Take the leap

News:

My exciting news is that at my brother's wedding on July 28th I met a special someone.  Her name is Stephanie and after being too afraid to get her number after the wedding I took the sneaky route and got it the next day from her cousin - Ha! (who happens to be my new sister-in-law - Alicia).  We stayed in touch after I returned to Wisconsin and I couldn't shake the feeling that despite her residing on the west coast and me in Wisconsin this was someone I could not pass on getting to know.  I just had this gut feeling...

So, after a couple of weeks of talking over the phone, I swallowed my fear and asked her what she thought of me flying out to visit her!

And, fortunately, she thought it was a great idea! (or I reckon I wouldn't be telling you this story would I:)  Our time together that visit was incredible and as evidenced by her coming to visit me in Milwaukee this past weekend things have continued to go well!

(Stephanie and me on a bike ride on a beautiful summer day in Portland!) 

(Stephanie at a recent friend's wedding; what a nice smile!)

The most recent exciting news is that Stephanie - you might want to take a seat for this one - will be joining me in East Timor for the entire 6 months to volunteer at the clinic...  (!)  I know, it seems crazy.  I meet a nice person, hit it off, and then invite them to work with me in a developing country full of tuberculosis and unsafe drinking water.

BUT, in defense of my sanity, I knew Stephanie was searching for a service-learning type adventure and was also in a position career-wise to take a chunk of time to make that dream a reality.  You also just have to meet her, Stephanie is a real go-getter and well-traveled herself.  The more I thought about the idea the less crazy it seemed.  So, I asked her.  I was on a labor and delivery night shift at the time and couldn't wait to ask so on a slow moment I sent her an email laying out my idea.  Her response was:

"OH MY GOSH!! You are blowing my mind yet again! Yes, I want to do this!!!!! AHHHHHHHHH, holy buckets of amazingness!!!!!!!!!!"

Which, I took as an affirmative:)

We are both extremely excited for this opportunity and have been busy preparing for the experience.  Which leads me to my next topic...

Timor-Leste:

For those that might have missed a previous entry East Timor (or Timor-Leste as it is called by those who live there) is one of the world's newest nations, gaining independence in 2002 after 3 years of bloody conflict with indonesia that followed a 25 year annexation.  By the time the indonesian military departed, the country was in ruins and most of the health infrastructure and other public institutions were destroyed.  It was into this gap that Dr. Daniel Murphy and the clinic he founded - Bairo Pite Clinic - stepped in to make a difference.  However, the going has not been easy.

Tuberculosis, malaria, and dengue are all common maladies.  Home births without access to a health provider have lead to high maternal mortality.  One out of every 270 pregnant women in East Timor dies during or shortly after their pregnancy; this is 47 times the rate of nearby Australia and trails only Afghanistan, Nepal, and Laos for the highest maternal mortality in all of Asia (1).

The Bairo Pite Clinic, located in the country's  largest city Dili, sees an incredible number of patients each day (539 per day in 2009) and provides a wide range of services from tuberculosis and HIV testing and treatment to maternity care.  They do all of their work on roughly $17,000  per month or $570 dollars per day!

(Patients waiting to be seen at the clinic - photo from BPC website)

For more details on the clinic and incredible work they do please see the clinic's website at the following link:

http://bairopiteclinic.org/welcome/

My role working  at Bairo Pite will be two-fold.  First, I will spend time caring for patients in the out-patient clinic, in-patient ward, maternity ward, small emergency room, as well as mobile clinics to out-lying communities.  My second role will be to assist the Maternal Child Health Program (MCHP) of the clinic which is training women from outlying communities to be skilled birth attendants with the goal of reducing maternal and neonatal mortality.

Stephanie will also be working to care for patients at the clinic and specifically with patient's needing rehabilitation.  In addition, she is a certified yoga instructor and the head of the clinic has suggested she teach the staff yoga!  We have been informed many of the staff are trying to learn English and this is another potential area where she is excited to contribute.

In preparing for this experience I looked into bringing medications and equipment but kept running into issues.  Procuring medications and/or supplies is not simple.  Aligning what people are willing to donate with what the clinic actually needs can be troublesome.  Transporting large quantities of medications and supplies across country lines can result in substantial tariffs, etc.  In the end I have decided to focus my efforts generating funds and plan to let the staff at the clinic put them to use where they are most needed.  I succeeded in obtaining one fellowship to support my work with the Maternal Child Health Program and will be using those funds as well some of my own.  I am also taking over funds from a Madison, WI based group that are long time supporters of the clinic.

And, I want to know if you would like to contribute to the clinic's work.

