Dr. Alina Popa: A Role Model

Alina Popa, M.D.

The people were meant to be cut off from the outside world, but her parents had a “smuggled-in” short-wave radio and they sometimes found the “Voice of America” broadcasts. If you were caught listening to such "propaganda" you were a dissident and were forced into hard labor or even killed. 

A year before the violent 1989 Romanian revolution a sympathetic member of the KGB went a step further and “sneaked” the small family a color TV from West Germany. Thirteen-year-old Alina saw Jim Henson’s Muppets for the first time; her “mouth dropped” as she was “mesmerized.”  

She was able to go beyond the Russian literature that had been available and read American works including, she told me with excitement, "Gone With the Wind,” the saga of one woman’s struggle for survival. She learned about John F. Kennedy and his soaring dreams; how he promised to send men to the moon "before the end of the decade" (with the help, we now know, of Katherine Johnson’s mathematical skills), and it happened. Alina just idolized him.

And she came to “love” American culture. She saw that there was something better outside of stifling Communist Romania. Not perfect, but better. And she saw that there could be freedom to be who you really are, freedom to be who you want to become. 

Buzz Aldrin and the Lunar Module on the moon;
 July 20, 1969 (NASA)

“As a child, you don’t know what you don’t know,” said Dr. Popa, infectious disease specialist, and full-time teaching attending at York Hospital, as we sat and talked. But the innocence of childhood passes. Even as a young teenager, she was aware that things around her were not as they should be. 

“It was a tough life," she said. "We learned how to shut our mouths and never say a word (against the government). Not even to your neighbors, friends, or relatives. You didn’t know who might betray you. We almost never talked about it at home, and when you spoke in the house you whispered because you didn’t know what the walls contained. Outside of the house, (the Romanian President) Ceauşescu is your father. You love him and adore him.” 

Listening intently, it was I who was mesmerized (and shocked). “Were you afraid?“ I wondered.

“No. I was angry and outraged. Knowing that this is not how human beings are treated,” she said. Yet, somehow, she could deal with it, she told me. What she could not deal with was the lack of electricity, the lack of water, the lack of heat, and, especially, the lack of food. The utter starvation.

There was rationing of sugar, flour, eggs, bread, milk, and whatever. You had to stand in line and wait for hours for your turn. But the shelves in the stores in Bucharest were often completely empty. “After a while,” she said, ”you don’t feel hunger anymore. When you are always starving your stomach shrinks.”

Waiting patiently for food in Bucharest in the 1980s 
(by Andrei Pandele)

The long winters were particularly “brutal.” It was terribly cold, the water pipes froze, and fresh food was scarce. It was the same diet week after week, month after dark month. “The only fruit was apples, and the only vegetables were potatoes... and pickles,” said Dr. Popa. 

There might be some pig fat (with no meat on it) and “stinky feta cheese” (kept on the outside balcony). Sneaking a bit of cooked meat, even in the countryside away from the city, could mean death if the (nosey) neighbors got a whiff of it and called the Securitate, the ruthless Romanian secret police.

Summer on her grandmother’s farm was a little better, Alina informed me, with more fresh fruit and vegetables, but she was still usually hungry. 

“It toughens you up. You don’t realize that your childhood is gone,” she remarked. While being forced by the harsh circumstances to grow strong emotionally and mentally she also shot up in height, and her pants and skirts were “always too short.”  

Her parents were underpaid engineers in the large state petroleum industry. They were overwhelmed by too much work and by having too little money. You see, as educated people in a communist society, they were the feared “intellectuals.” People who think for themselves. They could not be brainwashed “to act like sheep.” So the system oppressed them to suppress them...and to try to break them. 

Alina sensed early that education was a way out. She was determined to find something better for herself and she worked hard; she knew what she had to do. At 14 she passed the difficult exam to get into “the best high school in the country.” She did her homework by candlelight and her vision was permanently affected as a result. She was drawn to the sciences and had a special feel for mathematics. In fact, she was headed for a career in math. That is, until something happened.

At 15 she got “super, super sick.” It was summertime, and she went to the mountains with her father. She loved hiking with him and she was delighted to be in nature and free. But the weather suddenly changed (as I know it can in the mountains) and following the chilly hike she became ill with fever and congestion, maybe “strep pneumonia” (as she reflects on it now). 

Hiking in the Carpathian mountains in Romania 
(Mihai Constantener)

There was no money for her to see a doctor, and her condition steadily worsened. Her right eye became red and swollen. She became increasingly lethargic. Then unarousable. Her eye was (literally) “popping out.” 

Her frightened parents rushed her to the hospital where she had “signs of meningitis” as she had orbital cellulitis (an infection behind the eye, probably spreading from sinusitis). 

Alina was admitted to the pediatric ward but she was already a lanky 5’9” and there was no kiddie bed big enough to cradle her. One of the doctors gave up his own sack so her feet didn’t hang unceremoniously over the end of the mattress.

She rested and was on antibiotics for three weeks, and they saved her vision.  But while she was in the hospital something else occurred; she “fell in love” with medicine. She liked the smell of the hospital, she liked the cleanliness, she liked the food. She said she “just loved it.” She talked with the nurses and the doctors and asked them lots of questions “all the time.” She made up her mind on the spot and boldly told her cautious parents that she wanted to become a doctor. 

