Ripal H. Patel, MD, MPH, shares how his experiences working with fewer resources abroad and at home have helped him find better balance in his own practice.
One night in the tropics
Our long clinic day in Haiti was coming to an end.
7 a.m. start — with the day culminating well into darkness of the night, where flies buzzed and hummed around the illumination of the lanterns we set out. Just as we were wrapping up inventory for the pharmacy and looking forward to getting a beer at the local “bar” (a porch where a local villager served us the malty Prestige, a local Haitian beer), a woman rushed in with her child.
I looked at the baby and saw a beautiful child tightly wrapped in a bright, flowing, white dress. My translators saw something far more alarming: a limp and almost unresponsive child, with cracked lips not responding to touch. I learned quickly in Haiti no matter how sick a child became, they could still be wrapped in the most ornate of garments. And a flashback to all the bereaved parents I educate that bring their screaming children to the ER in the U.S. for non-emergent conditions: “We like crying babies,” I’d say. “But the quiet child that isn’t properly responding, that terrifies us.”
A frantic moment
The child had suspected cholera, and this was on the cusp of a recent outbreak. I looked frantically at my two nurses — one in oncology — and realized we only had two IV starter kits remaining for that day. In the sweltering heat we laid the child down, undressed her, and prepped a site on her tiny, bony arm. Cholera was not complicated management: just fluid bag after fluid bag to resuscitate the child, then antibiotics. The fluids we had; the kits we were short. Only two shots at it.
We were remote, hours away from Port-Au-Prince. My nurses were trembling and asked if I would take the first attempt. A part of me was frustrated, as I knew their skills for starting pediatric IVs were far superior. But I also understood their hesitancy and the repercussions for failure.
My first attempt failed, but on my second go, and with my nurse guiding me, we were able to obtain IV access and start fluids. Slowly, many fluid bags later, the child came back to a baseline mental status, and as we watched the child revive slowly, we breathed a sigh of relief.
Scant resources, tremendous care
As I sat back and was helping to close the clinic, I thought back to how grateful our patients were. When a staff member once asked me how long the clinic would run, I explained to her “as long as it took to clear the queue of about 100 people waiting to be seen.” Many had walked miles and miles to see the American team and turning them back wasn’t an option. I thought back to the obstacles: trying to give our pediatric patient a nebulizer but having to ensure the generator was working at the clinic to provide electricity. And to our scant lab testing and medications: a hemoglobin, urinalysis, and a malaria test. And despite all of that, the tremendous care we were able to deliver. Despite all we lacked, like the hum of a finely tuned car engine, the technicians triaged, the translators translated, and the doctors and nurses healed.
Those memories resurface every time I walk into one of my community hospitals in Texas, monolithic structures towering above the earth with shiny glass exteriors and expansive parking lots. The complicated and expensive EMRs, the bright lighting, the endless amount of supplies, and the outpouring of specialists available for consultation. A sense of sadness always sets in as I walk through the sliding glass ER doors. Could America do without just one of these institutions, and somehow what better good could we do if we magically transported it back to my village in Haiti?
Is sacrifice so bad?
Although I feel everyone should get involved in at least one medical mission in their life, at the minimum I encourage people to think outside the box, travel, and at least try locums. The risks are minimal, the duration is entirely up to you, but most importantly, it allows a physician to thrust themselves into a new community, locality, and with new staff, to gain an understanding of how things are elsewhere.
Yes, it involves sacrifice, but isn’t that why we went into healthcare? And is sacrifice so bad? Most of the places I work at are scant in resources. They have minimal consultants for back-up, and in that sense it takes me back to being a true emergentologist: stabilizing a critically ill patient and monitoring them until a transfer can be assured.
Back to the basics
Specifically, in our line of work, an overreliance on resources and consultants can at times mask areas of our own clinical practice that are weak. Haiti was one extreme of that. It showed me my need to improve IV skills on children, move patients through faster (or we would be there all night), and truly strive to minimize my orders and abstain from items doctors so frequently unnecessarily request (IV fluid bags, lab work), when it truly won’t contribute to the patient’s management. Getting a CT on a sophisticated EMR from a radiologist who is reading remotely in another state is one thing; looking at an x-ray film in the blinding sunlight outside the clinic is another.
Beyond anything else, I feel this mentality of gratitude takes a doctor back to something we utilized before we had all the technology: physical exam skills. And that alone makes me feel even more empowered and connected as a physician — realizing often I don’t need to rely on expensive machinery or resources to diagnose patients, often because most of my physician colleagues in the world don’t have them. My Haitian patient had dry mucous membranes, skin tenting (pinching the skin and it does not settle back down), delayed capillary refill (pressing on your nail and seeing a significant delay in it pinking up again) — all signs of dehydration. A good history and physician, they used to say in medical school, and yet how often I rebuked.
Finding the balance
The education of a physician in America is something we should all feel such immense gratitude for. I remember when I was living in Bangalore working at a charity hospital. There were no course syllabi for the residents: it was an outdated textbook in hardcover. There was no UpToDate: it was a dodgy internet connection that took 3-4 minutes to load each page if you wanted to look something up. Charting was paper (if that), the pathologies were exotic and complex, and yet those physicians were some of the most skilled and adept I’d ever worked with. Metrics, “sepsis fallouts,” patient surveys, and questionable billing practices — things that we all loathe as physicians — entirely irrelevant here.
To some capacity I feel every physician feels out of touch clinically with their practice and patients; I embolden each to find why — and address it. Working abroad, and serving in underserved areas in the U.S. through a locums model, constantly keeps that fine balance of doctoring in check for me — to appreciate in all its forms the resources I have to practice medicine, but equally empowered that I could practice as confidently without them.