I know these are hard times but if you feel this is a place and cause you would like to support I promise to keep you up to date with how your funds impact the clinic and the MCHP.

I will be at my present address (2) until mid-December if you would like to donate by check.  The BPC website has a donation link but I have been told the best way to maximize funds getting to the clinic is to bring them directly and/or create an account with a local bank in Timor-Leste and then do a one time transfer of funds (which can then be pulled out without losing money to ATM charges).  This is why the Madison group is having me bring their donation.  If you cannot or prefer not to support by check but would like to contribute I have a Paypal account we could us, just let me know.  While I cannot give you 501c3 status to get a tax refund I can promise to closely update you on how your generosity is making a difference in the lives of real people.

Thank you for reading and your consideration of supporting the people of Timor-Leste.

And as always I would love to hear how you are and what you are up to!

Warm regards,

Michael and Stephanie

1. World Health Organization (WHO) website, authors WHO Country Facts

http://www.who.int/countries/en/ [Accessed 1/14/12]

2. my address:
Michael Wauters
3011 S. 56th St. APT 7
Milwaukee, WI 53219

Milwaukee Spring + Summer 2012

Bike Project!

For those that do not know I am currently residing in Milwaukee as part of a program that focuses on urban under-served medicine and public health.  Thus, in addition to time in the clinic and hospital, we receive dedicated hours to work on a public health project.  I have been partnered with the Sixteenth Street Community Health Center (a group of clinics in South Milwaukee that primarily work with Latino patients).  My first project revolved around access to healthy and affordable food in the local communities and is detailed in a prior blog entry.  Since that time I have been working on something new...

Biking!

When I first arrived in Milwaukee I was told, hey, there is a pediatrician who is into bikes, you should talk to him.  I did, his name is David Waters (strange coincidence on the name huh?), and we immediately hit it off.  Based off our own experiences with the benefits and joy bicycle use can bring and newer research demonstrating huge gains in health and staggering cost savings if short inner-city trips less than 8km are replaced by bike we set out to see what we could do on the south side of Milwaukee to increase bicycle use. (if you are interested in the article please see: http://www.ncbi.nlm.nih.gov/pubmed/22049372)

After months of connecting with local community members as well as bike shops and organizations involved with bicycle use and advocacy we decided to take a dual-pronged approach of 1) holding an event to create excitement around bicycle use as well as 2) conduct a survey to delineate a more evidence based approach to increasing bicycle use on the south side.  The survey is in it's final revisions but just last Saturday we held the first annual Southside Bicycle Day and it was a huge success!  See pics below:

Our Bike day logo!

 We estimate between 100 and 130 community members showed up!  We had representatives from the Wisconsin Bike Fed teaching about safe city riding, free helmets we fit on kids (ran out and will need more next year), the Urban Ecology Center, The Hank Aaron State Trail (a great riding/walking path along a river close to the community that almost no one at the event had heard of!), Milwaukee Police Bike unit, bike mechanics from two local shops offering free safety checks and minor repairs to all comers, and lastly free t-shirts and food to top it off.

 Officer Lemke from the MPD bike unit and me with a girl who really wanted a pic with us!

Officer Lemke leading a group on one of two groups rides he conducted on the park's trails during the event.  It was awesome to see 30-40 kids and adults stretched out behind the officer in their orange event t-shirts like little ducklings!

Signing kids up for the next ride.

Anton from Ben's Cycle Shop gettin' things done!  Our volunteer mechanics (also Russell from Dream Bikes) were a huge asset to have at the event - thanks guys!

Melissa from the Hank Aaron State Trail about to explain to another participant the wonders of the trail and how to best access it.  Nice!

 Our planning team minus Dr. David Waters who could not attend unfortunately (but has been instrumental in making things happen).  L-R Ed, Tatiana (my "boss" so to speak), and me.  Couldn't have asked for better people to work with!

-------------------------------------------------

Other Awesome stuff I want to share...

Wedding!

No, not mine, my brother Matthew got married!  His wife, and my new sister in law, is Alicia, and we couldn't be more excited to "officially" have her as part of the family!  The big day was July 28th and we held the wedding and reception at my parent's place on Bainbridge Island.  I was worried hosting the wedding would get us all stressed out but in the end we all banded together to get the work done, enjoyed each other's company and that of many family members and friends we had not seen in some time, and had a great day!  The sun even came out right in the middle of the outdoor ceremony - beautiful - we couldn't have asked for more:)  Congrats Matthew and Alicia!

Patrick and me tag-team toasting our brother Matthew and his wife Alicia - great fun!


Couch Surfing!

