Monday, October 29, 2007

Patient assessment workshop by young doctors.

What would I do if a person walking in front of me suddenly collapses? He's holding his stomach and seems to be suffering from some kind of severe pain...

Much has been talked about basic life support (BLS), but that algorithm basically only applies to cases where the patient's heart has stopped. Well, then what do we do if a person's heart still seems to be working but he's unconscious and seems to be hurt in some way, is the question here. This is called advanced medical life support (AMLS) or international trauma life support (ITLS), and it's about assessing the condition of the patient in an emergency.

The algorithm consists of three major steps, and the first is called "Scene Size-Up", where the checklist assesses five points: body substance isolation (BSI), scene safety, number of patients, nature of the illness or the mechanism of the injury, and the resources that you have at that moment. The main purposes of this step is to provide safety not only for the patient but also for yourself, and collect information that can be gathered in a glance.

"Initial Assessment" is the second step, which is also the most important of the three. We assess five things here too: general impression of the patient, mental status, airway, breathing, and circulation. Does the patient seem severe? What's the level of consciousness? (AVPU - Alert, reacting to Verbal stimulation, reacting to Pain stimulation, or Unconscious?) Is there anything obstructing the airway? Is the patient breathing? What's the heart rate and condition of the peripheral circulation? Is the patient bleeding? Appropriate assessment in this step is vital, as the third step depends on the condition of the patient.

If the heart is not moving, we move on to BLS or advanced cardiac life support (ACLS). But if that's not the case, we first evaluate whether it's a trauma case or not. If it is, then we see if it's a single trauma or multiple. If it's single, we do a focused rapid examination of the injured area and ask the patient SAMPLE (Sign/symptom, Allergy, Medication, Past medical history, Event prior to the symptom) questions, while if it's multiple, we need to do a rapid thorough trauma survey of the entire body before asking the same set of questions. All of this is done before handing the patient over to the hospital.

Now, if the case is not a trauma, then we first see whether the patient is responsive or unresponsive. In the latter case, we must go through a rapid medical assessment of the entire body and check the vital signs (circulation and blood data). Gathering the medical history of the patient comes last, since one cannot speak at this moment. If the patient can respond to you, you gather this information first and then move on to rapid medical assessment and checking vital signs. Again, this is done outside or in the ambulance, before it reaches a hospital.

Of course, there's more detail and thinking to this, but the important thing about this type of learning right now is for us to do simulations with our fellow peers over and over to memorize the algorithm with your body, instead of the just the brain. Then we can move on to the details and the thinking of case-by-case scenarios. What's amazing about this workshop was that it was planned and carried out by a group of only first and second-year doctors and students. It really motivates you. :-)

Friday, October 26, 2007

AIHD 2007 reunites in October.

I really like these people.

And I think these people truly like each other. Almost three months have passed since the Primary Health Care (PHC) program at the ASEAN Institute for Health Development (AIHD) at Mahidol University, Thailand in August, but we're still close together. We're holding dinners and parties at least once a month, and the members just keep on coming. The October dinner was held on the 23rd, and one came from Nagoya by shinkansen, another came from Fukuoka, 900 km from Tokyo, just for the event. Two others dropped by at 10PM after finishing work and training, respectively, just to have a few moments to see who's here and what's up with them.

Just amazing. I wonder what got us so hooked up with each other... and no doubt I'm one of them. We had 37 Japanese in the flock in Thailand, and of course, not all of us come to join these events, but every time we get together, there's at least a dozen members, and what's both surprising and amazing, is that that number keeps on going up time after time.

And, we're all with different backgrounds. Not only are we comprised of medical or nursing students, but also people who already work, either in the medical field or somewhere else, or students from totally different areas of study (at one glance different, but actually connected). But there's some kind of intrinsic common factor that's keeping us together... :-)

Sunday, October 21, 2007

International Health Co-operative Forum.

