Orphanage work

We went out to an orphanage about 4 hours away from the city earlier this week, and my heart broke.  With rumors of children being fed once a day (reasons ranged from lack of money to not wanting to change diapers as often), I was surprised to find a clean facility with heated rooms, and all the children dressed in winter clothing, being attended to by their ayis.  My initial impression.

Then we started the medical checks.  With the exception of a handful of children, the rest of the children were grossly below their growth curve for height, weight, and head size.  Stripped of their thick layers of winter clothing, what was left revealed arms and legs that were just skin and bone.  Not to mention those children who, at a quick glance looked about 8 or 10, were in reality 11 or 16 years old, respectively.

Then we started noticing the little things.  Like how the ayis didn't know the ages of the children they were responsible for, ayis who had been in this place for more than 5 years.  Or the ayi who took a cookie from a child and ate it, cookies that were given as gifts to the children.  (One of our teammates specifically made cakes for the ayis in order to prevent this behavior.)  Or the room with school-aged ambulatory children and NO toys, books, tables, chairs.  NOTHING except for 4 blank walls.  Or how the orphanage director could not be found in the afternoon because he had too much to consume at lunch.  I could go on.

I'm not sure why I'm sharing all of this.  Perhaps it's a way to help me process through the shock, anger, and helplessness I feel.  Perhaps it's to give these children a voice.

And perhaps it's my way of asking you to get down on your knees for these children, and ask for a rescue, a transformation, a miracle.

Merry Christmas!

Christmas is crazy over here!  It reminds me of Mardi Gras (without the risque behavior) and maybe even New Year's - the streets are closed off to cars, there are people everywhere, and vendors line the sidewalks selling everything from candy to grilled meats to toys/clothing to fun headgear with flashing lights.  Not to mention that everything goes on sale the week of Christmas and the malls are full of shoppers.  Remember where I am...so when I say full, I mean FULL.  Oh, and in the midst of this, you hear songs like Jingle Bells, Winter Wonderland, and We Wish You a Merry Christmas blasting left and right.  Christmas has arrived and, boy, is it commercialized.

Christmas Eve is the night out, and Christmas Day is spent with friends.  Whereas we tend to spend this holiday with family, it's not such a big deal here.  But there is still the exchange of gifts, or apples.  It is tradition to give apples to one another for Christmas to signify peace.  The word for apple is "ping guo" and the word for peace is “ping an".  Christmas is called Ping An Jie.

Merry Christmas everyone!

it's worth it

Here are a few pictures of YB, one of our foster babies.  What a difference one month can make - you can tell just by looking at his arms in the two pictures of him lying on the bed.  How amazing and wonderful it is to see such change.  This is what makes it worth it!

THEN

NOW!

New families

We've had two new additions to our foster care program recently!

Meet JH - he is a 12 month old boy who has been with his new foster family for a little under a month now.  He had a surgery done on his esophagus and trachea (breathing tube) when he was younger and has had trouble gaining weight ever since.  We're hoping to help him grow with increased nutrition and lots of TLC!

And here is YB! (Sorry, this hospital picture is the only picture I have of him right now...I'll post another the next time I see him.)  YB is a 10 month old boy with Down's syndrome.  He also was not gaining much weight at the orphanage, and has now been with his foster family for about one month.  He was recently admitted to the hospital because he had a respiratory infection and needed oxygen, and just left the hospital a few days ago.

USMiLE

Gas stations like these are dotted throughout the city, and seeing one always makes me think back to the days of studying for the USMLE Step 1 board exam.  All medical students are required to take a 3 part board exam, called the USMLE.  In my opinion, the first part, or Step 1, is the most grueling and painful of all three tests.  Our medical school dean frequently gave us pep talks, or "USMiLE" talks to boost optimism and enthusiasm for studying for the Step 1 exam.  I'm not sure if they made me any more enthusiastic to study...but I passed!

train of thought...

Just thought I'd share with you a train of thought I had the other day...click on the links to see the other blurbs.