The title pretty much says it all.  In response to living alone in a two-bedroom apartment and being rather lonely at times I signed up for a website called couchsurfing.  The basic premise is to connect people who are willing to let someone stay with them for a night or two with travelers coming through. I was skeptical at first but the site has each person create a profile you can review and after meeting/hosting the two respective parties provide feedback i.e. "_____ was great to talk with, helped with dishes, and was very neat."  While I am not in a position to travel right now I have hosted some pretty cool people from all over the US as well as India, Germany, China, French and Italy!  And the bonus, the people I have hosted have all invited me to visit them in their countries - essentially I am creating a world-wide network of friends!


Karo from Germany and Spring (adopted name) from China.  We were just sitting down to an amazing chinese feast prepared by Spring!  Spring also helped me clean my kitchen and bathroom without me asking for it (don't worry mom, they weren't too bad to start with:)


Visiting a kite festival on Milwaukee's lakefront with two gals from France who visited me.  They had some huge kites!  The one's in the pic were at least a 100ft long!


Visit from my brother!

The evening after I finished 9 hours of testing for my Step 2 United States Medical Licensing Exam I had the awesome reward of being able to pick up my brother Patrick from the Milwaukee airport.  We had 5 days together and we packed it full of fun and adventure - two 60+ mile bike rides, several smaller rides, time at the lake front, a 10-12 mile trail run, cooking up huge feasts (including making pizza from scratch!), having friends over for dinner, visiting our grandfather and more.  It was a blast to show off my new home to someone who shares so many life passions with me!



The pizza team!  It was my first time making pizza from scratch and it turned out delicious!  L-R my brother Patrick, me, and my former med school roommate Anst who came for a day of adventuring with us.



Using basil from our med student garden we made home-made pesto, then added feta, brocolli, and mushrooms to top it off - yum!


Surgery Sub-Internship

From the above stories/pics you might think I am no longer in med school but this is not at all the case!  The fact that I only have time to write every few months is testament to my normal state of affairs:)

Third year ended well, I took my step 2 exam and I am now nearing the end of my first clinical 4th year rotation.  In the 4th year we are able to set our own schedule as long as we meet certain requirements.  I have started out with a month of general surgery and had the good fortune of being with a surgeon who is amazing and breaks all the stereotypes.  Dr. A loves to teach, is an incredible communicator and beloved by his patients, and has provided me with a great deal of responsibility and learning opportunities.

For example, one of the days we were on call Dr. A was in the operating room (OR) when he was paged by the emergency room (ER) that they had a patient with CT evidence of a perforated appendix and free air in the abdomen.  In medicine, free air is almost synonymous with a speedy trip to the OR for emergency surgery.  It usually indicates there is a hole somewhere along the person's intestinal tract and the patient is in acute danger.  Being scrubbed-in on a case Dr. A asked me to go to the ER in his stead, evaluate the patient, and report back to him with what I thought we should do.  Yikes!  This was the real deal!

Trying to remember the key history and physical elements of appendicitis and the criteria for sepsis I hurried down to the ER.  The patient I encountered was a 69-year-old man from a nursing home, wheel-chair bound after two strokes, with bad COPD (a bad lung disorder) and numerous other medical conditions.  While he was uncomfortable and had a distended abdomen he was not in acute pain and I could find no signs of peritoneal inflammation (certain signs that tell us extreme badness is happening inside the abdomen).  From what I could gather his intestinal perforation likely took place a week or so ago and what had brought him in acutely was nausea/vomiting and food intolerance secondary to his intestines becoming blocked or ceasing to function due to the inflammation/irritation within.

With his many co-morbidities and stable clinical picture I did not think taking him to the OR emergently was a good plan and might in fact do more harm than good.  However, I did not know if this was correct and bounded upstairs to share my assessment and plan with Dr. A.  After hearing my presentation he agreed with me (!) and upon seeing the patient himself he reaffirmed the plan.  Our patient is still in the hospital but has made moderate improvements and so far it has not been necessary to take him to the OR.

Needless to say, experiences such as this have provided me with a great deal of learning.  As I continue to gain more knowledge and confidence it has been most exciting!

Well that's all for now - please write back if you can!

Milwaukee

Starting in January I moved from Madison to Milwaukee to begin my 1.5 year long participation in the TRIUMPH program (TRaining In Urban Medicine and Public Health).  TRIUMPH focuses our learning on the needs of urban underserved populations and integrates public health into our clinical training.

