Bureaucracy: the medical student’s* constant companion

Or, a crazy stream-of-consciousness rant about my morning:

As a med school “super senior” who has done a fair share of away rotations, I have certainly seen a good amount of red tape, especially in my attempts to prove to away institutions that I am, in fact, vaccinated against mumps, OSHA-trained to safely dispose of needles, and insured against malpractice. But the bureaucracy I experienced this morning was, as my roommate put it, “a caricature of itself.” To briefly sum up the entertaining events of the morning: I started (rather, was supposed to start) a rotation today in toxicology at an unnamed hospital in the Midwest (I am applying for residency out here…can’t be too careful, ya know). After being unable to determine the exact date or time or location for anything this morning, despite multiple emails and calls to several people, I finally found a time and place to aim for. After waiting for ages in a boiling hot room of an ancient building with 40 other short white coats, we filled out some paperwork, then watched a video on proper needle-disposal and hand-washing practices (Really? Turn on the hot water? Ya don’t say), then attempted to get paperwork to get our ID’s (one of the only things I was told about the rotation I was starting was that I was not to show up without an ID). So I enter a very inefficient woman’s office (I already don’t like her…I recognize her name as one of the people who has never returned my phone calls), and am told to find my paperwork from a giant file cabinet, loaded with manila folders theoretically alphabetized by last name (welcome to 1954). She is flummoxed when I can’t find my paperwork. ‘What’s your last name? Are you sure you sent in your paperwork?’ Yes. Three weeks ago. ‘Are you sure it’s not in there?’ Yes. ‘What’s your last name?’ Rinse, repeat. She phones the administrator of my rotation, who…says she’s never heard of me. Despite the fact we’ve exchanged emails in the last week. Finally she admits she received my application. And although the papers themselves cannot be located, I have brought along an extra copy of all my immunization records. I am prepared! Yet I cannot get an ID because there is no list of all the negative TB tests I’ve had. I had a negative one in August (yay! No post-Africa TB for me) and records of one a year for the past 5 years (though with no listed results for the other ones). I explain that if my last one was negative, they’re all negative, because you can’t be positive and then negative. She says, “I know you’re trying to use logic, but I’m telling you I need this piece of paper.” Ah yes, silly me for using logic when I just need to produce a piece of paper. And here I thought the point of this was to show you I don’t have TB. Which I can do with this one paper I’m clutching in my clenched fist. But nevertheless, I understand it’s your job is to push paper, and you need this form. So the form gets faxed from my school’s student health department (good lord they are nice and helpful there), but all the while this is taking place, I am told to vacate my chair several times. Even when I’m not sitting in it (like when I’m in the hall pleading with the student health nurse to find my files, my bag and coat are still on it). But for some reason, this woman wants to have students lined up in a specific way: 1 at her desk, and 3 sitting in the chairs (which are not in a row) in her office. Nevermind that no students are actually lining up like this, they’re just entering her small office when the previous student leaves. And yet…she’s fixated on the fact that she needs her chair so students can sit in it while they’re lined up, even though no one is attempting to sit there. Eventually, just for entertainment purposes, I keep sneaking back in there and sitting in it while I’m waiting for my fax, just to see if she notices. Finally she accepts my vaccination sheet, and sends me off to get my ID. It’s OK that it’s 10:30 am and I was told to report to toxicology conference at 9am. Whatever. So I find my way to the ID badge office, and after telling the man working there I’m a student and handing over my paperwork, I am told, “A student? We’ve reached our quota for the day.” I look around. Quota? But there’s no one in here. There are three employees back there doing nothing. You’re telling me you can’t make me an ID? No, apparently there’s a “student quota” for ID’s which is usually met by 8:30am on a Monday. But, since an initial ‘no’ is rarely the final word, I am nice and persistent and smile and finally get my shiny new ID. (And I’m not even scowling in the photo). So, only two hours late, I start to make my way to toxicology conference. It’s in the Poison Control Center. I figure since no one answered my emails, I’ll just google the exact address and ask at the front desk. Seems simple, no? So I google it, it’s a block away, I go there and can’t find any doors where google maps tells me they’ll be (I know, I know, I should have learned by now not to trust google maps). So I call the administrator of the rotation to ask how to get there. “Oh, conference is at the poison control center downtown on Monday!” Of course, there are several poison control centers scattered around the city. Could NO ONE have mentioned this to me? Ok, deep breath. “And conference will be over soon anyway, so it’s not worth it to go over there.” Ok, that’s fine. I tell her I want to reach the program director to find out where and when I can meet her so I know what I should be doing for the rest of the day (since I can’t talk to her at conference like originally planned). I am told she’s in conference (duh) and won’t answer her phone, so I should send an email to this woman, who’ll forward it on (is anyone still following me here?? I’m confused just re-reading it, and I lived through it a few hours ago). I suggest I can just send the director an email directly, but the administrator would rather I send it to her, and she’ll forward it. Fine. So I hang up and send a one-line email about how to contact Dr. So-and-so. I wait. Five minutes later I get a response from the administrator (I am cutting and pasting this), “Did we speak or is this a recent e-mail. I thought we discussed that the conference was over at the poison control center downtown?” Um, what? I’m sending you an email because YOU TOLD ME TO SEND YOU AN EMAIL. And YES we just spoke it was 5 minutes ago!!! Ok, deep breath, calm response, saying I would like to reach the director I was supposed to be meeting at conference to see where I should go for the rest of the day. Five minutes later, another email, “They r done for the day. Conference is from 9:30 til 11:30. PLEASE CALL ME.” At this point I was beginning to think I was in some parallel universe TP'd in red tape, from which I was unable to escape.
Anyway, here’s hoping to a more efficient and well-organize day two…. ☺