The International Health Co-operative Forum was held today in Shinjuku, Japan. It's the 3rd forum after Tokyo 1992 and Manchester 1995, and the theme of this occasion was to decide on the global objectives of the co-operatives' approach to health care, especially after the birth of regional health co-op organizations such as the International Health Co-operative Organisation (IHCO) and the Asia-Pacific Health Co-operative Health Organization (APHCO).

We first had a general assembly featuring some very interesting speeches, one of which I will discuss later, and then we divided into five sectional meetings: world's health co-ops, primary health care, poverty and international cooperation, coping with aging societies, and international exchange of people. I decided to participate in, you've guessed it, the primary health care meeting.

There I met Dr. Yasuki Fujinuma, one of four guest speakers for this sectional meeting. Actually, I've met him before, at a primary health care workshop which was held at the end of September. He's currently the director of Center for Family Medicine Development (CFMD), and also works at the Ukima Clinic, a community-based primary health care clinic located near Akabane in northern Tokyo, and is actively involved in both improving medical education and developing primary health care in Japan. Ukima Clinic is one of the clinics I have an eye on, as it is doing very interesting health care activities at a community-based level. I hope to visit the place sometime next month. Anyway, the part of his speech that caught my attention was when he talked about the near-term plans of primary health care in health co-ops. He talked about three.

One, he stated the need for clinical training in primary health care clinics. He showed us some numbers, and it was something we could nod at. If there were 1000 patients, 88 of them would be going to local clinics while only 0.3 would be paying visits to university hospitals, but the reality is, most of the young doctors train in university hospitals and others alike, the ones that provide specialized, so-called tertiary health care. Clearly, there is a definite need to do at least some training at the community-based, primary health care level.

Secondly, he mentioned that the health co-op should take part in more international activities, taking advantage of the fact that there are co-ops around the globe. In primary health care, you look at the patient as a whole, not just the disease, so it's all the more important to know and understand the socio-economic and cultural backgrounds of the patient. International staff exchanges and training sessions would surely provide an opportunity to see patients with various backgrounds and also have a look at what cross-cultural health care is like. The infrastructure already exists and works around the globe, so networking those is the key here, and I believe the recently-formed IHCO and APHCO can play a pivotal role in this.

And thirdly, he urged that more research be done on primary health care, and also stated that the quality of co-op's primary health care activities must be improved. After all, medicine is still a world where the more specialized skills you have, the higher your authority. In other words, areas like primary health care where you need more of a broad knowledge than specialized knowledge in a certain limited area are not so highly regarded, at least in Japan, so the people need to show with undeniable evidence that primary health care is something that plays an essential role in health care. The co-op's primary health care activities need to be improved too, since obviously you need trust from the people and the community, and quality is what builds it.

When I heard Dr. Fujinuma's talk, I just purely felt moved, and encouraged, as those were exactly what I had in mind. Primary health care, community-based health care, cross-cultural and international health care, education, networking of people and organizations... all of these words I've been thinking about suddenly got connected in one straight line. It's really exciting and encouraging when you meet these energetic people who share similar ideas with you, and especially if that person is already starting to get some things done.

Can't wait to visit Ukima Clinic... :-)

Tuesday, October 16, 2007

Thanks for reminding me.

The other day I was talking about doctor-patient relationships with one of my friends who goes to nursing school, and it helped me remind myself of the image of the doctor I want to become.

Clinical rotations and training have started for her, and right now she's rotating through general hospitals to local clinics and health centers, while also shadowing nurses who are involved in various kinds of health care. And that day, she was complaining that some doctors really only look at the disorders the patients have and not the patients. In other words, these doctors are more focused on diagnosing and treating the disease, not the patient.

Then I thought... do I want to be that kind of doctor?
Well, I don't think so, but not to mean any offense to those doctors.

