Dr. Courtney Howard, MD

Although I trained mostly in large academic centres, I’ve spent much of my medical life practicing at the remote end of bumpy highways.  There is an elegance to it—an instant humility brought about by limited resources, a ‘we’d better stick together or we’re sunk’ solidarity amongst staff that evaporates much of the posturing that can invade hospitals. As an ER doc in Yellowknife, home of the most northerly CT scanner in the central part of Canada, I work in a relatively urban context but am 1600 km away from my referral center, and part of my job is to take calls from nurses and MDs at even more remote nursing stations in fly-in communities in the high arctic.  Consequently, my husband, pediatrician Dr Darcy Scott, and I are both used to filtering the management of critical patients through the lens of what is possible with a limited formulary of medicines and bedside labs.

The main reason for us to go to ASRI was to provide clinical mentorship during a leadership transition.  Head MD, Dr Nomi, was leaving to start the process of applying for specialty residency (the Indonesian medical system is similar to Canada’s old system: all medical students graduate after a year of internship and can work as general practitioners, with the option of applying for a specialty residency after a year or two).  The rest of the ASRI medical staff are quite early in their careers—so ASRI wanted to make sure there was a more senior doc around to provide guidance as Dr Nomi left.

It was a bit of a last-minute trip so we didn’t have time to do much more than get our own vaccinations in order before getting on the plane.  It having been about 8 years since I practiced medicine internationally, I was conscious of the need to review the diagnosis and treatment of malaria, Dengue, and Japanese Encephalitis, TB, etc once we arrived. What surprised me while we were there though was how little those diseases ended up being part of our work, but conversely, how much our end-of-the-highway experience allowed us to be helpful at ASRI.

ASRI’s physical structure has a hugely positive impact on the feel of medicine in Sukadana. We pulled up at ASRI’s new hospital, walked up the steps into its open-air waiting room, slipped off our shoes in accordance with Indonesian custom and took in the wall-sized panel carved with trees and orangutans and flowers with “ASRI” at its heart that is the centrepiece of the entrance area. There is something about attention to beauty in healthcare settings that increases my confidence that those institutions get it—the messiness, the art, the humanity of health and caring.  I found out later that this panel was carved in Bali and was Dr Kinari Webb’s gift to the new hospital.  It set the tone for our visit, and I suspect it similarly frames the experience of the patients seen at the hospital. This serves as the entryway to the best-feeling hospital I’ve ever worked at—seedlings and gardens surround open-air hallways with large images of Nature—orangutans, icebergs, a catalogue of local ant species– that end—not in a parking lot—but in greenery with an unobstructed view of one of the local hills. You could actually jump down out of the end of the hallway and simply walk into the forest.  It’s beautiful.

Our first day we met a flurry of people, took in our first morning meeting, and then started sitting in on patient interviews and reviewing challenging cases with the docs.  The hospital’s current testing options are slightly broader but similar to what is available at Northern Canadian nursing stations—complete blood counts, urinalysis, bedside glucose, EKGs, TB and Malaria smears, and bedside ultrasounds.  The electrolyte and blood gas machine and XRAY are set to come online soon.

Life in medicine is characterized by so many “holy cow—what do I do now?” moments that it’s almost startling to arrive in a new context and realize that you more-or-less know what you’re doing. At home we often care for Indigenous patients with the help of translators, so the interview process with Indonesian patients felt quite familiar, and the decision-making around treatment and transfer at ASRI is very similar to that in Canada’s North.  The biggest additional wrinkle turned out not to be tropical diseases but instead involved ability to pay. Patients from many villages receive deep discounts at ASRI and all are able to pay for both care and medicine with alternatives to cash (seedlings, manure, etc), but in the case of patients who needed referral to Ketapang or Pontianak for further testing or specialist consultation, many were either not yet covered by national health insurance (the government has a target of universal coverage by 2019) or were unable to cover the cost of travel and therefore not willing to go. My only other experience with a medical system where patients had to pay for at least some treatment was during my ER residency rotation at Shock-Trauma in Baltimore. I had not enjoyed the way every single medical decision had to be filtered through the lens of ability to pay there—and I didn’t enjoy it here either, despite all of the efforts that ASRI has made to make care affordable.

So then…how best to treat a patient that you know needs referral to a larger centre but who cannot afford to go?  My first afternoon we saw a 17 year old patient with a known seizure disorder who had missed several days of his seizure meds, seized twice in the AM, and then developed an inability to speak properly, and came in with a decreased level of conscious that varied between a GCS of 4 and 8—with a low-grade fever.  There was no history of trauma.  In any context, the differential for this presentation is huge—and was even bigger here: Dengue, cerebral malaria, Japanese Encephalitis—none of these were impossible.  He needed to be intubated and put on the highway and transferred to a higher level of care for the works—blood cultures, a CT head, a lumbar puncture, probably an EEG. And….he could afford none of these.  As this reality became clear, and I looked up Dengue Fever on Uptodate, a standard reference for us in Canada and the US, and beheld a list of diagnostic tests that were mere wishful thinking in this setting, I was filled with a familiar rage at healthcare disparities.