So, in the tenth grade, Alina changed her course of study from math and “heavy-duty” physics to biology and chemistry. The chemistry came naturally; it was all logical (”you count”). But “memorizing” (non-logical and messy) biology was a “struggle.” Dr. Popa is proud of her accomplishment, however, as she finished near the top of her large class.

She then began six years of medical studies (three years of theory followed by three clinical years) at the prestigious (and international) Carol Davila University of Medicine and Pharmacy in Bucharest.

Students hard at work in the ornate Carol Davila library
 in Bucharest (from Euroeducation.net)

But by the time she was 20 she became disillusioned with what she was seeing in the Romanian hospitals. Communism was gone, yes, but there was still incompetence, greediness, overt corruption, and misogyny. This was clearly not what she was dreaming about, not as the daughter of “fair and honest people who were not willing to be greedy and sell out.”

The border was open now. If you could speak English and pass the standard “Step 1” and “Step 2” exams you could practice medicine in the U.S.  So Alina decided to learn the “difficult” language (with unusual spelling and “a lot of “nuance”) and take the required tests.

But there was no money. Not for the exam fees. Not for an English tutor. And not for the (anticipated) airplane fare to the land of liberty, to America. What to do?

Her father knew his daughter’s goals, and he reassured her. He calmly told her that his grandmother had left him a valuable piece of land in the foothills of the mountains; the mountains where Alina became ill and found her calling. He would happily sell the property and give her the proceeds, more money than he could ever make himself. There was never a doubt about what to do; her parents, she noted, were completely selfless.

So Alina bought second-hand books and studied intensely (she “ate them alive”) for the exams. And she learned English. Not with an expensive tutor, but by herself.  With the fall of communism, she could listen freely to American music on MTV (when that was hip) and VH1 (for the slightly less cool). She learned how to pronounce the words by listening to music on the bus.  (Probably not the best way to pick up on “nuance.”)

Dr. Popa paused and told me that her father passed away three years ago (her mother still lives in Bucharest).  She cried as she recalled his memory, and his love for her, even as he reluctantly but generously let her go. As he let her go to find herself.

Anyway, she had to leave Romania briefly to go to Budapest for the Step tests. It was her first real travel experience. The city was “so beautiful” she told me. Bucharest had similar beauty once, “like little Paris,” she said. But much of the historic district filled with many homes, churches, and synagogues, was destroyed by the monstrous Ceauşescu “out of hate for religion” to build his €3-billion Palace of the People. 

The grandiose administrative "Palace of the People" 
in Bucharest (from Rick Steves)

Alina was anxious to finish medical school and leave the place that caused her so much pain. She was one of many who simply had to escape. Four million hurt people left, most of them for other parts of Europe, many for the New World.

I wanted to know how Dr. Popa and her well-mannered six-year-old son Gabriel came to be sitting together with me in my living room in York, Pennsylvania, rather than somewhere else in the country.

Alina left Bucharest behind and came to the U.S. in 2000. She had arranged for several interviews for a residency in internal medicine. The first was in Chicago at St. Joseph’s Hospital (with Northwestern), on Lake Shore Drive. It went well, and they offered her a three-year position before the “match.” She quickly accepted. 

Dr. Roberta Luskin-Hawk

It was at the Catholic hospital overlooking Lake Michigan, while interacting with students, that she discovered that she “loved teaching.” She knew “from that moment on” that she wanted to teach (a second unexpected calling). One of the attendings she most admired and “loved” was Dr. Roberta Luskin-Hawk, a prominent infectious disease specialist who, she said, “believed” in her. 

(Alina had been attracted to microbiology in medical school because “the Latin names [of the bugs] came naturally” to a native speaker of Romanian, “a Romance language.”)

Through watching and emulating Dr. Luskin-Hawk, Alina learned how to treat patients with one of the most feared infectious diseases of our time, HIV. She took care of Chicago’s stricken gay community and the area's mostly-poor injection-drug users. (In Communist Romania there were no gay individuals at all, she noted, without a hint of irony.)

After bitterly-cold Chicago, she applied “all over” for a  fellowship in infectious disease. She landed in warm sunny Miami at Jackson Memorial Hospital for two years of study (on a J-1 “exchange visitor” visa). It was there that she met the “beautiful” and “damn smart” Jamaican-born physician, (and second special role model) Dr. Lorraine Dowdy. 

Since Jackson was a regional referral center Dr. Popa saw complex cases involving immune-suppressed transplant recipients from across the South and HIV patients from the Caribbean, mostly migrants from Haiti and the Dominican Republic. 

On her “awful” visa she needed to take a so-called “waiver” job after her fellowship. That usually meant working in primary care for an underserved population or in an underserved area (“where nobody wants to go”) for three years before being allowed to apply for permanent resident status.

