Small World and Memories Past

Dear N. you sweet old lady,

I have only the faintest memory of you. I am told passionately by those close to me and to your family that I spent the better part of my childhood fiddling around in your house with your children's children. Now that, I do remember. You see when I was some 7 years old, I was infatuated with your granddaughter Z., P.'s daughter, A.'s sister. 

I have to look back, well at least at what these people have told me, and sit in wonder at the way our lives parted so long ago, and how they were brought back together on that fateful afternoon.

You are an ill lady, poor old N., 

I was surprised a few times to come across your name on our inpatient records. Always wondered how you were doing. Always wished you the best. 

I was surprised on said afternoon to see your name on the ER patient list. 

I was awestruck a few hours later as I heard your monitor beeping. Code Blue. 

I was there, in your final moments. I was helping. We fought hard to bring you back. It wasn't to be.

I was gutted, as your grandson A. said in no uncertain words: "let her go".

I am sorry. There was nothing more we could do.

I was tearful when I got out of your room.

I was torn to see A.'s face after all these years, calling the family with the news. Bluntness was the order of the day.

My dearest N. you see the people you have helped create, have made our life so much better. And from faint memories and tales told, you were keen to see us grow. 

I hate it that we had no chance to get reacquainted. 

My dearest N. 

May you rest in peace.

Thoughts go out to Z. my first childhood crush. and A., The ER physician who supervised resuscitation efforts on his own grandmother in steadfast composure, professionalism, and, ultimately, realism. You are an inspiration to us all.

The Bitter End

They called me to your room, I saw you for myself

I saw you, and my self was torn

Who you remind me of, I dare not say

The consequences I dare not see

Your habit, got the best of you

But you of it, have the worst end

And they will be there, to hold your hand

Your loved ones, till the bitter end

Themselves miles more torn than me

Written for a dying mother...

It all starts with a nodule...

We are taught by life to greet people with courtesy; always smile and say something nice, always ask how people are doing. You enter a sick patient's room on the morning rounds and say something like: "Hello sir, how are we doing today?", and hope for some optimism and a smile in return. Try doing that on the oncology wards. On a few of my first patient visits on the oncology floor, I was caught off guard by a 38 year old patient with a body torn up, on the inside, by a uterine cancer. Now in the terminal stages of her disease, N. answered my question in a way I was never ready to handle.
- Me, entering the room for the first time, smiling: "How are you today Mrs. [...] ?"
- Her, stating the obvious, pointing at her distended, asymmetric, diseased abdomen: "Well, how do you think I'm doing?"
Realizing the retrospective absurdity of my question to a woman with a mass the size of a basketball inside her, and many other little ones scattered around her frail and broken body, I froze for a second, and nodded, with my stupid, embarrased smile still stuck to my face, and proceeded to interview and examine her, gathering a few pieces of information to write my stupid little note in her chart.
How? How can you be pleasant to a dying person? I'm still learning here... perhaps learning that oncology is the single most impossible specialty for me to work in. Oncology, cancer, that indiscriminate, slow killer that catches persons and tosses their bodies around for seeming ages.
Cancer means you see your patient on Friday and think he's doing a bit better:
- Mr. H, a nice and unfortunate old man: "Thank you doctor for coming to see me, it makes me stronger"
and then you go away for the weekend and on Monday you hear the news that Mr. H passed away on Saturday, his son's wedding day. They tell you that Mr. H's son had been pushing since thursday for a discharge so that his father can die in his hometown, and to kindle a glimmer of hope that his father would get a chance to see his son get married, even if he has to feel this fatherly pride in a wheelchair. No such luck.

It's too much for me to handle. Too much to see this losing battle day in day out, too much to see so much suffering. Too much to see so much harm coming from what started as a small nodule, a small blip on a chest radiograph... Not for me.

Modern Medicine and Cruelty... The Positives?

Read Cruel Discussion and Modern Medicine.

I've talked and talked and rambled on about the disillusionment one stands to feel during one's progression in physician training over the years. My avid readers will remember the "Ladies and Gentlemen, Your Future Doctors!" 'saga'. If you don't, check out Part I and Part II. (Does time fly or what?).

Anyways in the second part I go on about how you lose this sense of idealism, this cleanliness, if you will, that people commonly associate with medicine. Now some one and a half years down the line, this incident comes and reshuffles my perception of the world of medicine and what it all stands for.

