After going to pediatrics, Michelle and I went to surgery. There we ran into Sanne again, and met Rio (a paramedic from SanFran). In surgery there was a C-section going on by Dr. Mattia, and knee stapling surgery, by a UK orthopedic surgery team, for a ~15 year old boy with severe valgus knees (knock knee). Katie got to do the epidural for the c-section and I held and comforted the boy during his epidural. Sanne was called on to help with suturing for the knee surgery. What an amazing experience.

How to go to bathroom in the Kenyan outback

Toilet paper in hand
First shine your head lamp into the bush to ensure no hidden water buffalo
Next take your machete (panga) and dig a 3" hole into the scorched earth (it won't go any deeper, I tried!)
Then do your business, cover and run back to the tent :)

Last day of mobiles

(Up in the mountains.. following the rains)
This morning I found another tick- it was on Siobhan's rain jacket- dry from hanging in the tree all night. Glad we left that one behind! After we woke, we went back to the outlook. The walk over is magical- soft smokey grass, dreamy and fluttering with white butterflies, flowers, bees, giant rocks and trees. Fuzzy vines wound and arched over the pathway- truely an eden. That day we drove on to a village through the black cotton (black volcanic mud) and near the old road to Isiolo. This town was the most developed of all our mobile villages. It had proper stores, including a restaurant- where we later ate chapatis, sukuma wiki, and cabbage with chai tea for lunch (at 4pm after waiting hours!). It was one of our busiest days, one patient after the next, till we had to turn people away so we could get to and set up camp before dark. There were many allergy symptoms especially itchy eyes. Possibly a type of tree in these hills. One man was an alcoholic and had an open wound on his left leg that wouldn't heal- for a year. I believe we gave him lycopodium and asked him to soak his wound in salt water and gave him calendula and arnica cream. We also told him to stop drinking alcohol and tried to explain how it is related to his physical health and healing. We also treated a man with goiter, a woman with multiple purple skin lesions below her knees, a man with tinea versicolour and recurrent typhoid, a child with pertussis and many others. It was a long but interesting day. To get to camp, we drove into the hills and took a left over a stream and through the trees, drove on past 2 clearings, made a wrong turn(?) and finally found our campsite... just right ;) Camp was decorated with a rhino mandible and vertebrae. It also had quite an elegant spiral wood and mud shower, plus an enclosed toilet house (presumably for the future ecolodge), which was locked. Once camp was set up we ventured into the wild forest, past many mounds of grassy elephant dung, into a jurassic gully to the elephant platform. This is a man made platform which is eventually going to be part of a tree top walk and ecolodge. It is built around a spiraling tree trunk with many vines hanging onto the podium. It looks out over a boggy pond, with a giant strangling fig tree making the main attraction... that is until elephants roam through. After dismounting the platform, we walked over to a giant fallen tree trunk and sat dangling our feet high above the ground, overlooking the boggy pond and island of psalm trees, calling back to the baboon troop across the bog. We were quite the attraction for the curious troop, deep in the woods. That night we had hyenas calling and were woken at 5am by baboons barking- literally- barking like dogs. After dinner we kept the fire going and had an improv vocal rhythm jam. Amit did a shockingly deep and powerful throat diggeridoo. Impressive hidden talent! After a few campfire songs were sung, like my flag boy, hakuna matata, the other day I met a bear, and some raunchy army cadences, we headed off to bed. This ended our very last mobile for this trip to Kenya.