*I realize that bad bureaucracy happens to good people everywhere. I have just experienced 95% of my life's red tape in the past four years.

WOW...

...I am the worst blog-updater ever. In my next life I'll be better at it, I swear.

A picture, just to make this post a little longer:

Wow, that's an oldie. I promise to update more often. Well, I guess all I can promise is that I'll try to anyway...

The Hippo says Hello

There he is. Yup, he's looking right at you.

The view of some houses from the river trip. We took a boat down (up?) the Ogooué river, into a giant lake, picnicked on the shore, saw hippos (see above), played soccer, took pictures, and celebrated the end of our roommates' (see below) stage (internship) at Schweitzer.

These are the triplets of the hospital. Not actually triplets, but they're all the same age, two have nearly identical names, they all lived (pretty much) on the same surgery ward, and they all have Buruli ulcers. I loved these girls so much, I will try to write a longer post about them. In this picture they are watching a video I took of them dancing on my bed. (No, they were dancing on the porch, but watching the video sitting on the bed. Goodness English is confusing.)

Two pictures I love of my roommates. L-R: me, the impossibly adorable Larry (girls get boys' names here), Narcisse, and Elizabeth A Point Sack.

new pictures

Some of the many birds' nests in the trees at the hospital.  I just liked this picture.

One of the many posters hanging around the hospital about AIDS ("Everyone together against AIDS").  

These roosters are so stupid.  I thought roosters were supposed to crow at dawn.  These roosters (and there are many of them, some mere feet from my head in the morning) crow at all times of day and night.  We now dream of coq au vin.  

A haiku, courtesy of my roommate:

Oh, stupid rooster. 

Crowing your virility

You're just a small cock   

Yay! Gabon's making headlines!

Oh wait, but not for anything good.  Please see the wonderfully-written nytimes article on the recent developments here.  In brief, the president of Gabon ("Africa's longest-entrenched autocrat") died this weekend.  The government has responded by closing the airport and borders and imposing a curfew.  But everything's just fine here, so please don't worry.  We are far from the capital, which is where things usually go down anyway.  Just wanted to write a quick note in case anyone was worried about me being in the middle of a politically-unstable central african nation.  And now back to your regularly-scheduled programming.  

New Pictures

Welcome, indeed. :) 

This is the hospital, outside the Polyclinique, where I spend most of the day.  This was taken on a particularly muggy morning, normally it's brilliantly sunny.  The yellow building is one of the surgical wards, but they all kind of look like that.  Those giant trucks are from the military hospital.  A large brigade of soldiers descended last week with ophthalmologists and otolaryngologists and their mobile exam rooms and ORs (the above trucks) and saw patients from 7:30 am until midnight.  People were sleeping overnight outside to have a place in line.  

Typical hairstyle.  Women are crazy about their hair here.  Everyone has an elaborate weave or a wig.  It's pretty awesome.  

We went to a culture festival in Libreville this past weekend, and this is a picture from outside the Senate building, where there were a bunch of different dance groups from all over the country.  It was pretty cool.  :)  (Gosh, I'm so eloquent this evening, eh?) 