I realize, writing this, that this is phrase that comes with age—familiar rage.  The first time I felt this anger I did not calm down so quickly.  In fact, it was the reason I joined the board of Canadian Doctors for Medicare.

In any case, in the clinical context, one must push those thoughts aside for another day. We re-loaded the patient with his seizure med, covered him for meningitis, got a malaria smear (which was negative) and watched him carefully.  My belly felt awful all afternoon.  He was so young.

And then he woke up. He was able to walk, but according to his family wasn’t responding normally.  Darcy pointed out that when Lori Billinghurst, the pediatric neurologist who visits Yellowknife regularly, is doing her other job at Boston Children’s hospital, they often hook seizure patients up to continuous EEG monitors and discover ongoing seizure activity when the patients seem to have an unexplained deficit.  So we gave him a small dose of diazepam to see if we could break a mostly subclinical seizure, but it didn’t make a difference.  We kept him for a few days on Ceftriaxone, in case there was a bacterial infection, but eventually he wanted to go, and so he did.

The patient had not returned to baseline and I still don’t know what was wrong with him.  He and his family seemed satisfied with the care—but this is a frustrating situation as a physician.  I am encouraged by the Indonesian government’s goal of universal health coverage—it will be interesting to see how situations like these change over the next couple of years.

There were many patients we could care for though.  I accompanied Dr Alvi as he did an 18 week ultrasound on a pregnant woman, who was very happy both to be able to have this done in Sukadana, and when Alvi let her know that she’d likely be adding a girl to her family of 3 boys.  We saw cases of asthma and croup and diagnosed geographic tongue on a feisty 3 year old, and a tonsillith in a 38 year old woman.  There was a young woman with a clearly enlarged thyroid who was back after stopping her thyroid meds, and a young boy with nephrotic syndrome and congestive heart failure—both of whom we referred on to receive care in Ketapang.

I noticed that many patients had initially been seen elsewhere.  Dr Mike, who has taken over from Dr Nomi as clinic manager, says that is common.  He explained that when ASRI started up in Sukadana in 2007 it was the only health facility in town, but since then a government clinic has opened up.  All patients can go to that clinic for free because of regional health coverage, but a percentage of them later come to ASRI either for a second opinion, because ASRI’s formulary of stocked medication offers more options, or because they have participated in other arms of ASRI’s work—the chainsaw buy-back program or goats-for-widows, etc–and view ASRI as their natural home medical home. It’s interesting how ASRI’s initial raison-d’être was to provide healthcare in a situation where there was none at all—and it is now joined by the government clinic in providing care to a still-underserved population while providing a comprehensive planetary health resource for the community.

The docs round together twice a day on inpatients, which is a good chance for clinical teaching.  It was fun to round with Darcy while he was there—we don’t often have time for in-depth medical discussions in the context of our ER-Peds consults in Yellowknife.  It gave me a different view of his development as a clinician and educator.  It’s nice to confirm that one’s husband is a pretty smart dude.  He put the docs through an informal neonatal resuscitation course over 4 afternoons while he was there, which was timely as ASRI’s maternity program opened up a few months ago. We were lucky to have him for a week and bit—but he then had to return to Yellowknife to do pediatrics call.

After Darcy’s departure I took over afternoon teaching sessions—we went through pediatric emergencies. They received my classic ER-doc’s diatribe about the importance of vital signs and paying attention to red-flags and do-not-miss diagnoses, and then we started into cases.  Respiratory emergencies, neurological ones, peds abdo badness—we hit the high points, and in doing so discovered that my kids could be reasonable standardized patients if given enough candy.  Elodie does a particularly realistic impression of severe respiratory distress.  It was fun teaching: ASRI is lucky to have bright, highly-motivated young docs—I could see their progress over the course of my time there.

As in many other rural contexts, the medical community at ASRI spends quite a lot of time together outside of hospital hours.  They welcomed us into their social midst and couldn’t have been more considerate of Elodie and Vivi, variously providing snacks, carrying them, holding an umbrella overtop of them so they didn’t burn in the equatorial sun, and one time trailing us all the way home from the beach on a scooter in order to light our path as we biked. We had wonderful adventures to the pool, the beach and the hills with the group, and have returned home with incredible memories of a warm medical community doing ground-breaking planetary health work—in an absolutely beautiful context.

Until the next time, Team ASRI.  Thank you.

Medical Life at ASRI: medicine at the end of a bumpy highway.

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