Most people work 6 days a week over here, and work the entire weekend if there is a holiday during the week.  We're in the midst of two holidays back-to-back right now, and many of the weekends surrounding these two holidays have been busy with work.  However, not all the days missed for holiday are being made up - 4 weekend days are given to work, but we are getting 8 days off for the holidays.  It's confusing, I think.  So I just go along with what I'm told by our staff...and make sure that my phone is always available, in case I miss a work day!

Our two holidays that we are celebrating are the Mid-Autumn Festival and the National Holiday (equal to our Fourth of July).  The National Holiday is based on the Western calendar, so it is always during the first week of October.  However, the Mid-Autumn Festival is according to the Lunar calendar, which is dependent on the phases of the moon.  This means that the Mid-Autumn Festival can occur as early as August or as late as October.  Also confusing, right?

Mid-Autumn Festival

The Mid-Autumn Festival is based on the Lunar calendar and occurs when the moon is at its roundest or fullest.  There are many stories and legends surrounding this day, with the most popular and well-known one about a beautiful young woman and a warrior prince.  They meet, fall in love, and for various reasons depending on which version you get, they get separated.  The young woman ends up on the moon, while the warrior prince remains on earth.  They are only allowed to meet in person once a year, which is the Mid-Autumn Day.

Today, the Mid-Autumn Festival is a time to gather with family and friends.  Since the moon is round and never ending, it symbolizes the relationships we have with our loved ones as a circle of friends/family as everlasting.  In celebration, people will go home to be with family and eat moon cakes, which are pastries filled with various items, such as fruit, egg yolk, dates, meat.  It's like the equivalent of our fruit cakes.  Certain fruits are also popular during this time, such as grapes, fresh dates, and pears.  Everyone at work this year were given moon cakes and either a box of pears or a canister of cooking oil.  The actual Mid-Autumn Day for this year was September 22nd.

The moon on September 22nd!

Moon cakes

Moon cakes

My box of pears.  These pears are small and round, and known to last longer than typical pears.

A city called NongCun

Another name for the Lunar calendar is Nong Li.  Nong is the same word used to express rural areas - words such as farmer, farming, countryside, all have the word nong in it...which brings me to a story about one of my first language lessons.

Nongcun was one of the first words I learned shortly I arrived.  It means countryside, but for a long time, I thought it was the name of a city.  Being unfamiliar with the local area and its surrounding cities, when people told me that they were from "nongcun", I automatically assumed they were talking about another city.  It wasn't until I was chatting with my ayi (or helper) about her hometown that my ignorance came to light.  She mentioned that she wanted to show me her hometown which was in the countryside, or nongcun.  And so I responded with an enthusiastic, "Yeah, I've heard of that place!  How far is it from our city?"  And I got a funny look from her, a repeat of the same conversation, and another funny look.  After some charades, I got it.  Nongcun - the countryside, any countryside, all countrysides.  NOT a city.

culture shock

I don't know if I've mentioned culture shock before, but I've definitely been experiencing it over the past few months.  I've come to realize that most of my culture shock actually stems from work, and learning to understand and accept the way things are done over here.  Well, "accept" is a loose term in this context.

Medicine, I think, by nature, can be a culture of its own.  And so why can't you have medical culture shock?  Let's see, I've been through the honeymoon phase (wow, so this is what a hospital looks like!) and the negotiation or withdrawal phase (I can't believe this is how so-and-so is being treated for such-and-such disease) so far.  Now, I'm beginning to understand a little about the logic behind doing certain things (such as giving antibiotics without checking a urine or blood culture)...so maybe this means I'm moving into the adjustment phase.