She was quite happy in 2005 when they informed her that she could satisfy the requirement by practicing in her specialty of infectious diseases in the under-resourced and impoverished downtown area of York.  She was made the medical director of the York County Health Center. This is supported by federal funds from the Ryan White (CARE) Act of 1990 (co-sponsored by Senators Edward Kennedy and Orrin Hatch--when working together across the aisle was doable and appreciated) that provides community-based grants for direct HIV services. 

While at the Center she took care of many patients with HIV (thankfully, a generally manageable disease now) and many individuals with hepatitis C (95% curable).  Dr. Popa also worked at Family First Health in the city and she taught residents from the York Hospital programs and medical students from Penn State and Drexel. She showed, yes, showed, them how to understand and navigate the specific and difficult challenges of caring for the underprivileged. 

Poverty and HIV (CDC Data from 2007)

(The risk of HIV infection through sexual contact can be reduced by more than 90% by use of the pre-exposure prophylaxis-or PrEP-antiviral drug Truvada. The monthly cost for this in the U.S. is $2,000 but only $8 in Australia. But as of June 2019, commercially insured individuals can receive it at no cost under the Affordable Care Act. It is currently underused.)

Shortly after receiving her cherished Green Card in 2011 Alina received a call from Dr. Kevin Muzzio at York. He was aware of her efforts in town and he told her that there was an unexpected opening for a full-time teaching position at the hospital. She eagerly accepted the offer, and she has been at WellSpan since 2012.  

The root of the word "doctor" is the Latin "docēre" or "to teach." And the essence of teaching is communication. Dr. Popa strives to connect with her students and residents and inspire them to develop the skills of critical thinking, careful analysis, and proper weighing of clinical data. And how to apply this to compassionate and individualized patient care. She hopes to serve as a role model for the next generation of physicians.

As Schwenck and Whitman (1987) have said: 

Patients feel that the most important characteristics of a physician that lead to high patient satisfaction are knowledge, understanding, interest, sympathy, and encouragement. These equally worthy qualities of an excellent teacher lead to high learner satisfaction.     

With this academic position (no long nights at the hospital), she has enough time to be an attentive mother too. 

(You see, I first met Alina at our JCC pool when I looked up from an especially slow lap and saw her gently and calmly interacting with Gabriel. I sensed that she was a physician and I took a chance, got out of the water, and introduced myself. I guess I recognized a doctor’s manner. I don’t understand how I knew this, but I just did.)  

Gabe’s half-brother, Edward, by Dr. Popa’s brief first marriage, is 15. Dr. Popa was busy and had been single for a while when she met her current husband, a Romanian physician, here in York through a mutual colleague. They are very happy, and she believes that “after 20 years” she belongs here.

(The interview was over and Alina was preparing to leave with her son [I think he was tired of patiently waiting] when she stopped and softly confided in me that she was “a little bit Jewish, too.” Her maternal great grandmother had escaped the Nazis in Transylvania.  She married a German and converted to Christianity, but she still baked “Jewish delicacies; breads and pastries.” I sometimes braid a challah for Shabbat, and hearing this nearly made me cry.)

Anyway, her harried residents have been known to exclaim: “Nothing fazes Dr. Popa.” 

She admitted, yes, that she can “put up with a lot of stress” and "still have a smile" on her face. 

Knowing her story, we can see why.


Reference:

Schwenck, Thomas L., M.D and Whitman, Neal A, Ed. D The Physician as Teacher. Williams & Wilkins, Baltimore, 1987, p.12.



Watching intently and learning:

"The Intubation" 
by (physician) Georges Chicotot (1868-1921)

And...

Dr. Alina Popa and family in front of the  
Liberty Bell at the National Constitution Center

By Anita Cherry 
November 22, 2019 (exactly 56 years after a very sad day for our country)

Gracia Etienne, MD, PhD: He Lives in Two Worlds

Gracia Etienne, M.D.

As he carefully cut the sutures the scissors snapped in half. They were designed as disposable instruments but they were sterilized and reused many times and the metal deteriorated. Seeing this, the usually sturdy surgeon “cried like a baby.” Sure, he noted, even in this third world country of his childhood, such one-time-use tools would be disposed of. But, “at one time.”   

(If you prefer, you can listen a reading of the story here.)

When he returned to York from the medical mission to a northern part of Haiti he asked the OR nurses to let him sift through the surgical “waste” before it was discarded. Items that have no value in one place may be prized elsewhere.    

Even now, more than ten years after that 2008 mission,  Dr. Gracia Etienne told me that he is moved when he thinks about the simple surgical tool that fell apart in his hands. 

Before that, he had been content to go on a volunteer medical mission every now and then. But was that enough for his terribly suffering country? To do more, he said quietly, he “needed a sign.”  

On Tuesday, January 12, 2010, at exactly 4:53 p.m. local time, a catastrophic magnitude 7.0 earthquake occurred 25 kilometers west-south-west of Port-au-Prince. Buildings crumbled and many thousands of Haitians lost their lives. “Okay,” he said, “I wanted a sign from above, but that was too big!”  

Map of the 2010 earthquake (www.britannica.com)

A week later, with plenty of medical supplies in hand, he was in Haiti trying to help. When he returned a bit later he wondered if he could do more. He decided to start a small orthopedic clinic. 