Friday- We woke ate fruit, packed up camp and drove to a waterfall on the way back to Nanyuki. This was a secret spot, only got to by hiking through the forest along a steep slope to a mountain fed waterfalling into rock and volcanic mud pools, with long vines growing down from the rocky walls. This place was magic and we hopped into the breath takingly cold waters (some climbed down the steep slope, and others cliff dove into the waters), and gave ourselves a full body volcanic mud spa- with an invigorating and cleansing rinse in the rushing falls. All for free! What an incredible way to finish our time with Amit and wash away the previous weeks. Once we returned to Nanyuki, we entered the stats from the mobiles and did some filing, and then finished up our paper work later at Kongonis over dinner. That night Magnus, Siobhan, her roomate Kelly from the US and Amit joined us girls and Lu at Kongonis. Magnus uncovered the extremely lacking list of gear the girls had for climbing mount kenya, and offered up his top of the line gear, including winter jackets, fleece and camel packs. We said goodbye to Magnus and went to bed one last time at Simba's Lodge.

Saturday morning we had arranged with Njoroge to pick us up at 8 am. We had breakfast, Katie and Michelle joined us to say good-bye, as they were heading off later for their trek up Mt Kenya. Rochelle, Lu and I were headed 4 hours west to Nakuru. We had a weekend planned to travel through the rift valley before heading to Mombasa. We gave Nicholas a good tip (our waiter for the past 3 weeks), thanked him for taking such good care of us, wished him luck in his plans to do college for hotel management, said good-bye and I gave him some canadian change as a gift. It was an emotional good-bye. He is the sweetest kid.

Njoroge took a short cut across a bumpy mud country road for an hour to the highway north to Nyaharuru, on our way to Nakuru. We made it in under 4 hours, with a stop at the Nyaharuru falls. Men were dressed up there in full tribal regalia, just for such an occasion as the 'wealthy' mzungu wanting to take a picture with them in exchange for Ksh. We bit.

Day 3 (first day of mobile)

Great start- got some chapati's from Simbas Lodge (where we stay) and a bowl of beans to take along for lunch. Driving was like the mind buster- the roads that lead into nowhere. Fields of goats, masai and scrubby brush plus a sprinkling of acacia trees and random bunchs of colourful purple or red desert flowers. Cacti bushes and trees were everywhere... Then we took a right into a field. Nothing as far as you can see. The 'roads' could better be described as ditches, with a wandering bump down the center- essentially tire tracks with rifts carved by water and elements. Amit tells us ' I don't have a very good sense of direction', as we turn into nowhere, 'I often get lost back in here'. Fork in the ditch- 'should we go left or right? I'm feeling like it's left, but I"m gonna go right first'. On into nowhere we go. There are no maps here, just masai goat herders and the odd kikuyu on bike who point the way to the church we'll be working out of with the mpala mobile HIV and counselling unit. They mobilize the community with their bright yellow 4x4- so they all know we're here. On the way we pass tiny villages of no more than 10 huts w/ mud and poop walls, grassy roofs and fences of bramble to contain their goats. In the church we set up our aluminum table. One woman with pelvic pains 50 yrs old (looks 35- they all look younger here than they actually are). We discovered after physical exam and hcg test that she was pregnant. She would have to make her way to the hospital for an ultrasound to rule out ectopic pregnacy or other serious complication. Another little boy had stomach pains and was missing school. He didn't know what his poop was like bc they go in the long drop. He was very clingy and weepy but no fever. No other signs pointed to an emergency. We gave him homeopathic pulsatilla in the end and informed his father to boil the water. Many people out here don't boil the water, either bc they don't know or they don't think it's that important and can't be bothered. Before moving onto the next village, after our lineup, we visited the nearby village to see an 80 year old man who was too sick to leave his hut. He had a recurrent cough for years with blood, chest pain and wasting. The flys were bad and the heat overwhelming, but a quick assessment made us suspect either TB or lung cancer. What's interesting out here is the mantou test for TB is almost useless b/c most have been exposed and have antibodies to it already. He would need a sputum culture and chest xray. We gave him 2 remedies.
Onto the next mobile- a small masai village, under a tree and across from the Sweet Water (Old Pejeta conservancy), where we would be camping that night. At the village, the kids gave us an enthusiastic greeting "Howa yoo, howa yoo?". One little girl with a big smile and big front teeth came up as I leaned against a tree, asked my name, told me hers- Rebecca and she began rubbing my thumbnail, then petting my hair and then wanted to do homey hand shakes over and over. So endearing. There we met a woman from the north (near the Ethiopean border- a Turkana tribe woman). She, her family and a number of others were displaced here from drought. She wore at least 20 beaded discs around her neck, and they all appeared to shave the sides of their head, leaving a braided mohawk on top parted to the front and back. She walked in sandles with her left foot on permanent tip toe from an old snake bite. She appeared extremely thin with child on wilted breast She complained of dizziness and was tired with no appetite, amenorrhea and lots of weight loss. Her BP was normal, but malnutrition and anemia were likely. After examination we gave her homeopathic remedies for anxiety, hormone balancing and mentrual regulation, as well as for the residual effects of the snake bite. I hope we can get an update later from Amit to see how she does after treatment. Another woman we sent to the nurse unit (Mpala, who we traveled with), to get malarial testing, eventhough there's essentially zero malaria in this area and her symptoms sounded a lot like typhoid. She had joint pain and a fever, some GI complaints, and a recent history of travel up near samburu, where there's more malaria. It came back negative. Nice to have such imediate access to blood tests in the bush!
Michelle had a fever, cough and headache, so she was out for the count, resting in the car. We were, however, joined by a 4th year med student from Holland- Sanne- who was touring with Mpala, and this day sat in with us, and had many questions for us... He had never heard of homeopathy before. He joined in with the physical exams and questioning as Amit translated.
The line-up was long that day but by 6:30, the sun was getting low, so we had to head to set-up camp. Our site was near the rangers village in this wild life sanctuary (Old Pejeta)... Lions and leopards and buffalo... Oh my! Since Mich was sick, I opted to sleep alone in an extra tent Amit brought. That night, strange birds cried, and I was worried they were hyenas at our camp. Then I heard foot steps.. thump thump stop, thump thump stop- but they were gentle. I soon realized it must just be a hare. I managed to fall asleep, but woke an hour later, spooked and I had to get out to go to the "washroom". I held my breath and listened- wondered what to do- then heard two consecutive forceful exhales. I called Amit and he joined me for a midnight bathroom trip, then I slept in his tent. He pointed out hyena calls in the distance and far away sounds of lions grunting (mating). After that I slept well (despite his story of a friend being pulled by a hyena out of their tent by their feet) until 6am when the bug chorus alarm clock rang.