After all, I believe the doctors who immerse themselves in facing the diseases rather than the patients are the ones who bring new breakthrough technologies and advances in medicine. I also feel that many surgeons belong to that category too, as they're more like artisans or craftsmen, spending a significant portion of their life just to build up skills, sometimes just to treat only a couple of diseases. But that's still necessary, no question.

But the picture of the doctor I have in mind is more like a general practitioner, and probably more general and broader than the term actually means. I'm not attracted to craftsman-type doctors, and this just comes from my tastes, you either like it or not. I want to be able to serve people with various backgrounds. Not sure why, but I guess it has something to do with the fascinating discoveries and thoughts I've had in the past through meeting many people, many of which have helped me shape what I am now. Through examining the medical problem of the patient, I want to interact and understand more about the patient, including one's socio-economic background. If this is done at a certain community-based level, I have a feeling it would enable you to see the strengths of the community, as well as the social issues that are underlying.

Well, in conclusion, whether the doctor focuses on the disease or the patient, I don't think it matters much as long as it makes the patient happier than before. And as long as the patient is happy, what form or type of approach the doctor follows is up to the doctor's personal preference. The doctor should be happy and comfortable too, about not only what he does, but also how he does it. Anyway, there will always be a need for both types of doctors.

I've always been interested in combining the characteristics of general medicine and public health in a clinical manner. You know how you want to face your profession, but there are times when that picture gets blurred, and this recent talk with my friend helped me see it clearly again. Many thanks to her. :-)

Saturday, October 13, 2007

Get some exercise and make a difference to your day?

I don't know why, but there are times when I can't concentrate in anything. I know what I want to do, and what I need to get done, but at those times, I either just don't have a will strong enough to do them or simply have no energy. It's nothing like agony, but something like chronic exhaust. Don't know why...

I had also been having sleeping problems until recently. Of course, living a rigorous and irregular schedule probably wasn't helping that at all, but still, I just couldn't get to sleep. I would go to bed, yawn, hoping to fall asleep... but then I would start thinking about all these things from what to do tomorrow to things I want to do in the future. Hours would pass away, and the next time I see the clock it's like four in the morning. No wonder I heard some birds starting to sing.

So today, I decided to go jogging with some of my friends who make it a routine to do it twice a week. We went to Yoyogi Park, one of the three or four big chunks of nature in cramped and bustling Tokyo. A nice day, 20 degrees celsius, beautiful blue sky, a weather not so common in the middle of October. It really helped me get refreshed, after all, I realized I hadn't really taken any exercise for a month or two. Boy, how just putting a pair of sneakers and going jogging with a couple of friends made the day so much different. After that I went to Jimbocho (an area in Tokyo with 150 bookstores) to search for a Japanese-Thai-English dictionary, and went on to Akihabara (an area in Tokyo with as many electric appliance stores) to do my part-time job.

I guess it's important to take some exercise from time to time, for reasons some of which I'm not sure of. Well, don't know how much difference it's going to make to tonight's sleep, but I think I'll go to bed now, hoping I have more concentration tomorrow. I've got to study dermatology... :-)

Monday, October 8, 2007

Social entrepreneurship.

I'm seeing this word more and more often these days...

A glimpse of the word may give you a weird feeling, as the words "social" and "enterprise" aren't often seen in the same sentence... well, at least until now they weren't. But today, an increasing number of people in Japan are showing interest in doing something for the society. Hence the popularity of jobs in the fields such as international cooperation. However, up until maybe a couple of years ago, these activities were thought to be exclusive to the non-profits and the government. Well, times have changed.

We have many global issues. Some of them are small, while others are bigger. Many people notice them, and some of them stand up and say "I've gotta do something about this." However, for them to really get down in the mud and get some things done takes more preparedness than just saying it, because (1) you need a lot of time, (2) you need manpower, and (3) you need to make your own living. But one who is willing to do all of this while simultaneously staying true to the passion to work for these global, social issues, I call a "social entrepreneur".