His boyhood home was damaged by the quake, with visible fissures in the walls, but it seemed safe enough for temporary use, and his father offered it to him. Dr. Etienne’s bedroom served as the OR, the living room was the recovery area, and the porch was the waiting room. “We did what we had to do,” he said. 

His father, a successful rice farmer, then saw what was happening and told his son that the people, his people, needed what he was offering. The grateful surgeon perceived this, too, and admitted that he was “hooked” as he gently ministered to the wounded. 

But before we go on with the rest of that part of the story we need to go back to the beginning. So...   

“How did you become a doctor?” I asked Dr. Gracia Etienne as he sat next to his wife Manotte in my living room.

“By default,” he simply said. In Haiti, he noted, there were three good options after finishing secondary school. You could go into medicine, you could be an engineer, or you could go into agriculture. The smartest students chose to attend medical school. 

He was bright, sure, but he was young and undecided about what to do with his life. So those who knew him best “pushed” Grassi into medicine. And once he started on that path he “fell in love with it” and “there was no going back.”  

He finished the first year and a half of medical school and was “living the Haitian dream” and had direction. But this was 1986 and the country was experiencing a period of severe economic strain. Tourism was affected by HIV, and the entire Creole pig population (the source of much of individual Haitian's income) was sacrificed (after U.S. pressure) due to feared spread of the African swine flu virus.  

Haiti's perfectly adapted Creole pig (from "The Star") 

There were violent strikes and political uprisings, and the ruthless and corrupt dictator “Baby Doc” Duvalier was forced into exile. Making things even worse, there was the beginning of a crippling embargo.  After awhile Gracia “couldn’t take it anymore.”

So in February 1988, at age 21, he put everything he had into two suitcases and moved to the States; he landed in New Jersey where he was “totally alone.” With only a visitor’s visa, he could not continue his education as planned and it took a year to get a permanent visa and a Social Security number so he could move on. During that difficult time between the two visas he “did a lot of crying”. But he was determined. He drove a taxi, first in New York, and then in New Jersey, to save up for college. 

With the needed documents finally secured, Gracia then studied biology at Seton Hall, signing up for as many credits per semester as was allowed. Halfway through his second year, he took the test for medical school admission (the dreaded MCAT)... for practice. He said he did “extremely well.” 

So, after only two years of college, he then decided to apply to medical school early... for practice. Unexpectedly, he was granted four personal interviews. 

And he was handed a letter of acceptance and a scholarship to Penn State Hershey (pause for this)...at the end of their interview. They then gave him a train ticket to get back to Jersey so he could avoid another tiring bus ride (His sinuous trip to Hershey from East Orange had been through the night to get him to the early morning interview on time.) 

“Were you surprised?” I asked.

“Yes, I was, “ he humbly replied. Dr. Etienne said he does not think he is smarter or more polite than the guy next door. Or that he behaves any better. You see, he has a very strong religious faith (grounded initially in Catholicism and now Pentecostalism) and he believes the hand of God guides him. 

So he entered medical school here without a bachelor’s degree in anything.  He had cautiously waited until then to tell his father “the truth.” That he was not actually planning to come back to Haiti, as he had led his family to believe. (His older brother was set to enter medical school in the U.S. but didn't go.)

Haiti remained under the economic embargo (that was in place for 14 years), and without the ability to trade the high-quality local rice with the rest of the world, his father’s business started to fail. Gracia needed to help. So, for nearly two years, as he studied medicine full-time during the day he worked in the Hershey sleep lab almost full-time at night to be able to send money home. 

He admitted that as he manned the sleep lab he could study, yes, but that he often fell fast asleep, a no-no. (This reminded me of the famous scene toward the end of one of my husband’s favorite movies, "Dr. Strangelove": Peter Sellers, as the president, trying to break up the confrontation between the American general and the Russian ambassador, demands firmly, “Gentlemen, you can’t fight in here! This is the war room!” As in, “You can’t sleep in here, this is the sleep lab!”)  

War room scene from Dr. Strangelove (from latimes)

Anyway, during medical school, Gracia had time to volunteer at a nursing home (maybe Haitian days are longer than 24 hours, I just don’t know). And it was here, as he saw many gratifying recoveries after hip surgery, that he “fell in love with the restoration of function.” And he decided to “go for it.” 

He first thought about being a trauma surgeon but was put off by “the lifestyle” (see Dr. Nikhilesh Agarwal's story, “Trauma Surgeon without his Mask”) and chose orthopedics instead. 

He did a five-year ortho residency at Downstate Medical Center in New York and he “clicked” with prominent spinal surgeon Dr. Paul Brisson. They got along well. They bantered in French in the OR and got away with saying not-nice things about the clueless others in the room. Even as a second-year resident, Dr. Etienne's technical skills allowed him to do major surgeries. He enjoyed the work.

Paul Brisson, M.D.

After New York, he went to Johns Hopkins for a fellowship in adult reconstruction. He then stayed on in academics for a few more years as a clinical professor.  Dr. Etienne operated on patients at Sinai Hospital In Northwest Baltimore (that was founded in 1866 as the Hebrew Hospital and Asylum), published a few scientific papers on osteonecrosis, and taught the orthopedic residents. 