There are 8 of us total, each person working with a local community partner on a variety of projects. I have been partnered with the Sixteenth Street Community Health Center (SSCHC) located on the near south side of Milwaukee.  They are a federally qualified health center with family docs, pediatricians, mental health specialists and more and they specialize in working with the Latino community.  In many ways it reminds me of SeaMar where I worked during Americorps.

(The TRIUMPH team!  A wonderful group of people.)

My role at SSCHC has evolved into two separate projects united by a common goal.  The goal is wellness promotion in the Latino community and specifically reducing obesity.  My first project assists a educational program run through the clinic called Healthy Choices.  It consists of 3 months of once per week 2 hour classes that each incorporate a main lesson ranging from why water is better than soda to the benefits of whole grains as well as introducing new types of exercise each session (yoga, zumba and more) and finishing with a healthy snack.  The program is targeted at the entire family and indeed there are 4 different curriculums for different age ranges (4-6 year olds, 7-11, teens, and adults) who all focus on the same message of the day but with age appropriate material.  The participants come to support each other and many a parent has said it is their child who begs to go and continues the family's participation!  

Graduates of the program feel they know how to eat healthier but do not know where to get healthy food at the best price.  My task was to visit 10 local supermarkets and find out which one's had healthy options and at what price.  After doing this I created a comparative shopping guide we now provide to the families and also gave several presentations on the results of the study.  The main findings were:

1) there is a great deal of variety in the availability and price of healthy food items in the neighborhood between different stores.

2) The supermarkets marketed to and most frequented by Latinos had the fewest healthy options and those they did have often had the highest price tag.

3) It is possible (theoretically) to buy healthier food and save money in the neighborhood (buying less meat is a key part).

(At one of the presentations.  I had to learn a few new words such as ajonjoli (flax seed) which was a tough one for me to pronounce!)

My second project is only just beginning and the goal is to increase bicycle use and appreciation in the near south side of Milwaukee, especially within the Latino community.  A dream of our team is to one day hold a Ciclovia.  For those who do not know what this is check out an example at the following link: http://www.ciclavia.org/about/

More on this project in the future.

Recent Life Highlights/News

OB/GYN:
Crazy rotation but I really enjoyed it.  Working in one of Milwaukee's large public urban underserved hospitals we encountered all kinds of extreme cases and I think I saw almost every major obstetrical (having babies) complication there is!  See my previous post from February for a story about one of them.

Am I in Alaska?:
First, let me set the stage with a little background info. Milwaukee sits on the western edge of lake Michigan and right through the middle of it runs the Menominee river valley. This symbolic rift divides one of America's most segregated cities, with the North being mostly African American and the south largely Hispanic. In bygone days the valley was the engine for Milwaukee's industrial powerhouse and as a result the river became incredibly polluted over time. Several decades ago the city decided to clean up the area and from past photographs you almost wouldn't recognize it now. The river meanders along forested banks and on land there are a plethora of new, greener, businesses and an awesome bike/walking path that goes from the lake many miles inland called the Hank Aaron State Trail (HAST).

(The HAST!) 

My first day biking on the HAST I noticed two people walking around in the shallows of the Menominee river. I had learned some of the info I shared above but still thought it not the brightest idea as I figured the river was probably none to clean after so many years of abuse. As I grew nearer I could see they were fly fishing and stopped to watch. This seemed rather futile as there couldn't possibly be any fish in the river. As that thought passed through my head I saw one of the men's poles give a heave and proceeded to watch them reel in some huge trout/salmon looking fish which I later came to learn was almost assuredly a cut-throat. I couldn't believe my eyes! It felt like I was in the middle of the wilds of Alaska!  Yet, a glance behind me revealed several sky-scrapers.  Definitely in the city.  Crazy.  So, if you want to come visit, don't forget your fly rod:)

Third Birkebeiner ski race: Due to a profound lack of snow this winter I skied exactly 3 times before the race this year. However, the cross training I got from biking the snow-free streets must have been enough as I did the hilly 50k course in my second best time (3:45 vs 3:30 last year and 4:05 my first year) which I was more than happy with.  XC skiing rocks!

Hanging out with my Grandfather: One of my original hopes when coming to Wisconsin was to reconnect with the substantial number of relatives on my mom's side of the family who call WI home. I have been able to spend time with many of them (all wonderful experiences - thank you!) but was really hoping to see my grandfather more. My new location in Milwaukee is just 5 miles from where he lives which as allowed us to get together on three occassions so far for such adventures as:  baking bread, watching Wisconsin in the March Madness tourny,  practicing knot tying, and the telling of many awesome stories (i.e. my Gpa recanting such incredible tales as how he was shot down in WWII, survived, was held prisoner, and eventually escaped).  I have an awesome grandfather.