In the OPD (Out Patient Department) we care for patients on a visit-to-visit basis. It is usually the least expensive form of healthcare, and so inevitably we get to see the less fortunate patients who are paying petty fees for consults with doctors in a high-ranking hospital. The ramifications of this, which I will save for another -long- post, and the experience of such 'encounters' sometimes shakes you to your core. The socioeconomic aspect that we never really come to face on the ward floors with high class (I hate to say it) patients is a rude awakening to say the least. So one of my last patients in the OPD Pediatrics rotation was K. an 11 year-old boy whose chart (We view charts before meeting with patients) said that he had growth failure. As I read more and more pages, and came across more and more test results and differential diagnoses, I got to the note that was written when K. had last visited the OPD clinic. At the time (some 2 years ago) he was diagnosed with Laron-type dwarfism. In brief, Laron type dwarfism (also Laron Syndrome) results from a mutation of the Growth Hormone receptor, and a subsequent Growth Hormone insensitivity leading to failure of growth due to severe IGF1 deficiency (IGF1 mediates the action of Growth Hormone).

The Visit

K. walked into the room and I immediately saw his prominent foreheaed (typical of the syndrome). To me he looked like a 4-5 year-old toddler, physically, and somehow even though I knew about his condition, I was still dumbfounded when he greeted me with a noisy low-5 followed by a firm handshake worthy of a grown man. Or when I heard his 11 year-old voice and his 11 year-old vocabulary. Or as I saw his 11 year-old movements manifest in a 4 year-old body. His 11 year-old self confidence, assertiveness, and demand of autonomy also struck me as he insistently forbid his mother from answering my questions for him. I think I've stressed it enough, it was one hell of a surprise, despite the fact that I knew about it.

K. was without a doubt the most pleasant patient I've had during this rotation. He had a persistent contagious smile that revealed a set of run down, crooked and decay nibbled teeth. He made jokes, played with my stethoscope, and everything else he could find in the room. The whole interview and physical exam took place in a light atmosphere and in the best possible conditions. NOT to be soon forgotten.

Of The Sadness of Reality
One promising modality for the treatment of Laron Syndrome is recombinant IGF1 (marketed under the name Increlex in the U.S.), which can bypass the action of GH on its deficient receptor, thereby restoring growth satisfactorily if treatment is initiated in a timely fashion.
Sadly, Increlex is unavailable in Lebanon. And apparently it is a very expensive drug, which as you might have concluded makes it a problem for an OPD patient struggling to pay even the LBP 10,000 OPD fee.
As documented in K'.s chart, K.'s mother was told about this treatment when they had last visited OPD. She was also told that it was not available and that there was no way she could afford it even if it were. She was coming a couple of years after that visit in the hope (in her own words) that "Dr. N had something new for her and her son".
- Dr. N: There still are no significant efforts to market the drug in Lebanon.
- Mother: Oh.
- Dr. N: As I told you last time we are trying but your son's condition is so rare that it's hard to find proper treatment here. And the expenses would be just impossible.

Dr. N once again sent K. and his mother home empty-handed. I could not tell whether the expression on the mother's face was one of disappointment, helplessness and resignation, or of expectation.

My Reactions and Thoughts

I was deeply saddened by this outcome and for a brief moment I felt helpless and ashamed that we had to send a patient home after telling him in no uncertain terms: "there is a drug for what you have, we're sorry but you just can't have it". So what are the issues here? I mean after stepping out of that personal, humane, human, emotional roller coaster ride of a first reaction, what are the circumstances that need to be discussed?

We hear a lot every day about how medicine has been commercialized to a degree where incidents such as these are possible. We also hear about how shameful it is that medicine is a financially driven institution. And what we hear most are the sad individual stories such as the one I've told you in my long and by now surely boring account. But what is the bottom line? If anyone knows me they know I'm a bottom line kind of person. So what is it in this case?

Well the bottom line, stripped of all emotion, all sentience, and all humanity, is a sad realization that money is and always will be a major, major factor in the drive for research of all kind. Putting all of this baggage aside, a patient is buying a product (in this case a drug that is the result of years and years of expensive research and trials), in order to use that product for personal reasons.

This is how impersonal and desolate the bottom line of modern medicine has become. And to me that's all that matters because there simply is no point trying to discuss how and why it comes down to this. So is it correct to assume that my disillusionment has surpassed all the good that medicine has brought and is bringing to this world? That in the end it can be boiled down to a simple transaction between a care provider, a pharmaceutical company, and an ill person?