Whether it's a private business or a non-profit organization, it must be a sustainable one for it to continue pursuing what it has to do. You need time, manpower, finance, and those resources also have to be managed effectively and put into use in the best way possible. So, I believe a business-like approach is essential for the non-profits too, the only difference between a business being whether its ultimate mission is to make money or to make positive changes to the society.

But then again, existing businesses are also changing. Long term survival in the industry has become more challenging than ever before. They need to thoroughly understand who their customers are and what they truly want. They all need to find their niche. And, catering to the specific needs of those people can sometimes also be considered doing something for the society. Ah... heading towards becoming "social enterprises"?

Of course, all of this depends on how one defines the word "society". And though many organizations will still remain like an ordinary NPO or an ordinary business, I believe the differences and the disconnects between those two will continue to erode, in a very positive sense. :-)

Sunday, October 7, 2007

Two months since Thailand's experience.

Time flies.

Already almost 2 months are about to pass since I participated in a primary health care program at the ASEAN Institute for Health Development (AIHD) in Thailand. The facility is on Mahidol University's Nakhon-Pathom campus.

When the program was over, my heart was filled with something... a strong passion, a strong will to do something. Of course, the program had a big impact on me, and that impact will probably be as big as making changes in my life in a very positive sense... but I'm not sure whether this was the direct reason for me feeling that strong something. It also kind of felt as if I were rushing.

Maybe I was too excited during the program that I wasn't able to "switch" that mode back to reality even after being pulled back into my everyday world? I came up with new ideas that I may want to try, and maybe I got too excited about them? Or, maybe I felt frustrated that I still didn't have the capability to start turning those into reality? After all, I'm still a university student, without profession nor money. Maybe all of these reasons?

It's like this... I had this liter of fuel in me, and I continued to burn it through the program, but the more I burned it, the more I was refueled. But after the program was over, all of a sudden, I was left with all this fuel but nothing to burn it for. It's like you all of a sudden have a big empty space.

I made really good friends during the program too. Maybe I just simply felt sad that itwas time to say good bye for now? The program itself ran for only 11 days, but by the time it was over, I felt as if I had known these participants for months, or even years. I had the opportunity to do some really deep, interesting, and stimulating talks with some of them. Those friends might turn out to be really close partners in the future, maybe some of them even closer than now.

Well, am I still excited? Yeah... of course. Why not? But, I have to be cool-headed, think ahead, and plan out things carefully. While there are things I can do for the society now, now's a time for me to put building my profession at the top of my to-do list. I need to and want to invest time in the future now. Meanwhile, I'd like to look back and share how the program had such a big impact on me, and may have on my future... maybe on another day.

Ah... how I enjoyed talking over those bottles of Singha... "Chai-yo" :-)

Wednesday, October 3, 2007

What the news on Burma tells us about the Japanese media.

How many times has the word "Myanmar" made it to the headlines of newspapers in Japan?

Not sure... but I'm pretty sure it's one digit.
And, I don't think it has happened for over a decade.

So it was amazing and fascinating to see news about the recent movements in Burma (Myanmar) on the very front pages of newspapers on September 28th, and some also on the 29th. All news programs covered the news on those days, and even the LCDs on the Yamanote Line trains were broadcasting it. But, this all came at the expense of a life of a Japanese humanitarian journalist, named Kenji Nagai, who had become a victim of one of the clashes in Burma a few days earlier.

Without his death, how many people would have even known the name of the country?

Dozens of crises still exist around the globe, and the Japanese media has so far done little to tell those stories. There are still many crises that have yet to be reported. If you look at the international sections of the newspapers, it's pretty obvious that they focus so much on North Korea, Iraq, and Iran. Of course, that's natural, but we have to always keep in mind that the world is much larger than that.