But he eventually looked around, and deep inside himself, and wondered, “What am I doing here?” He told me that this activity was not fulfilling; that he felt he was “faking.” He was unhappy, and the residents he worked with sensed that. A few of them were rotating through from the Memorial Hospital in York and they told him about the OSS (Orthopedic and Spine Specialists) group. Gracia was interested. He spoke with Dr. Vince Butera and Dr. Brian Bixler about joining the practice and, after five years in Baltimore, he left and moved to York. He’s been with OSS since.

He does shoulder surgery, hip procedures, and a lot of total knees. “The hip and knee replacements are two of the most successful procedures we offer now,” said Dr. Etienne. He said that we should try to protect our knees from “micro-injury” since this is the cause of “most of the osteoarthritis we are dealing with.” Running is a major culprit, and “there’s no need for it (as we get older).”  Being overweight and having a knee deformity are also important risk factors for the development and progression of knee arthritis.

The non-surgical treatment of osteoarthritis of the knees is intended only to relieve pain; no medical treatment, no treatment at all, has been shown to alter the course of the disease. 

What can be done before the surgeon takes over? The authors of the 2013 guideline from the American Academy of Orthopaedic Surgeons favored the use of oral NSAIDS (or nonsteroidal anti-inflammatory drugs) such as ibuprofen or naproxen, topical NSAIDS, and the weak opioid and serotonin/norepinephrine-active drug tramadol, for control of pain. They did not argue either for or against acetaminophen, opiates, or steroid injections. But they recommended against the use of glucosamine or chondroitin sulfate or even hyaluronic acid (Synvisc) injections.

When these symptomatic treatments are not enough to ease the pain the orthopedic surgeon can, in Dr. Etienne’s words, “offer the solution.”   The success rate of surgery is about 90% and the materials of the prosthetics have improved so much recently, he said, that total knee replacements now last at least twenty years.
 

Total knee prosthesis (medlineplus)

As I listened to this gentleman from Haiti, the only country established by a slave revolt, I wondered what his experience has been with respect to race and racism here. So I asked him.

"I can sense (‘institutional’ racism) and I can easily brush it off,” he said. But he noted that it is much harder to do that when he, himself, is the target of overt bigotry. 

He told me that when he was in Long Island tending to a local man who had broken his tibia the patient suddenly demanded, ”Get your (insert the skin color of your choice here) hands off of me!” Reacting swiftly, and with purpose, Dr. Etienne quietly asked the nurses to leave the room. 

He then firmly addressed the belligerent patient and said, “You are here to see me. I am not here to see you. If you need my help I am going to help you. But you cannot disrespect me.” He then took hold of the man’s misshapen leg with both hands and reduced the fracture; the patient winced but did not utter a single word.  

As I heard this I felt a squeezing sensation in my chest. I was ashamed, and I apologized to Gracia. I was saddened, knowing that we have not moved beyond our dark national history of racism. That more than 55 years after Dr. King’s speech, we are not able to judge people “by the content of their character.”

March on Washington for Jobs and Freedom 1963

Anyway, where were we? Let’s continue in York. 

It turns out that Dr. Etienne’s young son went to a church-based school and when Gracia met the very busy couple who ran it, the Revs. Wendell and Juanita Burden, he “fell in love” with them. Night and day, weekdays and weekends, they have been taking care of their “relational” Pentecostal congregation located in a poor section of the city. Dr. Etienne joined them, studied, and is now an ordained pastor in their church. And (in his spare time, I assume) the Reverend Dr. Etienne hopes to unburden the Burdens.

Meanwhile, to give back to his people (who have still not recovered from the 2010 earthquake and were later hit by hurricane Matthew in 2016), Dr. Etienne, with his wife, founded the non-profit foundation MIVO in 2009 (the website can be found here). They built and then added on to the small outpatient hospital since then. Their goal is to “bring orthopedic care to the underprivileged in Haiti in the name of Jesus.” 

This is Gracia’s passionate calling as he arranges week-long missions to the hospital every three months and brings a volunteer medical team of about a dozen to join him. 

A few reliable Haitian nurses manage the hospital in his absence and stay in touch with him by phone for difficult cases. When he and the others are expected to be in attendance the people line up all the way to the road (the hospital is set back a good bit) and wait for hours. 

The MIVO orthopedic hospital in L'Estere, Haiti (MIVO) 

Dr. Etienne and his colleagues were scheduled to have a session this month but the situation in L’Estere and Port-au-Prince is currently too dangerous.  According to the New York Times, “violence and economic stagnation stemming from a clash between the president and the opposition are worse than anything (the Haitians) have ever experienced.”  Thousands of protesters are filling the streets, seeking to chase out another corrupt leader. They are blocking the main roads and creating chaos and mayhem. 

So, as this is being written (late October 2019), Dr. Gracia Etienne is stuck in the Dominican Republic, the country making up the western half of the island of Hispaniola that is shared with Haiti. He still hopes to provide his simple orthopedic clinic with much-needed surgical supplies, including plenty of “disposable” scissors, and to return there himself when it is safe. 

But the immediate future does not look promising. One may need to rely on faith. 

Please stay tuned.