The answer is a resounding NO. To me there is always a positive side to this. One positive side that will not be affected by the source of motivation of pharmaceutical companies, is that no matter what happens, medicine will always strive toward a common goal. And that common goal (besides, of course, the financial rewards) being what it is, which ranges from the curative eradication of disease to the palliative nature of the most trivial of pain medication, I can confidently say that medicine does more good than harm.

Sure, unfortunate patients will benefit less than others and K. here is a prime example. But if we consider the long term outcome of the situation, we are hard-pressed to see that had there not been this monetary incentive for research, Increlex would have probably never seen the light of day! But the bottom line is that it HAS. As a result of this, we HAVE a drug, it IS helping SOME people and maybe one day this drug WILL be available to everyone. I will go out on a limb here and say that an inevitable period during the life of this drug (and this applies to all drugs and forms of medical treatment or diagnostic tools one can think of) when it will be administered in a discriminate fashion among patients is only an obstacle, a hurdle that we will overcome in our drive toward global availability and affordability of the drug. This situation now is better, in my humble opinion, than not having any drug at all, and I would be surprised if anyone argues otherwise.

Sad. But true.

Cruel Discussion and Modern Medicine

Overheard at the OPD Pediatrics Clinic between physician and a patient's mother.

Mother: What can we do Dr. N?

Dr. N: There is a new and effective drug for what your son has. But it's too expensive. Neither you nor I can afford it.

Mother: So what's the solution?

Dr. N: ..........................................

P.S. I will elaborate on the case soon.

No Comment...

No comment, because I can't say how it feels to connect with someone like you do when that someone is your patient. And even less when you spend hours in that room talking and talking and end up wondering if you'd ever meet someone as interesting, as insightful as them, and with a story as captivating as theirs...

There's no describing it. Much like there's no describing what it felt like when I got this note after saying goodbye to Mel, who was leaving the country for good. It felt like saying goodbye to an old friend.

Goodbye Mel, All the best.

First LVAD implant in Lebanon - The misconceptions surrounding a highly successful operation

"A team of AUH surgeons has successfully carried out the first artificial heart implant operation in Lebanon, saving the life of a 37 year-old man and father of four".

That is the claim of many renowned media sources in Lebanon. Click here to read the official AUB article by Maha al-Azar.

I'm currently, and incidentally, on the Cardiothoracic surgery rotation at AUH. Yey me. I was surprised by a phone call on Thursday night and a friend screaming at me for not telling them that the first "Heart Transplant" in Lebanon was performed at AUH. Shocked, I thought to myself, there's no way I didn't hear about that one!! Then came another call, another newspaper article, another overheard conversation... All with one, or two, or three things in common... The misconceptions, the misconceptions, and the misconceptions. I just thought there were too many scientific blunders on the part of the media and their reports have been massively misleading at best. The following is a roundup of the misconceptions I thought people should be aware of...

Misconception 1 - This is NOT a Heart Transplant...

...And even if it were, it would not be the first one in Lebanon. The first heart transplant in Lebanon (a real heart transplant) was performed at the Hammoud hospital in 1999. Click here to read about that.
This is an LVAD, or Left Ventricular Assist Device (more on that later) implant. The original heart is still in place!

Misconception 2 - This is NOT and Artificial Heart Implant...

This is an LVAD (Click here), NOT an artificial heart. Let me explain. An LVAD, as its name implies, is a pump that merely assists the biologic heart in its function. It neither takes over its function nor does it replace it or completely take over its role. It ONLY assists it in its function by taking some of the work off its back... The biologic heart is still in place, functioning properly with the help of an assistant, if you will.

The implanted LVAD.

An Artificial heart, the Jarvik.

In contrast, an "Artificial Heart" is... well... an artificial heart! It is a complete heart-like pump that replaces the biologic heart, which is taken out of the patient on the OR table. It is still an experimental technology with only limited success in the United States.

Misconception 3 - This is NOT a life-saving device...

The AUB article also states that the operation saved the life of the 37 year-old patient. I am sad to point out that this is not the case. An LVAD implantation is what we call a "bridge to recovery" or "bridge to transplantation" procedure. This device is designed to help keep cardiac performance at an acceptable level for a limited amount of time pending one of two events:

- The recovery of a mildly diseased heart as a result of decreased workload afforded by the LVAD: Bridge to Recovery.
Or:
- The availability of a matching donor heart for transplantation: Bridge to Transplantation.