Valentine's Day update

Feb 14, 2010
We've been having a wonderful time here. Wednesday night we had a dinner at this beautiful forested loft hut restaurant by the fireplace in honour of our new dutch med student friend going home. Wed day we went to an HIV orphanage, but all kids were at school, so we just had an orientation and then went to a secondary school to do a little talk on preventing HIV. We did only the final part of the talk. That day we visited a neighbouring trades college in the country and had a demo at the pottery workshop. He even showed us how they gather the clay from a mountain river and go through to get the finest particles- cool. He was great too, seems he puts so much love and positive energy into his dishes. Thursday we were back at the hospital and did some TCM tongue and pulses on patients in order to do case managements on them. Then we did some more surgery observation- a plate and screw into femur after rebreaking the old compacted break. Interesting. Couldn't get a great view, but that was ok. There weren't enough lead jackets in surgery, so we had to stack and huddle behind Rio in his jacket to block us from the xrays. (Rio was a paramedic from San Fransico, now aiming to become a doctor). Friday we did case managements and research and then presented our findings to our group. Sat. we did a Transformational breathing workshop- it was amazing- and something I've been wanting to do for a long time (under a different name). Last night we went out to party with some of our new friends we met through surgery- ie. Rio, the guy from San Fran and one of his buddys we also came to know (they volunteer at a girls at risk school called Daraja Academy). Was fun, but a few disappointments and awkward moments. Oh well. Today was a day off, and we sat by the pool and burned our leg :) oops. Now just have to finish up a case management.