Or in French: S'il vous plaît restez à l'écoute.

And in Haitian creole: Tanpri rete an kontak.


References:

1.  Isaac, Harold, and Kohut, Merideth. “All but Poverty and Despair is at a Halt in Haiti.” New York Times. October 21, 2019. Section A, page 1.

2.  King, Martin Luther 1963: archives.gov/files/press/exhibits/dream-speech.pdf  

3.  Lozada, Carlos. "Osteoarthritis." Medscape. Updated 10/21/19.


Recommended Reading:

1.  Allport, Gordon W. The Individual and His Religion. The MacMillan Company. New York, 1950.

York Water Company Reservoir Park 10/27/19 (SC)

Anita Cherry

Dr. Nikhilesh Agarwal;Trauma Surgeon Without His Mask

Nikhilesh Agarwal

“Why is the FBI looking for you? What haven’t you told me?” she demanded when her soon-to-be husband came home from on-call duties at the hospital. In “the most off-handed way,” and with absolutely no concern, he told her that they are not looking for him. 

There was no more to be said. But the next day the FBI agents returned, asking questions. Once again, he quietly told his fiancée that they were not looking for him. The third time the feds appeared at the door they admitted that they had the wrong man; they were after a different Dr. Agarwal.

Dr. Nikhilesh Agarwal surmised that the FBI did a full background check on him when he applied for U.S. citizenship. There was, thus, no more for him to say. Though he is a “private person” he is “not secretive,” and he had nothing to hide from them, or anyone else. You see, he has no interest in, or talent for, deception.      

Dr. Nikhilesh, or Nik (as he is affectionately called by his colleagues) was raised in New Delhi. His father, a strict vegetarian and observant follower of Hinduism, had moved to the teeming city from the foothills of the Himalayas for a university degree and to start a family.  He worked in the federal government in an import-export licensing division. He went to law school while he was working. 

Beautiful quiet foothills of the Himalayas

He didn’t practice law, but as he witnessed “rife” bribery and corruption in the government he could not be silent. Nik noted that this “very very strong sense of self-righteousness” often got his father into trouble. He would say something, be investigated, and then suspended without pay for months.

A busy, noisy, not-so-beautiful, but vibrant street in New Delhi

Young Nikhilesh was the fifth child in a family of eight (seven brothers and their baby sister), and yet he felt that he was the “heir apparent” to carry on his father’s religious practices. But, “intellectually, it never added up” for him, and he became an ever-questioning skeptic. Though he says a prayer in the morning (out of respect for his father) the rest of the day he is “a committed atheist.” (This reminded me of food journalist Mark Bittman’s suggestion about first trying to be a “vegetarian until six” before diving in fully.)    

Moving on. “How did you get into medicine?” I asked.  He couldn’t really say. But from the time he was about ten, when his father was not in good health, he knew that he wanted to be a doctor. Not just any doctor, but a cardiothoracic surgeon! He took a “straight and narrow” path. He did the required one year of college before the five-and-a-half years of medical school in New Delhi. 

He came to the U.S. at 23. He did an internship at the poorly funded D.C. General Hospital, the only "public" hospital serving the District (until it closed in 2001). He notes that “they had the dubious distinction of being sued for not having a CT scanner” (in the late 1970s). 

D.C. General after it was closed
and was turned into a temporary homeless shelter  
(from "The Washington Times")

Dr. Nikhilesh moved on from there and did a full general surgical residency and a cardiac fellowship at Maimonides Medical Center in Brooklyn (“the largest kosher hospital in the world then” and a major innovator of cardiac technology including the first pacer). This was followed by a heart fellowship at St. Vincent’s Charity Medical Center in Cleveland in 1977. 

But as he looked to the future he (correctly, it turns out) sensed that advances in the medical treatment of heart disease would greatly reduce the need for surgery. So he changed direction and took advanced training in trauma at the Shock Trauma Center in Baltimore, the world’s first facility dedicated solely to the treatment of trauma.

As he told me his winding story, I wondered why Dr. Nikhilesh picked such an obviously high-pressure, technically difficult, messy, and emotionally demanding surgical specialty. So I asked him.

A trauma bay at the end of a messy case  

“I just liked trauma,” he said softly. And then added, “When you have Asperger’s you don’t notice it’s hard.” 

Asperger's? Now I definitely needed to know more. 

It seems that Nik “always” felt that he was somehow different than his brothers; that he was socially awkward; that he was just not interested in what people were up to; that he could easily walk away from things that he liked; that he doesn’t “suffer” feelings of guilt; that he may ignore the people that love him; that he doesn’t return phone calls from family when he knows he should, etc. 

However, despite his constant searching for self-knowledge, he “didn’t connect the dots,” until three or four years ago. “The lightbulb went off,” he noted, when he turned on the TV one day and accidentally caught an episode of “The Big Bang Theory.” As he carefully observed the main character, Sheldon, he said to himself, “This is me!” 

He immediately went online and answered one of the many Asperger’s screening questionnaires. Well, as it turned out, he didn’t have enough of the required behaviors to make a diagnosis. But he was (and still is) convinced that he lies somewhere “on the spectrum.” 