The LVAD used in this case was the Heartmate II by the Thoratec corporation and is claimed by Thoratec themselves to be able to provide circulatory support for only up to ten years. Now keeping in mind that these ten years are the result of the most optimistic and optimized calculations, it is clear that we should be expecting 5 to 10 years, more realistically, before there is a need for a new intervention. And we would still be optimistic in that we are neglecting all the possible complications that the poor guy could face.

I am not trying to rain on anyone's parade, and least of all the patient himself or the thousands of others with heart problems. I just think it's a shame how the media are having a field day with his story and modeling it, be it willingly or unknowingly out of lack of scientific knowledge, to fit the textbook picture of a world-class achievement in medicine, or that of the wonderful doctor or hospital saving lives by the millions. That this life has been saved is simply not true, and while I am truly ecstatic that this operation took place where I work, and even more ecstatic to see its success and the time it gave our 37 year-old father of four, I cannot emphasize enough how much of a temporary solution this is for our patient, who is, at the end of the day, whom we should think about before anyone or anything else. I can only hope he and his family know what the future holds for them.

This is a milestone in the practice of Cardiothoracic surgery in Lebanon, one that I am proud to witness during my young career. I just can't stand it being taken out of context in this manner. The authors of these articles and their sources shoud be reviewed.

The Emergency Room... Oh the Anarchy!

If I had one word to sum up the ER and what comes through there in a day, it would be Chaos. But it's amazing. Challenging in a way I could never have imagined. It took me 2 days to realize that what you can learn in one day of an ER clerkship really amounts to more than you will learn in 2 weeks of patient care and follow up on the ward floors. There is no comparison. You can see, examine, process, and discharge 10, 15 patients a day with ranges of problems so varied it'll make your head spin!

On any typical day you can see:

-The prissy church choir girl (girl being a serious misnomer here, seeing as how she was 74, but hey...) who "burnt" her hand trying to put out a blanket, placed a bit too close to a candle, caught on fire near the church store room. She had two of her fingers covered with melted nylon which stuck after cooling down. She came to the ER not because she had a burn, but because she had no idea how to remove this thing of DEATH that had entrapped her silly fingers!!!

And then minutes later...

-The poor 24 year-old construction worker (A.) who had a 6-kg rock fall over his head from the top of a 9-storey building while he was out for a walk on his break. He sustained multiple fractures of the skull, and was brought to the ER with his mashed brains pouring out the top of his head. Scientifically speaking, and to put things in perspective for my med readers, the brain CT report was significant for multiple skull fractures reaching the base of the skull, severe depression of a part of the calvarium deep into the brain causing midline shift, trans-tentorial herniation, and severely increased intracranial pressure with all of its sequelae.

We stabilized his vitals after 3h of fighting and 4 L of I.V. fluids.

The poor guy died in the ER exactly 48 hours later.

This is a small idea of the spectrum of sights and colors we see on a day at the ER. But what struck me the most is surprisingly not the patients. It was not the drama, the excitement, the rush of dealing with life and death. It was the patients' families. Why? It became apparent to me how everyone saw nothing but themselves, nothing but their own, and just dismissed everything and everyone else in complete and utter disregard.

As poor A. was expiring in Trauma 1., we were also handling a patient (in S2) with mild head trauma. He had been hit by a car at low speed and hit his head against the windshield. He was awake and oriented, and his studies all came back negative, so basically he was fine. All he had left was a small laceration on his forearm that we had to suture before we could send him home. Naturally when the alarms went off on A.'s monitor screaming that he was going into severe tachycardia and O2 desaturation, we all left S2 to go check on A. and see if there was anything that could be done. Obviously there wasn't.

Now imagine this. Coming out of Trauma 1, heavy with heartache and shaken to your core by your first ever encounter with death and a patient who slowly died in your hands, you and your resident take a tough walk out to the ER waiting room and make sure the parents know that their worst nightmares have come true; "we are truly sorry to have to tell you that your son passed away 2 minutes ago. There was nothing more we could have done."

Now imagine walking back into the ER, in that state of mind, to find an obnoxious old lady, S2's grandmother, in a panic, screaming at you and yelling all sorts of nonsense asking you how it was possible for "doctors" to leave his wound uncleaned, knowing that she was coming to see him. She hates the sight of blood apparently.

How could we? how could we have such disregard for her great presence and not have wrapped him up before we tried to help a truly dying person? I don't have an answer to that.

