The Poverty Industry

His tall, imposing figure in a thick down camouflage jacket nearly blocked the door as he stepped into the examining room. The unshaven face made a thin veil over his pock-marked, scarred cheeks. As I sat down by the desk he stood with a massive slurpie in one hand and a blue licorice strand in the other, occasionally using the licorice hand to run over the top of his head and flip his pony tail behind him, hesitant to sit down. This picture of a hardened criminal juxtaposed with a nervous child seemed strangely incongruous.

I got out of jail yesterday and I need my methadone script.
Why don't you have a seat? I venture.
All I need is my juice. Can I have all my meds daily dispensed? Its just easier for me that way. And can I get my meth script for two weeks?

Okay. No. No. Are the answers.

Have you used since coming out?
Not much.
How much is not much?
Just a couple flaps of seven and a rock or two.

Its like learning a new language. The language of drugs and poverty. His body quivered in frustration and his words were angry in response to the answers he was given. He stormed out with a two day methadone prescription in hand. Why so angry? In his eyes, this crazy doctor had just cost him $40.

$10 per week of methadone prescription, that's $20 for a two week script.
$10 per week of other prescription drugs if they are daily dispensed by the pharmacy.

Methadone and poverty are big business. Several pharmacists in the downtown East side have built empires around this. They receive ten dollars as a dispensing fee on any medication. So for methadone which needs to be witnessed daily, that's ten bucks a pop. If the patient is on six different medications and the prescription is written to be given out daily by the pharmacy, they just made sixty bucks in a few swallows. So big deal, the pharmacist is getting rich off of tax payers' dollars. Just a little entrepreneurship, right? I'm sure doctors do the same thing with 'efficient' billing and sneaky tax cuts. Right up until you start paying a person with an addiction to bring you their prescriptions. Giving them money that goes straight back to crack, heroin, booze, or crystal meth.

Then there's the recovery house business (some run jointly with a pharmacy no less!) There are a few run by the health region, but many are privately run with no restrictions to what they provide. They survive by getting most of your welfare/disability check deposited directly to them and providing you food and lodging. The worst stories are of six people crammed in small rooms, harassment, abuse, open drug use, and horrendously unhealthy cheap meals.

One of my favourite Jesus stories (other than saving the party by turning water into booze) is when he looses it in the temple courtyard where people are selling stuff. He knocks over tables in righteous anger against those who prosper from inequality and take advantage of the poor. Poverty and injustice break my heart, more than that they piss me off. Something deep down in my gut bubbles with anger. But exponentially worse in my mind at least, is those who prosper from the brokenness of others.

Here's where it all comes full circle. As a medical professional my living ultimately comes from suffering humanity. If I am not actively involved in trying to change the system, in preventing suffering and not just benefiting from it, by definition I become the oppressor. Stick that in you pipe and smoke it doc! Who are you judging anyway?

Overwhelmed by Hope

"I don't like dirty people. And I don't like people who love their drugs more than their kids."

These were the words of one of my colleagues, a good friend in fact, who I have great respect for. We do the same job yet we see the world from opposite ends of the kaleidoscope. Apparently I quite like dirty people. I've been doing an elective in addiction medicine in the Downtown Eastside and I love it. I love it so much that the question as to whether I really needed to deliver babies the rest of my life flittered across mind. Don't worry, it was only transient, I will definitely be returning to the happiness ward. However, I have worked with some passionate, maybe nearly crazy, but undoubtedly inspiring individuals who have dedicated their lives to working with a deeply vulnerable population.

Poverty, addictions, homelessness, prostitution. Words you think of when you imagine what is apparently the poorest postal code in Canada. Strange. Because its where I feel most welcomed. People talk to you on the street... granted, not always soberly or eloquently. They yell greetings at each other. They sell nick-knacks on the sidewalk: a speaker system, a pound of Starbucks coffee, 4 litres of fruit juice, an instant pawn-shop appears and disappears in minutes. They know each other by name.

I don't want to idealize things, they have more than their fair share of heart-wrenching experiences, abuse, and crippling addictions but I wonder where there's more love. In the Eastside or in lovely, sterile, rich Point Grey, closer to my residence (ouch).

They have a photo contest each year run by the Pivot Legal Society and have a book just recently published with photos called Hope in the Shadows. My heart breaks to hear my patient's stories, but somehow they reflect to me the essence of what it means to be human. In their pictures you find love and community.