Lorna Wing, F.R.C.P.

(Medical writer Steven Silberman noted that it was the psychiatrist [and mother of an autistic child] Dr. Lorna Wing [1928-2014] who first used the term Asperger's syndrome [in 1981] for "high-functioning" individuals with the autism traits. Traits that she concisely identified as being difficulties with social interaction, social imagination, and communication.  This was not a standard diagnosis until 1992 and it was removed from the DSM V as a separate condition in 2013.

Wing also coined the term “autism spectrum” which “provoked pleasing images of rainbows and other phenomena that attest to the infinitely various creativity of nature."  She said that “all the features that characterize Asperger’s syndrome can be found in varying degrees in the normal population” [Silberman, p. 353].)

Anyway, this sudden and unexpected insight into his brain's social and emotional wiring caused Nik to reflect on some of the decisions he made over the years: 

Maybe working every other night and being chronically sleep-deprived was not such a good thing for his family. Maybe leaving his family at a social function to “fend for themselves” while he rushed off to the hospital for a sick patient wasn’t the best idea. Maybe not taking a real vacation every now and then wasn’t helpful. Maybe advising a patient’s anxious family members to go home for a rest when their loved one was still unstable in the ICU came off as unfeeling or uncaring. 

Maybe he could have done things better if he just knew more about himself.     

But what he did know, and early on, was that he could do surgery. That he could manage the complex, stressful, and sometimes chaotic situations that trauma may present. That he loved what he did. That when he was taking care of patients he was in his element. 

R Adams Cowley, M.D.

While finishing his training in the cauldron of downtown Baltimore with Dr. R Adams Cowley (1917-1991), the well-known trauma pioneer, he received inquiring phone calls from York. Neurosurgeon Dr. Ronald Paul and general surgeon Dr. Thomas Bauer wanted to recruit him to start a trauma service for the area. 

Dr. Nikhilesh drove north on Route 83, settled in York and carefully developed and grew the complex multidisciplinary program. However, there were (territorial) politics involved in the process of accreditation, and it wasn’t until 1986 that York Hospital was designated as a regional trauma center. Nik led the team and served as director until 2000 when Dr. Keith Clancy was brought in to take over the administrative duties. Nik graciously moved aside.   

The service has been quite busy since its inception (with over 2,000 trauma visits last year). After he was no longer director Dr. Nikhilesh practiced general surgery and enjoyed teaching, and he continued to serve the community as a trauma attending until 2015. His practice has changed since then, as he now does vascular and general surgery as an independent physician. He was cut off from the surgical residents for a while but was recently asked to do some teaching again, and he agreed.  He feels most comfortable “at the bedside.” 

After the tens of thousands of patients he has treated in his career, I wondered if there were any who touched him especially deeply.

“Yes,” he said. There was one particular woman, he recalled. She was a Jehovah’s Witness in her early 60s. She had multiple traumatic injuries (“she was banged up head to toe”) and had profound blood loss. Her hemoglobin was down to a critical 4 grams (the normal is around 12). She refused blood transfusions on religious grounds, and yet she managed to survive more than five months of fluctuating critical illness in the ICU.  But the day after she was finally stable and ready for rehabilitation she suddenly arrested. 

Dr. Nikhilesh was at an early morning surgical conference when he was informed of the shocking event. He instantly “knew” that she had a massive pulmonary embolism. (He had thought about placing a vena cava filter to prevent this well-known late catastrophe after trauma, but he was worried about causing bleeding.) He immediately left the conference to rush to the patient’s room. He did an emergency bedside thoracotomy; he opened her chest to resuscitate her and remove the clot. 

But she could not be saved. He mourned her loss for nearly a week.  This was the only individual he truly grieved for other than his father (who died while Nik was in medical school).

(Pulmonary embolism may cause 10% of late deaths after trauma despite measures to prevent it.)

The most common causes of early death after trauma are devastating brain injuries (about 50%), where the neurosurgeon is urgently needed, and severe blood loss with vascular collapse, shock, and multiple organ failure (about 35%), where the general trauma surgeon must quickly survey the situation to identify sources of bleeding to control them as soon as possible. Dr. Cowley, building on his military experience, developed the concept of the first “golden hour” after trauma, during which aggressive care is most effective. Time is critical, and many lives are saved by rapid and coordinated high-level trauma care. (The survival rate at Shock Trauma, for example, is close to 97%.) 

How common is the problem? Very. Trauma is the leading cause of death in the U.S. in those under 45, and the third-leading cause of death in those 45-64. It is an extremely serious (and apparently underfunded) health problem.

CDC: Causes of death by age group (unintended trauma is in blue; suicide is in green)

The surgeon leading the team--and it takes a large and dedicated team of doctors, nurses, and support staff--needs to have a cool head and the ability to size-up and control a situation efficiently. And it helps if he (or she) has a calm and reassuring demeanor, as Dr. Nikhilesh has been said to exhibit by those who have watched him work.

(Princess Diana, I recently read, was awake and responsive after the tunnel crash. But she was treated on the scene for an hour before being taken to a hospital. She died as a result of critical blood loss due to a “small tear” of a pulmonary vein that “should not have been fatal,” according to an autopsy. On the other hand, when President Reagan was shot he was immediately rushed to a trauma center where he was stabilized within 30 minutes despite massive bleeding due to his chest wound.)