This was even more destabilizing to me when I thought back at A.'s parents' reaction when we told them what had happened. Actually it was not in any way worse than the old lady's panic. No. Even less dramatic in my opinion.

So is worrying about a loved one an all-or-none sentiment? Can anyone worry, but at the same time have as little as an ounce of consideration? Can anyone worry, but realize that there are priorities and that there are always people who are worse off??

The answer is, YES, worrying is an all-or-none sentiment. From the stupid prissy choir girl who came for a hand-cleaning session, to the exceedingly unfortunate A., rest his soul, brought in by the Red Cross with only a few breaths of life left in him, and to the mind-twistingly annoying and naggy fat boy who twisted his ankle and had no signs of injury remotely indicating even as much as an X-Ray, you will be surprised to see that the parents all act in the same craze, the same insanity, and the same "treat-my child-first" attitude. You will be surprised to know that sometimes it is even reversed, that families of patients in dire emergencies will seem more composed and cohesive than families of patients with petty scratches not even worthy of a band aid. And for now, this is what makes the ER stand out.

Patient Insanities on 10 North... Have a Laugh

Well I figured it was about time I shared some more stories about our dear patients on the surgery rotation. Here are the three cases that spring to mind... Actually there's a fourth one, but she deserves a post of her own so come back soon ;)

The crazed grumpy old man on 10 North.

K.H. has been driving all the floor insane for about a week now. Anxiety attacks, flamboyant claims and accusations that make me wanna scream out in anger... To put things in perspective, one of his latest complaints was having a nurse that smiled too [damn] much!! He even told her that to her face! Hilarious and sad... The poor guy has been one of the most complicated medical cases we've seen so far, with several operations, intestinal leaks and what not... Understandable? Granted. But it is still annoying, and yet funny in a marginally twisted sense, if you see what I mean, to hear him complain about things the world of medicine has never known, like diarrhea caused by walking!!

[Note]: "Patient is not doing very well, complaining of general anxiety and unable to tolerate hospital stay. He is pain free and is refusing to take his anti-hypertensives and anxiolytics by mouth. He refuses to ambulate for fear of diarrhea." Making sense are we? LOL

[Plan]: "Start I.V. Lexotanil"

The nice and healthy middle aged Man on 9 South.

M.D. is A previously very healthy, strong man. After extensive surgery, he seems to be recovering nicely, and is happy to see me every time I walk into his room. Always a good sign to see a patient greet you with a smile. It is so rewarding and puts an inexperienced mini-physician such as yours truly at ease and makes the job that much easier. I walk into the room, M. smiles and brags about how well he's doing, is always anxious to show me how good his breathing is getting, or how comfortable his lazy-boy chair is, with its fancy electric recline and foot support functions. Me, smiling "I wish I had one of those at home, Mr. D!!" It has been a pleasure following this one up. He's staying till the end of the week.

[Note]: "Patient is doing very well, tolerating regular diet, passing stools and flatus, ambulating freely and using incentive spirometer as instructed. Bowel movements normal, no pain or discomfort reported upon defecation. Patient is pain free and has no new complaints. Plan for discharge soon."

The distant old lady on 10 North.

S.D. was a 70-something-year old lady we followed up for about a week, some few weeks ago. I had completely forgotten about her, until I met K.H.

She had her own set of problems, like being too good to look at us med students, or letting us examine her without her attitude, or having not one, but two of her private nurses in her room taking care of her and making our lives miserable... Case in point: M. my colleague was about to draw blood from S.D.'s arm. It was her first time doing that, and she was looking for the vein, taking her time to locate it with some degree of certainty. After all, you don't want to poke her majesty for nothing! Some odd 20 seconds later, S. just lost her patience (bear in mind that M. hadn't even picked up a syringe yet!) and with her face turned away from M., called her nurse and said: "ta3e shoufe hayde shou 3am ta3mel sarla se3a!!" Translation "come here and see what this one is doing, it's been an hour!" Priceless!!

[Note 1 ]: "Patient is pain free as confirmed by private nurse. She is non compliant and refused to be examined, claiming that the nurses already gave her a physical."

[Note 2 ]: "Patient is pain free as confirmed by private nurse. Physical exam not done because patient is sleeping"

And for the record, all that the nurses do is take temperature and blood pressure and stuff like that so...

Difficult patients are a real challenge! I still need to work on that area! Something about them shakes my confidence! But they're funny to tell your friends about!

S.D. and K.H. ? a match made in heaven! We couldn't help but try and imagine what these two would be like living together! Imagine the children!!!