Dr. J- Rant Of The Day

I work with a rather, uh, charismatic doctor here. He likes going off on rants about various subjects from time to time, that range from the incompetence of some staff to the living conditions of Chinese workers in Gabon. His chosen subject the other day was the state of medicine in Gabon. Which is: not good. The government has been unable (or unwilling) to pay its bills to the hospitals for quite some time, and the result is that all of the hospitals have been on strike since January. (Not this one, it’s funded mostly by international foundations.) So the result of the strike is that sick people are not getting medical care, then when they’re gravely ill, they come here (to the HAS: Hôpital Albert Schweitzer), where often it’s too late (Dr. J-: "Do they think we're magicians?!"). The HAS has also been relatively overwhelmed with patients since the strike started: the maternity service has patients on mats on the floor, because they’re out of both beds and mattresses (“Patients are on the floor, four to a room! That is no way to treat people”). The medicine service sometimes keeps patients in maternity and surgery because there are no medicine beds left. It is frustrating that the government is unwilling to pay for medical care for its citizens, and it’s easy to place blame on any number of factors for the fact that people are suffering and dying of treatable diseases simply because there are no resources available to them, so his next statement caught me off guard: “And who is responsible for this?? We all are.”

Weekend pictures

We spent the day yesterday going to see a old mission in Sindara, about a 1.5-hour drive from here, picnicked at a "waterfall," (really, rapids), then stopped at a swimming hole on the way home (N.B. ASF Boston: I didn't swim).

Good thing we were in a 4x4.

View from inside the chapel at the Mission at Sindara.

Yes! Just like the real ones.

The swimming hole where we got attacked by the fouroux, tiny insects (so tiny you can barely tell they're not specs of dirt on your arm) that are not, to my great distress, deterred by any amount of DEET.

What is it exactly that you DO do?

(those able to identify this quote win a travel-sized bottle of DEET)

So…what do I actually do here? Ok, a brief rundown of the day, if you’re interested:
1. Get up, thrash out of mosquito netting
2. Wait for shower (four people who all start work at the same time share one bathroom)
3. Have cereal (fake cornflakes…that’s all we’ve been able to locate) and instant coffee out on the porch (heaven…I’m telling you)
4. Go to the medicine ward, or the Kopp, as it’s known, which is maybe a 5 minute walk from here, depending on how hot it is outside, to start rounds at 7:30. (Actually on Wednesdays and Fridays there’s a grand rounds type of meeting/presentation, where someone presents a topic or case to the staff, which starts at 7:30, so then rounds are after that.)
5. Round with the team, which consists of two doctors, 1-3 nurses, and me. There’s a little cart that we drag around that houses all the charts (really, cards the size of half a sheet of paper in plastic covers that have seen better days) and order sheets (for labs and x-rays and such) and a bottle of alcohol for hand washing and a trash bin and even a little vase of plastic pink and flowers. Next to every bed there’s a wooden board hanging on the wall with a spreadsheet that includes the patient’s vital signs (with the temperature graphed, so you can see its trend with a quick glance) and medications. It’s so simple. Patients get taken care of, medications get ordered and given, vital signs get taken and recorded, and there’s none of the triplicate record keeping that keeps rounds at home dragging on till 1pm.
6. Off to the Polyclinique, which is a giant waiting room with small exam rooms off of it. It is normally anywhere from 90-110 degrees in the waiting room, but, blissfully, the exam rooms have window air conditioners. See patients until noon or 1.
7. Have lunch from 12-1, then a break from 1-2:30
8. See patients from 2:30 to anywhere from 3:30 to 5:30, basically until they’re all seen. (Top reasons for coming seem to be: hypertension, AIDS, fever and headache and/or body aches [treated as malaria, even if the blood test for malaria is negative], and tuberculosis)
9. Go back to the Kopp, where it is now approximately 95 degrees after the day’s sunlight has run its course, and record all the lab values that came back during the day, as well as see any new patients who were admitted.
10. Either do yoga, or run, or sit in a tired and hot heap on the chair in my room directly under the fan.
11. Dinner is at 7 exactly. If you’re not done by 8 there’s a stern talking-to from the ladies who work in the dining hall (who are, I must add, all very nice).
12. Putter around until bed, either watching 30 Rock (a favorite pasttime around here), or going to the lab to use the internet, or going to the nearest town to have a beer, or removing large bugs from one’s room, or duct-taping the screens down, or hand-washing clothes, or…you get the idea…there’s always stuff to do.
13. Go to bed, rinse, repeat…

Some pictures

The view from the porch

My beautiful room

N.B.:  It takes literally an hour (or more) to upload one photo, so pictures are going to be few and far between...sorry. :( 

Things I've learned this week...

1. There is an entire country off the coast of Gabon.  It’s called São Tomé and Príncipe, and it’s the second-smalled country in Africa (after the Seychelles).  It’s an archipelago of 12 or so islands, the two largest being São Tomé and Príncipe.  According to my guidebook (the only one ever published on Gabon, as far as I can tell), the islands were formed from volcanoes, and were unsettled when the Portuguese came in 1470.  All the islands comprise 386 square miles and have about 165,000 people, and they speak Portuguese.  