My Yellow Man

A friend asked why I didn't write more posts when I was doing internal medicine since I speak about it so much. Truth is, I wrote more than ever, I just couldn't post them. To me my writing seemed crass, cynical, and unfeeling. I read them and found a part of me I didn't want to see. It was uncomfortable.

My world resembled the House of God, where instead of having names my patients were diseases. I spoke of Gomers* that I always hoped the medical students would have to admit and not me. I managed to strike a deal with my senior resident to assign me the injection drug users instead of the old people with complicated (yet boring) histories who are terribly hard to turf to another service or discharge. Stepping out of my body I saw myself as someone I wouldn't want to hang out with and didn't respect. Despite my attempts to label and depersonalize my experience, there are patients that I can't forget. Like the Yellow Man.

He was transferred from a small hospital with hepatic encephalopathy, straight to the ICU. He was a deep yellow hue. His liver presumably pickled by years and years of alcohol. He was 50 and nearly died in the ICU. But not quite. He then came to my team as my patient. His belly taut with fluid, of which 6 litres had already been drained and his limbs wasting away, his cheeks sunken. My Yellow Man couldn't talk, he moaned at times, laughed eerily occasionally, slept infrequently, and constantly chewed. On the bed sheets, on my hand when I wasn't careful, on the ear of his stuffed rabbit. His eyes darting from side to side, he squirmed to get out of bed constantly and eventually had to be restrained, his breath rasping. The treatment for hepatic encephalopathy is basically diarrhea to remove the toxins affecting his brain. It sounds inhumane but we just give laxatives everyday. The nurses tired of the constant cleaning and at some point he got a rectal tube... in addition to his catheter and feeding tube.

Truth is, my Yellow Man didn't sound like a nice guy. His partner was reluctant to visit, apparently there had been repeated abuse. His kids stayed away. He had an impressive criminal record, I guess he liked starting fires. At one point I consulted the GI service. The fellow who did the assessment told me the look in his eye was "pure evil" and recommended I consult psychiatry and not give him matches. We joked about my Yellow Man, and yeah, like psychiatry wouldn't curse me for such a lame consult, he's chewing on a stuffed animal and can't even speak.

I went in every morning each day of my rotation. Talked to him as if he knew who I was. Listened to his breathing, checked his belly, made sure he was still peeing and that he hadn't pulled the tube out of his nose that was feeding him, and tried to figure out what to do. He got a lung-full of blood at one point, went back ICU, came back to me and the ICU said they wouldn't take him back. I tried to turf him back to the peripheral hospital he came from for palliation but they wouldn't bite.

We thought he was a vegetable, and a sociopathic one at that. He repeated pulled out his feeding tube and we were at a loss of how to provide nutrition. Showing no signs at all that he wanted to live and no improvement in his condition. The family member that would always visit was his 'sister', a close cousin. She would come with her daughter, stroke his head, speak to him softly, wash his face, and claim he understood it all and responded. With her he sat up and ate an apple piece by piece. I chatted with them a lot. She called me 'Shaun' and was determined to take him home and feed him freshly squeezed organic fruit juice with this new juicer she had bought. I met her on the rooftop patio once when she was on a smoke break and offered her one of the donuts I had made for my team. As she took one her eyes welled up and she hugged me. She smelt like cigarettes and pine trees.

The last day of internal medicine I was on call and my Yellow Man started having trouble breathing, his oxygen saturation plummeted, the x-ray showed an aspirational pneumonia and he became drowsy and exhausted, gasping through his mask for air. I called the family and they came... all of them. I walked into the previously empty room now filled with a dozen people. A large native family, they sang and prayed and asked if I'd like to say a few words, Dr. Shaun.

My call ended and I left. I never say goodbye to my patients. Never let them know the new team will be by tomorrow. I can't stand the discomfort of it but I wonder if they care, if just another white coat means anything to them. I heard my Yellow Man died. His life seemed unhappy, even tortured and his end was uncomfortable. And what was my part in it all? What could I say in my last few words? I said that I knew he was loved.


*Gomer (noun: "get out of my emergency room" - a patient who is frequently admitted with complicated but uninspiring and incurable conditions)

Run Across Africa

Their names are Erin and Reuben and they are going to Run Across Africa. From the Atlantic Ocean in Namibia, through Zambia and Tanzania to Dar es Salaam and the Indian Ocean. That's a distance of 4200km so they'll average a marathon a day for 100 days. Its possible that they are in fact crazy, but they are undoubtedly passionate and dedicated. Dozens of sponsors are contributing and the money raised will go to education programs in the countries they are running through.

