Plastic surgery travels.
Part of what had attracted me to the specialty of plastic surgery was a desire to use my skills in resource-poor areas of the world. I am privileged that my practice, primarily in a large multi-specialty group located outside Los Angeles, afforded me the opportunity to do this work. I have warm memories of patients in rural areas in the Eastern Cape of South Africa, northern Malawi, and eastern Democratic Republic of the Congo placing their trust in a “lady surgeon” from America.
The providers I met worked under incredibly difficult circumstances: they had inadequate supplies, few medications, minimal governmental support, and little pay except for the gratitude of their patients.These providers could have relocated and had much easier lives in other countries, but they remained to serve their communities. I am forever grateful for their generosity of spirit and humbled by their dedication to their work. For many people living in these underserved areas the thought of undergoing an operation was more frightening than dying; in these communities, death was common while an operation was a rarity.
Techniques long abandoned here in the United States had reasonable patient outcomes (especially given the circumstances) in other parts of the world, so I learned to keep an open mind in whatever situation I found myself. One experience with a patient in Haiti remains with me, and it reinforced my desire to make a change from reconstructive plastic surgery to palliative medicine.
Haiti, after the earthquake.
I volunteered at a field hospital set up in the immediate aftermath of the devastating 2010 earthquake in Haiti. Conditions were rough. People lived in rows of tents often with more than five people in a tent. The weather was hot and humid with dramatic rainstorms at night. Food rations were limited, and although we were lucky to have a clean water supply it was always at risk. And our patients, were still trying to locate family and recover from the trauma of the earthquake. Although we were well stocked with medications and had a makeshift operating room, providing care was challenging. I was the oldest doctor among the volunteers, as most had only recently completed their residencies, and I was one of the few non-emergency medicine (ED) physicians. Although I had extensive experience working in resource-limited areas, I had never worked during an ongoing humanitarian crisis.
Most of my coworkers had never worked in either situation—their medical experience was limited to well-equipped, state-of-the-art Western (mainly U.S.) hospitals. One morning, as I was walking among the tents, a woman who looked very worried pulled me inside her family’s tent to have a look at her mother. Mrs. G, the matriarch of a large family living at the site, had a history of “a bad heart.” She looked terrible—her color was pasty and she was short of breath. We were able to get her to the treatment tent where the other doctors were working. As I am not an ED doctor, I moved aside to let them evaluate and care for her.
Although some cardiac medications were administered, they didn’t help. It was obvious to us that she needed more care than we could provide at our field hospital if she was going to survive. The doctors decided to transfer her to a medical camp near the airport; that camp was run by an American university and could provide more advanced care. But the camp was well over an hour away and would require transport by an “ambulance” on the terrible and crowded roads. There was no guarantee she would survive the transfer or survive her illness even with a higher level of care. I advocated for another treatment plan: to administer doses of IV morphine- to make Mrs. G more comfortable. And to explain to her and her family the real situation—that it was likely that she was nearing death. The options were to transfer her to a place for more advanced medical treatments far away from them, with no guarantee of success, or to have her remain in the camp with her family and keep her comfortable whatever happened. My recommendation was not taken; the other providers felt she could be “saved,” and this woman was taken (with one family member allowed to accompany her) by ambulance for advanced care. I was quite upset when I heard that Mrs. G had gone into cardiac arrest during transport and CPR was done all the way to the facility, at which point she was finally allowed to be in peace. Although I do not doubt the good intentions of the doctors I worked with, I still believe she and her family should have been more active participants in the treatment decisions.
Maybe Mrs. G would have decided to be transferred, but in their hope of “saving” her (which may not have been possible no matter the treatment), these providers did not give her a voice. Instead of dying comfortably, surrounded by her extended family, she died with increasing symptoms and with strangers performing CPR. This experience solidified my desire to go into palliative medicine and to use my position to teach other providers how to work together with their patients to make a treatment plan that respects the patient’s goals. Aggressive, potentially life-prolonging treatments aren’t the way for everyone. The memory of Mrs G remains a part of my work every day.
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I can see how this experience propelled you in the direction of palliative medicine. I do hope that the young physicians learned from you and this experience that there is a time and place to allow a patient to pass with dignity and surrounded by family and love
Sometimes doing the “right thing,” doesn’t mean saving a life.
I love your blog. I will be sharing it with my team!