2. There are a lot of Chinese people in Gabon.  According to an article from the nytimes, Gabon is running out of oil, and to compensate for its lost income it’s allowing Chinese logging companies into protected forest.  Not good.  But anyway, the hospital has anywhere from 3-6 Chinese men out of 26 beds, all with malaria, none speaking any French.  There’s a lot of charades going on on rounding. 

3. There are many things I like so far about Africa, but hand-washing, line-drying, and then ironing all my clothes (botflies get killed by the heat) isn’t one of them.  I think I’m going to take my chances and put most of my clothes in the hospital’s industrial-sized washers (with notoriously hot water).

AH! A bug just fell down my shirt.  Ok, zen with the bugs, zen with the bugs, zen with the bugs…  

Buggin' out

So I've been sitting here for about 45 minutes, trying to be ok with the ants.  Because it's Sunday, the research lab where we use the wireless is locked, which is how I find myself sitting on the back walkway using the computer, and trying to be ok with the ants.  They are everywhere.  They're not the little annoying ones that walk in organized lines by the billion (I can't even describe this, it's so amazing, I'll try to take a picture), they're the bigger black ones.  They keep trying to invade my space.  I keep shooing them away with (HAR) my shoe.  If they get too close I brush them off the balcony to the grass below.  I haven't killed one yet, though I think one or two haven't made it off the balcony injury-free.  There are too many to try to kill them all anyway, and I think killing animals on the grounds of the Schweitzer hospital is kind frowned upon by Schweitzer himself wherever he is.  You know, Reverence for Life and all that.  Then I decided to scoot up a bit and give them a little path behind me, so they could still hug the wall and get from one side of me to another (I was leaning against the wall), and I think we've worked out a mutually beneficial situation.  I don't have to spend half my time brushing ants away, and they can still go about getting breakfast, or going to ant church, or whatever it is they do on Sunday morning.  Letting them mill about so close to me is doing nothing for my near-constant feeling that bugs are crawling on me though.  Then I think I'm just paranoid or crazy, but then end up with zillions of bug bites all over (and in clothing-covered places).   I have even found spiders biting me.  Spiders.    I should just stop trying to fight the bugs.  There are way more of them anyway, and they can't kill me.  I'm going to try to be more zen about them, and just live and let live.  I'm probably scarier to them they they are to me, right?  I'll just keep putting hydrocortisone on giant itchy red spots and tuck my mosquito netting in real tight at night.  

Week 1: And so it begins

Thus begins our rotations here in Lambaréné.  I am doing adult medicine, and the other American medical student (also a white girl named Elizabeth, to maximize confusion) is doing pediatrics.  This week so far I’ve been in the inpatient wards in the morning (rounding on 26 patients in as many minutes) and the clinic in the late morning and afternoon (today: 2:30 to 4:30, hardly the schedule we're used to keeping at home, though it is oppressively hot, effectively limiting how many hours one can actually work during the day).  On my current to-do list: 1. Learn French, 2. Learn medicine, 3. Learn to understand Gabonese French, 4. Learn names of medicines in French (Esidrex?? Never heard of it.  Oh, wait, it’s hydrochlorothiazide?  Riiiight, I have heard of that).  The doctor I was working with actually left to go get something yesterday and said, “Ok, you can see this next patient while I’m gone,” and I was like, ummmmmm thanksbutnothanks.   It takes me 10 minutes just to read the notes from their previous visit, because they’re all in illegible French with abbreviations I can’t figure out.  Oy.  Adventure!  (Ça va aller...at least I hope.) :)  

I’m already a little bummed out (for lack of a more eloquent phrase) by the sick people.  Not that sick people in the US don’t bum me out, because they do, but I’ve already seen a few people this week who are sick.  Like, I look at them and wonder how it is they’re even still alive.  I saw literally the most cachectic girl I have ever seen in my life yesterday.  She was 22 and weighed maybe 65 pounds.  Good lord.  AIDS is a scary thing.  She'd been sick for a year but hadn't come to the hospital until now.  I just think of millions of dollars being spent in the US chasing incidentalomas (translation for non-medical people: incidentalomas are little shadows and blips that are discovered incidentally on CT's and MRI's done for other things, and usually turn out to be absolutely nothing) and it makes me crazy.  