It makes me want to jump on a plane and go, I suppose that's rather predictable of me... jumping on a plane to Africa. But instead I get to contribute in another, positively vicarious way. I'm on the medical support team. How cool is that?!? The 'team' includes two docs from Victoria, myself, and my friend Teresa, a fellow resident at St. Paul's. We'll take turns being 'on call' for the runners and their support team as they jog across the continent. There's something rather exciting about being on call in Africa despite being planted quite firmly in Vancouver. Our 'remote' medical service will include text messages and emailed questions about diarrhea, dehydration, sprained ankles, malaria, bug bites and hopefully nothing catastrophic. It feels good to be involved in something bigger than my current world of residency, St. Paul's, and yuppie Vancouver life.

Check out the web-site.

That cracking and hissing is the sound of your fading youth

"Can we try something a bit more technical?" Fatal last words before we dropped over the edge of the mountain on those swanky full suspension mountain bikes and I launched myself over the handle bars within the first minute. It was spectacular, painfully exquisite even. Both my dramatic wipe outs and the view across Lake Atitlan as we wound our way down the mountain towards the sparkling water surrounded by volcanoes. If you're hiking and slip, you might cut yourself on the rocks but its a bit of a different story when there's a large piece of metal entwined between your legs. I was pillaged by that bicycle, worth every minute though! Gears cracking followed by the hiss of air from the back tire... either that or my knees were cracking and hissing. At the end of the day, I realized I had reached a new stage in life, where you take ibuprofen before doing ridiculous things like mountain biking down a volcano instead of after when the pain has already set in. Truth is, I'm getting old!

The biking was the culminations of an incredible week at a women's health conference in Guatemala. The content included topics like women's health and human rights as well as discussions of current challenges in sexual rights in Guatemala. It was absolutely fascinating to dialogue with Guatemalan obstetricians about their take on unsafe abortions and how to decrease maternal deaths from post-partum hemorrhage. A statistic I did not know was that abortion rates remain the same whether it is legal or illegal in the country. As usual, medical problems are often more about social and ethical issues than science.

It was delicious to all my senses to be back in Latin America. Life somehow seems more brilliant in colour, the pools are deeper, the smells more marked, life appears fuller and more vibrant to me. Spanish rolling off my tongue, gorging myself on fresh fruit and avocados the size of my head (okay, not quite). I soaked in all the colourful textiles, the familiar foods, the sounds of life and joy and pain, my soul danced again.

On a hike up Pacaya, a rather active volcano, I realized I had not forgiven my parents for something that happened in grade 8. My geology class went on a field trip to the crater of Huahua Pichincha, the volcano that towers over the city of Quito. They wouldn't let me go down the crater, ridiculous I though! So I sat on the crater's edge with the other two losers who also had been cheated out of this life changing learning experience. Oh the misery! So as I stood but a meter from the bright orange river of lava, my skin tingling and my soles melting I finally let it go. Mom, dad... you're off the hook, I got my fix!

Coning

This is something I wrote over a year ago as a medical student in Calgary and I was reminded of it being in the pediatric emergency here. I haven't edited anything, reading it now the emotions and descriptions seem so crisp and fresh and I wonder how my perspective has changed.

The Children’s Hospital emergency department. As a medical student you rotate through for a week and you either love it . . . or you really don’t. I had just finished seeing two really cute kids from Newfoundland here on holiday, one of them had fairly severe asthma and the other had, uh, a cough. I was sitting at the desk listening to one of the emergency docs ranting about people using the health system when they didn’t need to when an ambulance pulled up. The staff was pretty lackadaisical, apparently there hadn’t been a patch to let them know the ambulance was arriving which normally happens so they can be prepared. They were unsure what to expect, but didn’t seem too worried.

“3 year old boy, seizing for about 45 minutes before he got to a Medicentre clinic, given valium while 911 was called. Briefly stopped on the way here but now showing decerebrate posturing and his right pupil is blown.” The history reeled off by the paramedic. It was like an electrical shock passed through the nurses and docs who were in the area, all heads turned, and rushed with the stretcher into the trauma room. The tension was palpable, superimposed with a forced calmness. His mom following the whole procession, hand over her mouth, crying silent tears. Seemingly forgotten in the intensity of the moment. The family had moved from Vietnam 3 years previously, she spoke in faltering English, searching for words when she was asked what had happened. Flustered and crying. The doctor, put her hand on her arm, a gesture of sympathy but it seemed cold and calculated in her attempt to get any information she could out of the mom. “Page ICU, neuro, respiratory, and social work stat. Let CT know that we’ll be there in 5 minutes.” More and more bodies appeared out of nowhere. I had been told during orientation to watch the trauma rooms and get in there whenever I could so I had followed with the rest and tried to stay out of everyone’s way. It was clockwork, everyone had a role. Recording, drawing up meds, preparing to intubate, it all happened at once. I counted 17 people, all around the stretcher which laid the small body of this 3 year old little guy, Daniel. Writhing back and forth, to the untrained eye it could even look like he was just having a bad dream. To the medical professionals in the room, it mean he was ‘coning’, there was something increasing the pressure in his head and part of his brain was herniating. As if suddenly remembering something, one of the nurses turned to mom and asked if there was anyone she could call, any friends or family? No, no family in town, but the husband was on his way, he just had to pick up the 3 month old on the way.