Japanese news is so domestically-directed, so to speak. A lot of the news is very local. Most of them cover things that occur inside Japan. There are couple of reasons I can think of, but the biggest reason is probably because Japan is not a multi-racial nation. It's also an island, geographically isolated from the Asian continent, and has a history of having closed its doors to the rest of the world in the Edo era with just a few exceptions... this might also represent the character of this race. Not sure how much this is related to the topic, but anyway, the majority of the people do not feel the need to know what's going on in places like Darfur or Burma, at least not until it involves a life of a person who is Japanese.

To add further to that, most of the programs on TV are those viewers want to see. The latest "trends" of the people have so much influence on TV programs here. Of course, the private TV stations always have to keep the sponsors happy, so it is often difficult, but how about NHK, the biggest public broadcaster and by far also the largest Japanese broadcaster overall? Why do they have to care about viewing rates? There is no need to worry about pressure from sponsors, so in my opinion, they should concentrate on telling people what we really need to know, from an ethical and moral point of view. I feel they are the only organization that has the capability to truly pursue that job, both financially and technologically, and I believe that is their niche, and their social responsibility. :-)

Monday, October 1, 2007

Comparing the non-profit sector.

With organizations such as Peace Corps and Teach For America getting a lot of attention nationwide, I don't think it's an overstatement to say that the non-profit sector has grown to become one big industry in the United States. Over 1.6 million non-profit organizations (NPOs)... now that's an amazing number.

How about in Japan? Um, not so close. Well... not close at all.

Of course, comparing the numbers directly is unfair and incorrect, since the term "non-profit organization" varies between countries. For example, in the US, hospitals, universities, and religious groups are also categorized as NPOs by the laws over there. But even considering that, there's a vast difference.

Why? Well, I've come up with 3 major reasons.

One, there's no Bill Gates in Japan. Many people in Japan have been complaining of economic disparity in recent years, and though it is true that the gap between the rich and the poor is widening, the difference is still minute compared to other so-called developed countries. After all, Japan has a tendency of giving equality priority over fairness, but this leads to another story so I'll stop with this here... Anyway, when I say there's no Bill Gates, I mean by there are no billionaires in Japan. So compared to the US, there is much less money people can give away.

Two, there's a big difference in law. While I've already pointed out that the definition of NPO covers a more extensive area in the US, there's another big difference: tax. In the US, if you donate to an NPO, you're exempt from paying tax for the amount that you donated. In Japan you're not. Actually, a similar law exists, but has only been applied to about 30 NPOs so far. Simple, but big difference. No wonder big companies and billionaires in the US give off a lot of money to foundations and other NPOs if they don't have any big business plans for the near term.

Three, the culture and values of the people are different. I can list many examples here... One example is, in Japan, though many people are often angered by the way the government handles its responsibilities, the people still put a lot of trust on them. For instance, in the US, the majority of people would prefer to cooperate with NPOs than a government-affiliated organization such as USAID, but in Japan, many would prefer to work with JICA (the Japanese counterpart of USAID) than NPOs. Same with the regular private, business sector. For example for cellphones, the majority of people still prefer to use NTT, the successor to the communications arm of the government.

The religion is different. Donations and charities play a key role in religious activities in the US such as in Christianity, and religion also remains a big part in one's life, or at least bigger than in Japan. Here, the majority of people don't care too much, which can obviously be seen from the fact that there are as many Buddhist temples as Shinto ones and many people don't have preferences about which to go to. Of course, this is more complicated than I've said, but I won't get off track for now. People donate to temples, but the money flow stops there. The temples don't do charity kind of work. I also feel something like a natural "charity culture" in Christians.

Then there are differences in values. I think more people care about being socially responsible in the US than in Japan. Again, this is just a comparison and I don't mean everyone in the US does and everyone in Japan doesn't. But, here in Japan, more people are concerned about how to make their own lives better. However, this is starting to change though... which is the good news. An increasing number of companies are teaming up with NPOs and publishing corporate social responsibility (CSR) reports. Of course, some do this for the sake of building a better corporate image, but nonetheless, when few companies start, others will have to follow... :-)