While researching the advancements in trauma surgery I watched an interesting TED talk by Australian Dr. Russel Gruen entitled “Playing God; A trauma surgeon’s view on death vs. science.” He first sought God's help when he was an intern; he returned from work one day to find policemen at his door. His brother had been in a hang-gliding accident. He died. He was 21, and now he was gone. Dr. Gruen found that God could not help. 

During his ten years as a trauma surgeon he has looked for divine intervention from time to time, but, sadly, he hasn't seen it yet. However, he sometimes experiences technology coming to the rescue. But when it does not, as is still too common, and the patient gradually succumbs to their injuries, “life, on the way to death, looks like dusk.” The busy trauma surgeon witnesses much sadness.

The progress in acute trauma care in recent years includes the quick transfer to a level 1 trauma center (as the York Hospital has been designated since October 2009), bypassing closer but less well-equipped facilities, rapid resuscitation with blood products (not just fluids, as had been the practice), better control of bleeding (including use of topical agents such as QuickClot, that promote rapid clotting at the site), timely CT scanning, early definitive surgery, and concerted efforts to prevent contamination (since sepsis is a major cause of late deaths), among others (that are way too technical to mention or for me to understand). (Yes, that was a complex sentence about complex tasks that need to be done at nearly the same time.)

Getting back to our subject, Dr. Nikhilesh confided in me that he is a “surgery addict.” What does that mean? For example, after one grueling 40-hour trip to India by himself, when he finally arrived it was two in the morning local time, but four in the afternoon body time. He told his brother (a physician) that he was “so tired that the only thing he was good for was some surgery.” (I think he was exaggerating for dramatic effect, but I’m not sure…)

[How to cope better on long cramped flights? Maybe chair yoga could help.]

Seated forward fold pose (Paschimottanasana)
 from JURU: "8 Airplane Yoga poses for a long flight."
(I still can't breathe!)

(At 115 minutes into the interview, Dr. Nikhilesh’s cell phone rang. He hesitated at first but then looked at the screen and answered. It was his brother. Nik said he would call him back “in a little bit.”) 

What is on Nik’s mind other than cutting people open and patching them up and sending them on their way? Well, he worries about us. “The human experience is cursed (in its seeming unchangeability),” he said. And “we never really know ourselves. And other people see us and (try to) interpret what is going on in our brains (but) they will never know.” 

So he is frustrated as he learns that what we know about others, even our loved ones, is often “completely wrong.” For instance, when his wife sees him and says, “Why are you angry?” and he isn’t angry at all, he wonders (how often this misinterpretation happens).  “Others don’t see us with the microscope we think they have,” he said.

Because Dr. Nikhilesh feels that he has the Asperger traits of social awkwardness and a relative lack of empathy he has worked diligently to improve his listening skills and to be more aware of, and sensitive to, the feelings of others.

He reads a lot and thinks deeply. He is concerned, for example, that our children are “taught the 3Rs” but remain unschooled in the “advances in psychology (including the psychology of well-being) over the past one hundred years.” Advances that help us understand ourselves and our role in the essential interconnectedness of the world. 

Eastern philosophy informs Dr. Nikilesh that conditions beyond him are (mostly) in control (of what happens next), that there is always cause and effect. 

According to a 2018 Medscape article: 

Individuals with Asperger syndrome have normal, or even superior, intelligence while demonstrating social insensitivity or even apparent indifference toward loved ones. Indeed, individuals with Asperger syndrome have accomplished cutting-edge research in computer science, mathematics, and physics, as well as outstanding creative work in art, film, and music. Many prominent individuals (e.g., Albert Einstein) have demonstrated traits suggesting Asperger syndrome...An unknown number of adults with Asperger syndrome may be undiagnosed for their entire lives.

As Nik strives to learn more about himself, about who he is at the deepest level, about his inner self, his patients and colleagues may be comforted in knowing that they are with the precisely right Dr. Nikhilesh Agarwal; that there is no mistaken identity.

The Bhagavad Gita, the sacred central text of Hinduism, states:

“The wise work for the welfare of the world, without thought for themselves...perform all work carefully, guided by compassion” (3:25-26).


Bibliography:
  
1.  Brasic, James Robert. "Asperger Syndrome." Medscape. February 13, 2018.

2. The Bhagavad Gita: Introduced and Translated by Eknath Easwaran, 2nd edition. Nilgiri Press. Tomales, California, 2007. 

3.  Silberman, Steve. NeuroTribes: The Legacy of Autism and the Future of Neurodiversity. Avery (an imprint of Penguin Random House), New York, 2015.

4.  Rhee, Dr. Peter. Trauma Red: The Making of a Surgeon in War and in America's Cities. Scribner. New York, 2014.

The first verse of the Gita and commentary in Sanskrit in 
"Illuminated Manuscript of the Jnaneshvari"
Artist: Unknown; Indian; 1763
(photographed by SC at the Virginia Museum of Fine Arts)

Anita Cherry