I saw everyone buzzing around as if in a blur of activity, the only constants were Daniel on the stretcher and his mother, frozen in the same position, sobbing, hand over mouth. Clueless as to what was happening. The reality hit me, her world was ending right in front of her eyes, her pain and fear hit me in the gut. A nurse would stop once in a while put her hand on her shoulder and explain that they were going to try to stop the seizure, put a tube down his throat to help him breath, and take him to CT to get pictures of his brain. They were doing everything they could she said. The mom just shook, is shock. After what seemed like an hour but was actually a few minutes ‘social work’ arrived, apparently their job was to be with the mom. When she entered, she was the fifth person to ask if dad was on the way. Yes, yes, he’s coming. It was almost something people asked when they didn’t know what else to say and could offer no other consoling words.

In all of this I stood, an observer, a witness . . . was it possible I was invisible and had no part in what was happening? There to learn primarily, but I can never stop the feelings and thoughts that go with academia.

He was wheeled into CT, the respiratory therapist bagging him all the way. Mom sat outside CT with the social worker, a crowd of nurses and docs went in to watch the scan as it happened. There was a bleed in his right hemisphere, and yes, he was coning, uncal herniation, the bottom of his brain was squishing out below his skull. Was there trauma? Should we suspect abuse? Where’s the dad? Did he have a mass there previously? A near chorus of wild speculations. I’m with the emergency doctor and a resident, we stop on the way out as we pass her. “There’s some bleeding in your son’s brain, we’re going to take him to the ICU. Don’t worry, we’re doing all that we can for him right now. Alright? Is your husband on his way?” Yes, he coming.

The emerge doc goes to see the next patient, knowing that Daniel is now being taken care of by the intensive care physicians and the neurosurgeons. I’m full of questions and the first year emergency resident can’t hide her eagerness to use this as a teaching case. As she goes through the CT scan with me on the closest computer explaining the pathology in detail the dad walks in pushing the 3 month old daughter in a stroller in front of him. He asks where his wife and son are, the resident, immediately somber, takes him straight to his wife who is with the ICU doc. Things are explained, now in a bit more detail, the prognosis is not good. Tears well in his eyes. They assume he understands all that is happening. He too covers is face with his hands, cries out, crumpling to his knees. Sheer pain. “My son, my son . . .” his wife joins him, they cry together, sobbing uncontrollably, shaking as they embrace. My heart broke.

I was sent back to emergency to see more patients, my mind was nowhere near the child with croup, or the roller bladder who needed some stitches. The nurses stood in a group, “what could we have done differently? We didn’t get a patch from the ambulance. He really should have been intubated already by the time he got here. Why did they wait so long? They should have called EMS from their home. Is there anything else we could have done?” Constant questioning, reassuring themselves that they couldn’t have prevented this. And my role? I learn, at this point in my career I am a witness to both the functioning of the health care system and heart ache along the way. A family’s life is forever changed, we pause for but a second, and then the system keeps on clicking, like clockwork.

We've Got a Bleeder!

Helpful Hint #216

When an 8-year old zips his foreskin into his zipper there are some important points to remember:

1. Do not panic.
2. Do not just unzip it.
   
3. Do not look the father in the eye.
4. Do not make comments involving anything remotely like: 'good thing you're not Jewish, you never know what you might have caught in there!'
   
5. Give pain control (morphine, tylenol won't cut it).
6. Get bandage scissors and cut the jeans in a large semicircle starting at the waistband and going around the crotch.
7. Cut straight across the top of the zipper so the zipper easily falls open.
8. Apply pressure.
9. Suggest sweatpants for the next few days.

If gave me a flashback of the opening scene from Something About Mary. I'm just learning so many useful and relevant new things every day.