Or not.  During my weekly home visit to a local foster home today, one of the kiddos looked like he was in respiratory distress (breathing fast, retractions, grunting, flaring - all bad signs).  I watched him for an hour and a half, and decided he needed to go to the hospital to be admitted.  Remember my last post about hospital costs?  Well, the ER doctor who saw my patient decided that it was necessary to admit the child to the ICU because the respiratory distress was so severe.  However, his foster mom said that she could not afford the ICU rate and could only afford a general admission bed...so that is where he's staying for the night.  I'm keeping him in my thoughts tonight.  The family had to sign something before being admitted to the general floor - I think it was an acknowledgement that the hospital had recommended ICU care but the family had refused.  Kind of like an AMA (against medical advice) agreement, but the patient still remains to be treated.  I'm shocked.  I'm shocked that such decisions (in fact, nearly all medical decisions) are determined by money.  Never in my training have I seen a child refused medical care because of lack of money.  Especially when they show up at the doors of your emergency room.  In obvious need of medical intervention.  But this is the way things are over here...and it frustrates, angers, and disappoints me.  So I guess I'm still in the negotiation phase.

...and more postings

A game of ball

We had a one-day work retreat last month and we spent it at an outdoors restaurant about an hour outside of the city.  The morning was spent playing baseball and the afternoon was spent doing team-building activities.  For many of our staff, this was their first time to play baseball.  For some of them, it was their first time to even hear about baseball...but they all played and we all had fun!  We even discovered some with a natural talent for the game!

Friday meetings

We have a lunch meeting every Friday where we can share, read, and learn together.  The meetings have been held at my place for the past couple of months.  All medical and non-medical staff are encouraged to attend and lunch is provided.  For me, it's a great time to get to know others better, especially the non-medical staff.  My favorite time of the meeting is actually in the beginning because not everyone has shown up yet, and it's a great opportunity to have some good conversations.

The front door to my apartment...and I think this is only with 1/2 of our staff!

Getting in shape

Almost every night, multitudes of people will gather outside and do some type of group exercise activity.  This night, I think they were doing some kind of line dancing.  I've also seen ballroom dancing and tai chi.  People will meet throughout the city and in the neighborhoods - this was taken just down the street from my apartment.

a beautiful day

Today was an absolutely gorgeous day.  The sun was out, the sky was blue and clear, the high was 80F, and there was a perfect breeze, not too windy but frequent enough to keep you comfortable while out in the sun.  The weather reminded me of my college days in Austin, TX when the spring moved into summer, sitting outside of Mozart's studying and chatting, then hopping over to Hula Hut for a tubular taco, and ending with some scrumptious fried ice cream.  Aah, the memories.

Well, I think this has been the most beautiful day I've experienced since living here.  I couldn't help but smile while being out and about today.  It was truly one of those days that lifted my spirit.  May you experience one of these days this summer!

Postings...

An unexpected guest

I had a visitor fly in a few months ago, literally.  Take a close look at the picture and you'll see the airborne friend who appeared in my bedroom from out of nowhere.  Even now, I still can't tell if he's creepy or cute.  Not sure how he got into my apartment, but it didn't take him long to find the open window!

P.S. If you can't tell, he's a bird.

Dragonboat Festival

We had 3 days off in celebration of the Dragonboat Festival in June.  The actual holiday was June 16.  Traditions include dragonboat racing, eating sticky rice called zhongzhi, and wearing colorful bracelets.  For reasons unknown to me, our city did not have dragonboat racing this year.  I was disappointed, too.

I spent the actual holiday with a friend, who took me to a nearby park and river, which also has an amusement park in it.  We ended up trying out some of the rides - my favorite were the bumper cars because all the other bumper car drivers were just as enthusiastic as we were, and we had a blast ramming into each other.  Afterwards, I was invited to a birthday party in the evening at one of the local universities, so I got to experience my first birthday party here!  The celebration included eating zhongzhi (because of the Festival), singing, opening presents, eating cake, and ending the evening with dancing to American songs outside (chicken dance, electric slide, hokey-pokey).

Personals for the elderly

Yep, this is a wild ride where you sit unstrapped and the contraption just goes around and around, up and down, left and right.  I wonder how many leave with whiplash...

Bicycle numero dos

All decked out for a rainy day.  Fortunately, it was only "mao mao yu" that day, or light drizzling rain.

