Leaving Bali

Enjoying a last peaceful morning here in the open courtyard of the villa, and then soon it's off to the airport. Last night I stood next to a rice paddy and watched the sunset. The big volcano was out, floating on clouds, and I counted over 130 kites as I slowly turned around. I'm really going to miss this place.

Serious about kites

Several times now here in Bali I've seen kites disappear into low-lying clouds....

Bikinis, fruity drinks, carnage

I've been seeing some very interesting cases lately, including some great teaching cases for the junior doctors. (Unfortunately, I can't share any of the enlightening, poignant, or instructive details here, for fear of the privacy consequences.)

However, I will share my top five tips for safe travel in a tropical surfing paradise (physician-recommended, mother-approved).

• Don't get drunk while on a balcony, roof, or while otherwise not at street level.
• Don't try to ride a motorbike in local traffic unless you really, really know what you're doing. (Or while you're drunk.) 
• Don't try to surf, body surf, or boogie board in circumstances that you're not absolutely sure you can handle. (Or while you're drunk.) 
• Carry a flashlight if you're going to be walking places without streetlights. (Especially if you're drunk.) 
• Don't get drunk while on a balcony, roof, or while otherwise not at street level.

As you can imagine, in the past two weeks I have collected multiple clinical cases to illustrate each of these priceless jewels of advice. However, enough people will never follow these tips that an ER doc will always have job security.

Code bluish

This week I've been teaching an advanced cardiovascular life support course to the junior doctors. (ACLS, in medical certification parlance.) I had just taken them through a role-playing scenario involving a crashing patient, when all of our pagers went off with a code blue (hospital code for a crashing patient). We ran down to the ICU, and I was thinking, wow, best ACLS lesson ever -- well, for the doctors in the course, if not for the patient. But when we got there it turned out that someone had just pressed the button by accident. At least no one could accuse me of arranging a code for educational purposes.

Impressions of Bali

Bali is very, very serious about kites. There are dozens in the sky in any non-urban place you go. They're big, they fly high, and many of them are quite elaborate. Some even seem to have noisemakers attached. Very cool.

Ah, the weather. Tropical paradise, need I say more? Warm enough for shorts and tee shirt 24/7 but not oppressively hot or humid. (At least not while I've been here.) In fact, at the villa where I'm staying the wall between the living area and the pool (yes, the pool) isn't even a wall -- it's simply open, with bamboo shades that are always raised. This is what it looks like from the balcony:

I know they're an ancient and widely-used symbol, but still, the swastikas can be a bit distracting. Passed a restaurant the other day with a stone carving of a swastika above the door, over which was carved "Welcome." [Sorry, no pictures of swastikas.]

But most importantly, the people are just lovely, genuinely warm and friendly. Among the hospital staff everyone is collaborative, and I've detected very little of the ego and competition that characterizes medicine in the U.S.

Really looking forward to the coming weeks here. And what could go wrong? It's not like there will be a demon sneaking up on me from behind to punish me for my sins or anything.

Limited resources

Prior to my recent round of music blogging, the last time I had really recorded music was in the late 90s. Now I'm starting to experiment with all the advances in music technology that have taken place since then, and I feel like a technological caveman who's just been thawed out of a block of ice.

Right now I'm sitting in a villa in a Balinese suburb with a laptop, a pair of headphones, and a few pieces of very inexpensive hardware and software, and I'm able to write, record, and share original music. By current standards I'm working with very limited resources, but still, this is pretty neat.

Ya gotta love the 21st century....

Patient privacy and the end of a blogging era

It's a little hard to believe, but this month marks four years since I started blogging. Despite my occasional digressions (tornado liveblogging, etc.), I've mostly written about the process of training to be a doctor. Along the way I've written plenty about my personal experiences, but I've also tried to convey a sense of some of the larger issues, often by discussing some of the memorable cases and patient interactions I've had over the years.

I believe that writing about these topics is an important part of my being a physician, apart from any clarity or catharsis that it may give me personally. Most of the public's impressions of how medicine works are based on singular, overhyped news stories and misleading fictional portrayals onscreen; almost none of this reflects what it's really like when the majority of us die, lose loved ones, suffer major injuries, or just try to get relief from our ailments. Medicine is a huge, complicated, often impersonal system that interacts with people at their most vulnerable moments. It seems to me that illuminating the process of delivering health care is potentially beneficial for whatever small sliver of the public that occasionally reads this humble blog.

Generally, I've treated the most profound and significant interactions in short essays. I have always tried to do this in the most respectful way: I never reveal details that would identify the patient or situation to an outsider, I never present the situation as comedy (well, unless it's actually funny -- and even then I strive to stay respectful), and my motivation is always to share and illuminate profound experiences of our shared humanity. To the extent I have failed in this, I hope that it is due to my limitations as an author, and not because there's anything wrong with the concept of doing this.

However, a few weeks ago the risk management team from the medical center came to talk to the emergency medicine residents. Their concern is that any discussion of patient care in a non-scholarly context exposes the hospital to legal action (true, unfortunately, in the current “medicolegal” environment). Basically, the message is: don't share your healthcare experiences in a public forum.

Patient privacy is of huge importance; I certainly wouldn't want my private medical details showing up on Facebook. However, I don't think this is what I do. And although I'm certainly not in their company, I don't think that's what Oliver Sacks and Atul Gawande and Abraham Verghese and Lewis Thomas and other medical essayists through the years have done, either. I strive to make every essay that I write about a clinical experience pass this test: if the patient were to read the essay, would they prefer that I had not written it? In every essay I've posted, I believe that the anonymous people whose stories I have shared would feel that I had done them and my readers a service by illuminating the experience. Equally important, I believe that I have followed the first principle of medicine: do no harm.

In any case, the hospital administration has now prohibited us from writing about or discussing anything about patient care or clinical work in any public forum. It's backed by severe sanctions, more than a mere resident physician can really afford to risk.

In the end I plan to practice medicine in the best interests of my patients, and damn the legal consequences. I also believe that my essays matter in some small way to a small number of people, and that they are important. However, after much soul searching, for now I'm going to take down all posts relating to patient care. This is the first time I've ever been censored and what do you know -- I'm backing down. I feel a bit cowardly for caving, since I don't think I've done anything wrong, but I need time to consider the situation.

In the meantime, I'm going to focus more on the music blogging over at Notes from an Open Window. I'll keep writing personal posts here while trying to figure how to adapt to the new situation. And my apologies to the voiceless patients to whom I tried to give a voice.

Ben-Bob in Bali

Settling in here in Indonesia. Still working on internet access in the villa where I'm staying, so this is a quick post from my office at the hospital. We're already into an intense schedule of teaching and the junior doctors are avid learners, so it's very fulfilling work.

I'm hoping that once I get internet access from home I'll be able to post photos, etc., depending on the speed of the connection. I've been asking about where to go for gamelan music, so keep an eye on the music blog, too.

Taipei airport early morning

On my way to my next rotation -- Bali! It's kind of an unbelievable stroke of luck, but I'm going to be rotating at a hospital there giving emergency medicine lectures, doing bedside teaching on rounds, consulting on medivac decisions, and on call for consults 24/7.

I'm posting from the Taipei airport, where I'm transiting early in the morning. No place open for post-trans-Pacific flight rehydration but all the duty-free shops are open and there's wireless, so I guess I can't complain.

Anyway, I've never heard a bad word about Bali and I've never been before, so I'm off to see for myself. Hope to have a reliable enough internet connection that I can post about my Indonesian adventures.

Meanwhile, don't forget about the new music blog. I posted a new recording just before I left, and who knows what I'll be posting while I'm in Bali....