(Preparing to chow down on one of the meals we created)

Bikes: Maybe it's because I'm working on a project to get more people biking that I've had bikes on the mind but for whatever reason I've been exceptionally excited about them and riding them all over. I've discovered an incredible network of paved and off-road paths/trails around the city and each weekend go out exploring more of them. On my last rotation (primary care) I had two clinics set at opposite sides of the city but I still wanted to bike. The round trip ended up being just over 30 miles but as my afternoon preceptor didn't start until 2pm I had enough time to bike the hour plus down to her clinic after my morning clinic. I think I might be in the best biking shape of my life from commuting so much! The downside of such high mileage with a pack on was lots of pressure on my wrists and "areas that don't like lots of pressure" so I recently got a rack and some panniers.  Best decision ever; I can't believe I didn't make the switch earlier!

I've also become enamored of cargo bikes recently.  They can carry so much stuff you don't hardly need a car anymore!

(A smiling lady I do not know on a sweet cargo bike)

If you want to see more check out this awesome video of cargo bikes: 

http://momentummag.com/videos/copenhagen-cargo-bikes/index.html

Plans: In early January 2013, bar any unforeseen roadblocks, I will be heading to East Timor for 6 months to work in clinic and small hospital.  East Timor is roughly 400 miles NW of Darwin, Australia in SE Asia.  At that time I will also be assisting a Maternal Child Health Project that trains skilled birth attendants to help reduce the staggeringly high maternal and neonatal mortality in the country.  In preparation I am learning as much Tetum as possible (the most commonly used local dialect) and luckily have been put in touch with two fluent speakers who have graciously been my informal instructors for help with pronunciation and tricky grammar.

Ita diak ka lae?

To learn more about the clinic see:
http://bairopiteclinic.org/welcome/


Finale:
This video blew my mind.  Earth is an amazing, and fragile, place.  This video made that message hit home in a powerful way.
http://www.youtube.com/embed/nGeXdv-uPaw

Thanks for reading!

Crash

Note: The names have been changed to protect identity.

Maria came up to the floor in the middle of the night already at 5cm and pushing. Her and her husband spoke only Spanish and yet there was no available Spanish translator. I volunteered that I could communicate with them as I speak Spanish and introduced myself to Maria and her husband Juan. Between contractions and with Juan’s help we were able to get a brief history. Maria was a 34-year-old G4P3-0-0-3, all uncomplicated vaginal deliveries. We tried to calm her and get her to stop pushing until she was fully dilated but it was to no avail. Eventually she reached 10cm but by this point, hours later, she was thoroughly exhausted. With her permission we elected to pursue an epidural to see if getting her pain relief and rest would allow her to recover and push again. Just after the test dose of the epidural went in the fetal heart tones dropped into severe bradycardia and did not rebound.

A tense minute passed and then there was organized chaos. Nurses grabbed Maria’s bed and hauled it out of the room, someone was on the phone yelling for the operating room to prepare for a crash c-section. I tried to explain to Juan why all of sudden his wife was being rushed out of the room for emergency surgery. After showing him where he could wait outside the OR I headed in just in time to see the fastest “birth” I have ever witnessed. From initial incision to removal of the baby was under a minute. Examining the uterus the cause of the bradycardia was found. On the posterior aspect of the uterus was a gaping hole – spontaneous uterine rupture. The odds of this happening to a woman with no history of uterine surgery are infinitesimally small but there was no arguing with what had happened. The team worked valiantly to repair the uterus but could not control the blood loss. The massive transfusion protocol was activated and after 4 units of packed red cells the team elected to remove the uterus to save Maria’s life. By this point a Spanish translator had arrived but as they had to stay with Maria I was the one who would exit periodically to update Juan. His baby had been taken to the NICU and was doing well. We went to visit the baby but Juan’s attention was focused on his partner. He kept repeating that all he wanted was for her to come out of those double doors alive.

Two days later I was finishing up a last errand when I heard someone call my name from down the hall. I turned to see Juan and his three children. A big grin was on his face. He thanked me for being with them two nights prior and introduced me to his kids. They were on their way to post-partum to meet up with Maria who was being transferred there after recovering well and being discharged from the ICU. After helping them figure out how to get into post-partum I left, my face splitting into a smile. As a medical student there are many days where I wonder what if any contribution I am making. On that night though, I knew my contribution had meant a great deal to Juan and Maria. This experience reinforced for me the importance of communication with not just the patient but those that care about them as well. It also reminded me that as medical students, while we may not have much clinical experience yet, we can still be an important part of the healthcare team.