Behold my most prized possession in this photo, the helmet.  While my foreign friends incur stares whenever they go out, I blend right in...except when I don the helmet.  Sometimes I'll try to stare back to see if I can out-stare them, but then realize that it requires me to take my eyes off the road.  I'm not ready to put my helmet to use in that capacity, so I willingly look ahead and try to ignore the attention.  An elderly man on his bike complimented my helmet the other day, telling me that it looked very nice on me.  I tried to emphasize to him that I was wearing it for safety and not for fashion.  I don't think he got the idea.

Sorry, but there will be no picture of my bike as I do not have it anymore.  Yep, it got stolen.  Not even a full month...but I still have my helmet.  Perhaps my next bike will make it to the blog!

Thoughts to share

This past month has been filled with some significant "firsts" for me and I wanted to share them with you, as these experiences have impacted me quite a bit, not only on a personal level but also on a professional level.

*  My first house call - I made my first house call to check up on a newborn with jaundice.  Over here, newborns and moms remain at home for the first 30 days.  For the newborn, their first visit to the doctor may not be until the first set of immunizations are given, which would be at a few months of age.  In fact, there is not much emphasis on routine well-child checks over here, so a child is usually seen only when he/she is sick or in need of immunizations.  Because of this, all of our residents have very little experience with caring for a newborn, the newborn exam, and common newborn findings/concerns.  Moms must also remain at home for the first 30 days.  Family members often come to visit and help out during that time.  Some traditions I've been told that moms must follow during this time - eating only certain foods, not bathing, and staying in bed.  But back to my patient - she did indeed have jaundice and ended up being hospitalized, treated with phototherapy and antibiotics, and had a full recovery.  Both baby and mom are doing well now.  I really enjoyed making these housecalls because 1) I love caring for newborns, and 2) I got to see my patient and her family in their home setting.  It was nice to meet all members of the family, and observe them in their home and their interactions with one another.  My patient is blessed with a wonderful family who already love and care for her immensely!

*  My first patient death - I returned from Yushu to find out that my patient whom I had been following for the past 4 months at a local orphanage had passed away.  Before I left for Yushu, there was active discussion between me and the orphanage about getting a blood transfusion for my patient because she was severely anemic.  While a blood transfusion may sound like a simple process, it can be quite complicated for an orphan.  Many factors have to be considered - transportation, timing, availability of caretakers, cost, etc.  While these factors were being considered, my patient passed away.  I'm not sure what the exact cause of death was (no autopsy was done), but it sounds like she was bleeding at the time of her death, and most likely died from that.  This loss has been extremely hard for me.  As a resident, I cared for patients who died despite all that we did for them.  And that's the difference - we did all that we could for them and we used all our resources available.  One thing that I have noticed here, and have attempted to understand, is that there are resources available to help our patients but they are often not utilized.  Why?  I don't know.  I have some ideas but, ultimately, it comes down to the fact that I just don't fully understand this new culture I'm in.  I keep asking myself, "Did I do all that I could for this patient?  Could I have done more as a consultant beside making the same recommendations time after time?  Would a blood transfusion have made a difference?  Could we have prevented her death??" Losing a patient is difficult.  Losing a patient because resources were not used is not only difficult, but also frustrating...and makes closure so much harder.  It's times like these that I remember I do also believe in a God who is good.  Though I may not understand why things happen, He can be trusted in all things and He is greater than anything I am able or unable to do.