Those of you calling out outrage, relax. We're not making fun of our patients. It's not like that. It's just that these few cases are too entertaining to forget. So we document them! See? it's a noble cause! But seriously, they all get the same respect and standard of care... Rightfully so!

Patients: for a change...

I am happy to report that the long awaited feelings of gratification, satisfaction, and sweet fulfillment have come through during these two past weeks of hospital clerkship (the first two weeks in Med III). This is it. What I have been waiting for since I graduated from high school, and even a few years before that, if you will deem meaningful the idealism of a foolish teenager and his noble aspirations to save the world one patient at a time. This quest, this mission, now surely tarnished by disillusionment and eroded by its relentless and savage conflict with the grit of reality, this enthusiasm, and idealism, or what's left of them, is what I am trying to salvage at this time in my life and career. The fact is, I can proudly say that at last, at long last, I have the power to do something about it. I, your dedicated and enthusiastic medical student, now have enough to work with to impact people's lives, no matter how limited that impact may be. Flashback 3 weeks ago: I was just another student in a classroom counting the seconds before it was time to head back home or to the pub for a few drinks. Now, for a fast change, things are different. Let me tell you the story of a patient who made me realize that.

N. is a sweet old lady patient I was following up. She was one sick lady, with heart problems, kidney problems, and diabetes. One of the many, many long term complications of diabetes is peripheral vascular disease. simply put, this means that diabetics have problems in their blood circulation and as a result, there is impaired blood supply to the lower extremities. Impaired blood flow means impaired oxygenation, impaired eventual wound healing, and impaired immunity in the affected area. This is why you see 'informed' diabetics and think that they're anal about foot hygiene. It's simply because they've been informed that even the smallest abrasion or cut to the skin of their feet could result in devastatingly painful ulcerations and invasive infections that could ultimately warrant the amputation of a toe, or even the entire foot or leg in severe cases. What makes it worse is Diabetic Neuropathy, another complication of Diabetes that impairs sensation in the lower extremities, meaning that any wound, abrasion, or developing infection in a hidden area could go undiscovered for months, without the patient feeling so much as a tingle. Read more about The Diabetic Foot and Diabetic Foot Care.

N. had had diabetes for many years, and after an ulcer between her toes failed to heal and got infected, she lost her little toe, which was amputated to prevent the infection from spreading further up her leg with dire consequences. The first time I examined N., she immediately reminded me of my grandmother (Read); an exceedingly sweet, but obviously worried old lady, more open to suggestion than anyone could imagine. Even long years of fighting with chronic disease, life saving operations, and medications, along with a roughed up body both inside and out, had failed to embitter this inspiring character. The best of it all is that all she had to do was smile.

After this introduction it's time I got back to the point I was trying to make. People like N., with limited resources, bad or no insurance, are usually treated and let go as soon as possible. This is the sad reality of health care today, and is something that I'll be sure to write about when time and inspiration permit. The bottom line is that after a successful operation, N. was about to be sent home with her foot well on its way to a full recovery. Sadly, no one really took the time to sit down with N. for a few minutes and explain to her what steps needed to be taken to avoid another visit to the operating room. My group and I (Myself, M, and G.) felt that we could do it. Why not? It is now our duty to care for our patients, examine them, and help in their treatment and convalescence. Why would we not be responsible of raising some awareness and help them also by preventive measures? We went to N.'s room and gave her a talk with a few crucial instructions on how to care for her feet. And yes, this is the essence of what I've been rambling about for the past 3,000 words or so. We did that, and I like to think that we DID make a difference in N's life. Only time will tell, but things are looking up.

M. told me a similar story about one of her patients. She felt the same as I did, but the feeling is a bit new to us. It's something that, deep down, you know is right and that you are 100% sure that you're doing the right thing, but that still feels awkward, for some reason, and you're always worried that it's not your place. Well, I think it is. And I'm sure that if we don't do it, no one will. If we somehow lose this enthusiasm, this 'flame' that sadly has burned itself out in all but the newest blood in the health care system, we can be sure that no one, especially not the hardened veterans with their cynicism, will kindle it back to life. And it is the patients that will ultimately pay the price. Who else?

I said goodbye to N. with a few last minute instructions and reminders, and she told me how grateful she was, and the last words she said before I left will stay with me for a long time.

"Ra7 a3mel metel ma eltelle ya 7akim!"(I will do exactly what you told me to, Doctor!) - said a proud and emotional N. ...