Ok, off to bed.  Under my recently re-strung mosquito netting.  Now hopefully it won't fall on my face in the middle of the night, causing me to brush it off my face in a panic cause my half-asleep brain is concerned it's an ant colony, or a hungry mosquito family, or a bat.  Or a spider the size of a yorkshire terrier that we calmly (ahem) removed from my roommate's room the other day.  (Picture to follow)

La Petite Union Européenne

This is a very interesting place, for reasons I didn’t expect.  Dinner every night is a veritable melting pot of nations.  Some of the faces around the table: A couple from the Ukraine (internist and surgeon), a nurse from Switzerland (the German-speaking part), a man from Switzerland (the French-speaking part), a nurse from Spain (who retired from a career as a lawyer and then became a nurse), two Gabonese students, and a doctor from France (who is on sabbatical from a 20-year career as an internist in the French Antilles and drove here from France).  On the way back from dinner the other night in town, we were piled into the back of a big van, and we picked up a German student on the way, and suddenly everyone in the back (except the Americans) started speaking German.  (As Other Elizabeth said, “This conversation has taken a turn for the German.”)  And I kind of enjoy conversing with someone when neither of your first languages is the one you’re speaking in.  There’s no self-consciousness about grammar or pronunciation when the person you’re talking to probably won’t notice anyway.  

First attempt at a video...

Ok, ok...I know it doesn't play. This appears to be a youtube problem (a widespread one). I'll figure it out later. It's too hot to think right now.

Finally in Lambaréné

Well, the day has arrived. After, oh, 10 or so years of wanting to go to Africa, here I am! I am a little oppressed by the heat to fully enjoy the moment, but I am pretty excited. (Oh god, I just checked and weather.com says it's only 89 degrees outside. Could this possibly be true? I would have bet it was 95.) Luckily, there's no lack of modern conveniences here, including a small library with air conditioning and wireless internet. So...so far it's kind of like home, except for the bats in the walls. Anyway, it's pretty exciting to say you're on a new continent; that doesn't happen often in life.

So, this is not a place you'd pop over to for the week. To get here: a 6-hour flight from Boston to Paris (which landed at 12am Boston time, which was 6am Paris time, and I was very confused by the loss of the night. I mean, you can wake me up at 11pm and serve me coffee and orange juice for breakfast, but that doesn't make my body believe that it's really morning), then a 5-hour wait in the airport (with totally uncomfortable chairs not conducive to napping), then another 6-hour flight to Libreville, Gabon. Then waiting in lines in the airport, then a stay overnight in an airport hotel (it was 6pm by now), then a 4.5-hour drive from Libreville to Lambarene (see car below) the next day. Which included one exciting stop: the equator! We stopped at the sign (also see below) and I stepped across it, my first time entering the southern hemisphere. Yay! Then we finally arrived in Lambarene around 1pm. See photo of the welcoming committee below. Yesterday was a holiday, so there was a party going on, but we were too exhausted to go, we just unpacked and napped. And tried to figure out things like: how to hang mosquito netting, where the toilet seat went, how to prevent the bats from getting into the bathroom, why the towels are the size of hand towels, where to find dinner, etc. It was all very taxing on my jet-lagged and tired brain.

When I have more energy and my computer has more battery life, I will post more. I know you're all on the edge of your collective seat. :)

Stopping on the way to Lambarene

Really white girl on the equator

Part of the welcoming committee at the hospital

(A pelican, the hospital mascot)

(Why don't US hospitals have mascots? Discuss.)

I AM ACTUALLY ALIVE: Life updates, Musings, etc

So, I haven't lost the URL of this blog, nor forgotten it exists, I've just...I dunno...been lazy. There, I said it. No feeble excuses about being "busy," cause I've found time since the last post to watch 3 seasons of Alias and 30 rock. I have been doing real rotations for the last 4 months, like M-F 9-5 (or 8-6) ones, except this month, which is more hours and days per week than I care to count up. I wrote some posts in the last couple months but never actually edited them and posted them, so maybe I'll do that eventually. Now, though, many exciting things are happening! It is, of course, the vernal equinox, which would be easier to understand if it weren't 40 degrees out and 30 in my apartment. And yesterday was Match Day! NECN was at our school, and you can watch the clip here if you weren't lucky enough to be there. :) People have matched to all sorts of exciting places, and my classmates will soon be (gasp!) residents. And as if welcoming all the fourth-year-med-students-and-soon-to-be-interns back to the hospital today (we had yesterday off...it's kind of a national holiday in the world of medical education), my resident greeted me looking like this:
It's like she was saying, "Congratulations on the Match! Soon you will look like this. Make sure your scrub pants are tied real tight." (In case you're wondering, L-R: personal [hospital] pager, stroke pager [stroke intern off today], code pager, pre-pre call [i.e. back-up admission] pager, PDA.) Oy. I'm glad I'm putting of graduation and internship for another year. :)