*  My first hospital encounter - One of my patients was admitted to the hospital this past week for hyponatremia (extremely low sodium levels in the body) and seizure.  We think the hyponatremia most likely caused the seizing.  She was seen at one of the best hospitals in this city and, as her PCP, I got to see a little of how hospitals work over here.  Here are some of my observations:
Patients pay for everything up front - medications, IV supplies, IV solutions, labwork, imaging studies, etc.  The doctor will write an order for labs or medications, and it is up to the patient to get this done.  If it is labwork, the patient must track down a nurse to draw the blood, then take the blood over to the laboratory, and pay for the test to be done.  If it is medications, the patient takes the prescription to the pharmacy and purchases the necessary medication.  If the medications needs to be given through an IV, the patient must find a nurse to place an IV (or go to the IV station) and have the medicine hooked up for them.  If patients are admitted, they must stand in line to get a room, and once assigned, must pay up front for the first night.  If they are unable to pay, they lose the room and cannot be admitted.  My patient was admitted to a regular floor and the cost is about 20Y/night.  An ICU admission costs about 1000-2000Y/night and the cost includes around the clock nursing care as well as any labs/tests or medications needed during that time.  For this particular hospital, the ER cannot do a lumbar puncture (spinal tap) or intubate if the patient stops breathing.  These procedures can only be done in the ICU.  Treating with IV management is extremely popular over here (in fact, there are many businesses that specialize in making and selling IV chairs), and this hospital was no exception.  Each time my patient lost her IV, which was quite often, we had to take her to the IV station to get a new one placed.  The nurses were too busy to come and place an IV at bedside, so we had to go to the station.  And the station, of course, was packed with families everywhere getting IVs for their children, without any order or visible lines.  Throughout the hospital, you would see families carrying sticks (no fancy IV poles here!) with an IV bag at one end connected to their child - they all looked like they were going fishing.  Interesting, huh?

And on the lighter side...

* My first bike - and hopefully, only bike!  There is a pretty high rate of bike theft over here.  I was told to buy an old, used bike to avoid it getting stolen.  But I think that's how the seller got the bike in the first place...  Oh, and my bike helmet cost more than my bike.  Go figure.  Picture to come soon!

Around the neighborhood

Do you see the man sitting on top of the cargo?  All you can see is his head.  A pretty common sight over here.

Below are a few pictures of the marketplace in my neighborhood.  It's a few blocks long and filled with stands selling fresh fruits and vegetables, fresh cuts of meat (chicken, beef, lamb, pork), grains, and all sorts of other tasty items.

My friend with her vegetable stand.

Meat stands like this one are scattered throughout the marketplace.  You can buy the meat in one piece or ask them to cut, slice, or grind it for you.  I think they will even trim the fat for you, if you ask.

Freshwater fish!

Shellfish of all kinds -  mussels, clams, oysters, etc.

Playing cards in the marketplace.

Signs like these are posted along the street throughout the city, each with a different message, but all relating to traffic safety.  I don't know if you can read this message, but it says, "Loving your wife, your children and your family, amounts to nothing if ignoring traffic laws and regulations."

Children playing a game in the courtyard below my apartment.  I think it's a version of dodgeball with a much smaller ball.

Many of the ups and downs of childhood remain the same over here...such as losing your baby teeth!

The pineapple man in front of my apartment complex.

I'm not sure what the logic is behind this, but the city has been uprooting their trees, so you see empty pits like this lining the sidewalks of the city.

Dogs are pretty well taken care of here in the city.

Finally!

Spring is here!  We're about a month late and the "April showers" are now May showers instead...but it doesn't matter because spring is finally here.  It is so refreshing to the soul to see the trees blossoming and flowers starting to peek out from the ground.  The city seems to be coming alive with this warmer and brighter weather - vendors fill the street selling food and household goods, parks are filled with families flying kites and having picnics, neighbors are sitting outside their homes and chatting, kids are running around and playing games throughout the neighborhoods, and there's the sound of music from birds chirping in the trees.  Ok, so maybe not the last part.

Yushu

  As many of you may know, there was an earthquake that hit Western China a few weeks ago on April 14th.  One of the towns near the epicenter of the earthquake, Yushu, was destroyed.  Thousands have died, and many more are injured and grieving the loss of loved ones.  Medical relief teams have been pouring in to help, both Chinese and non-Chinese.  I went in with two other colleagues last week to help but we were detained in the capital for a little bit due to restricted access to the road leading up to Yushu.  However, we were able to make it up to Yushu!  After a 30-hour truck ride to Yushu, we arrived in time to help relieve some of the other doctors who had been there already for about a week.  We joined a team of relief workers sent in by a local non-profit organization called Plateau Perspectives.  After working two full days, we were asked to close the medical camp because the government was setting up local hospitals for the people of Yushu.
  Most of our patients that we saw were either Tibetan, Hui, or Han Chinese.  Many did not speak Putonhua (Mandarin) and interpreters were necessary.  Thankfully, we had some wonderful interpreters available who worked alongside us and it was a joy to work with them because they always had great attitudes!
  Fortunately, most of the emergent problems had already been seen and taken care of in the early aftermath of the earthquake.  By the time my team arrived, patients were mainly being seen for chronic conditions such as hypertension, headaches, stomach problems, back pain, etc.  However, there was also a lot of anxiety, fear, and stress associated with the earthquake, too.
  I wish I had seen what Yushu looked like before the earthquake.  Now, there are tents everywhere lining the streets and people walking around with just the clothes on their back.  Some buildings are still  standing with large cracks down the walls.  Piles of stones are everywhere.  Various relief organizations have been passing out food and clothing throughout the city.  Trucks filled with supplies continue to dot the road up to Yushu.  Our campsite was able to set up a water filtration system that filtered the nearby brown river into clean water for the people around us.
  Although there has been so much devastation here, it has been incredible to see how many various organizations have come together to help this city!  Communities in the capital have come together to send up supplies and workers.  Various religious, political, and ethnic groups have worked side by side to provide aid.  There is a sense of unity and cooperation in working to help rebuild this town.
  If you would like to continue to keep tabs on how Yushu and the earthquake relief work is coming along, check out http://yushuearthquakerelief.com/.  This link is through Plateau Perspectives.

 The truck that we rode up in, piled high with supplies.  As I mentioned above, it took us 30 hours to drive from the capital up to Yushu.  Typically, it should only take about 12-14 hours.  I'm not sure why it took us 30 hours, although I have a few guesses - it was our driver's first time to drive to Yushu, the road was in terrible condition with huge potholes and cracks every few feet, we were going about 20-30 km/hr (seriously! I was sitting right next to the driver and had a pristine view of the speedometer).  Thankfully, we didn't hit any bad weather or have any car troubles...otherwise, who knows when we would have arrived in Yushu!

My teammates, Peter (our team leader) and Zeb, in the backseat of the truck.  There were 6 of us total, 3 in front and 3 in back.  The blue pillows in the back are oxygen pillows for altitude symptoms.  Unfortunately, Zeb ended up in another medical camp once we arrived in Yushu so we didn't get to see him very much.

Our taxi driver.

 The highest elevation during our trip.  Yushu is about 4000 meters (12000 feet).  Altitude sickness was a serious concern for all the workers in Yushu.  Symptoms can range from minor effects of headache and weariness to more serious conditions such as cerebral and pulmonary edema.  The only true cure is to go down to a lower elevation.  Our team started taking preventative medicine days before we arrived in Yushu and, thankfully, suffered only some headache and weariness.  The air is also thinner at higher elevations, which means it is more difficult to get enough oxygen with each breath.  Simple activities, like walking or running, can easily cause you to become short of breath and feel winded.  I felt winded just going to the bathroom!

 Here is the water filtration/purification system that was set up by our camp!  You can see the river in the first picture where the water came from.

A Buddhist monastery on one of the hills of Yushu.

The river near our camp site.  I later found out that this river also receives the sewage waste.

Our camp site from the back.  The large blue, green, and white tents were where we saw patients, kept medical supplies, and ate.  The small blue tent in the center was my tent.

 Our pharmacist preparing lunch for us.  She had such a servant's heart!

 Seeing patients in our clinic tent.

The above pictures are all from Yushu, around our site.

Crossing the Yantze River on the way to Yushu.

Our two traveling companions that made the 30-hour trek with us up to Yushu!

The Tibetan plateau...very brown!