#010 - Dr. Katherine Horan - A Neonatologist without borders

Dr. Katherine Horan is a neonatologist from Baystate Medical Center in Springfield Massachusetts. She has gone on multiple field missions with Doctors Without Borders in West Africa. She recounts her experience in various settings including Chad, South Sudan, Mali and the Ivory Coast. 

She also gives amazing tips on how to get started in global health work for anyone interested.

Enjoy!

As always, feel free to send us questions, comments or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through instagram or twitter, @nicupodcast. Or contact Ben and Daphna directly via their twitter profiles: @drnicu and @doctordaphnamd.

As always, feel free to send us questions, comments, or suggestions to our email: nicupodcast@gmail.com. You can also contact the show through Instagram or Twitter, @nicupodcast. Or contact Ben and Daphna directly via their Twitter profiles: @drnicu and @doctordaphnamd. The papers discussed in today's episode are listed and timestamped on the webpage linked below.

Enjoy!

Transcript

Ben: 0:05

Hi, friends, welcome to the podcast Daphna. How's it going today?

Daphna: 0:46

I'm doing great. My little ones at grandma and grandpa's house. So I don't I'm trying to figure out other than the podcast what to do with my time.

Ben: 0:55

I'm sure you I'm sure you get busy. Before we introduce our guests for this week, I want to announce again that we are having a book club episode that is going to air on August 1. The book, which we encourage you to get is called The Strange Case of Dr. Cooney, how a European showmen saved 1000s of American babies. The beep The book is available on Amazon, audible Kindle, anywhere you can find books it is available. We'll have done raffle the author of the book on the podcast and please feel free to send us questions that we can submit to her by July 23. You can send questions to NICU podcast@gmail.com. Or just send us a Tweet at NICU podcast. This book club is in part sponsored by the med book club on Twitter at med book club one. So don't forget to send your questions and read the book and interact with us. So that's that's really exciting. So this week on the episode, we have Dr. Katherine Horne, who is an Assistant Professor of Pediatrics at Bay State University. And, Kate, how are you today?

Unknown: 2:03

I'm very good. Thanks, Ben.

Ben: 2:05

It's so official. We've known each other for so long and yet this is so crucial.

Unknown: 2:09

are old old friends. I was his first babysitter ever when he had his little daughter.

Ben: 2:14

Usually you say it like that it's so much more than that. It's not that she was our first babysitter. She's the first person we ever trusted with our child. That's

Unknown: 2:29

that's the baby. Yeah. That's huge. I was freaking out the whole night.

Ben: 2:37

Well, Kate, it's great to have you on the show. And I guess definitely do you. Do you want to start or?

Daphna: 2:48

I'm sure I have some questions. I know Ben has some questions. He's He's always refining his very good questions. So but my first question just to get us, you know, started out the out the gate, I think you'll tell us a lot about your life and your experience with Doctors Without Borders. But I guess my interest is kind of learning. Kind of your early, early career. How did you know? How did you get interested in medicine to begin with, and I think that'll tell us a little bit about your interest in global health.

Unknown: 3:22

So I was just one of the lucky ones. I was like five and I was like, Mom, I'm gonna be a doctor. So it just, it was so I really considered a divine gift. I knew exactly what I wanted to do. And I went and tried a lot of different things. But I thought it was just such a clear goal. And then specifically global health. It's kind of a cute story. So I was 12 years old. Did I ever tell you the story, Ben. But I was 12 years old. And I was waiting for a music lesson. And there was a table with a Newsweek magazine article on it. And there was this big pictorial spread about the Kosovo refugee crisis in the 90s. And it was all about doctors without borders and how they were responding to it. And I mean, I was taught I wouldn't read Newsweek, but I was just stuck their waist, you know, with with time to spare and I just I remember reading it and looking at the pictures. And I was like, This is what I'm going to do. And I left this show, listen, and I went to my mom, I said I'm going to work for doctors without borders. And she was like, and, and then almost 20 years like that was October of 2019 95. And then like exactly 20 years later I left for my first mission was MSF. So it just I just knew that I had to do it. And my life would not be complete if I didn't. So I left residency and 2015 and I headed straight to the field with MSF. Kind of having no idea I thought I'd do one mission and I ended up staying for two years. So kind of how

Daphna: 4:52

we should let our kids be bored from time to time they may find themselves

Ben: 4:58

and that's what's interesting. And that's what's interesting about your path, right? I mean, you finished your residency at Baystate. And you were pretty much then a general pediatrician. And you went to the field in Africa mostly, and and then completed two years with Doctors Without Borders, and then came back to the US to pursue a fellowship in neonatal intensive care in Miami.

Unknown: 5:24

So like, how did that all connect? So funnily enough, the reason I am in Unit intelligence is because of MSF, I had no idea when I finished residency that I would be doing this, I thought I was going to do global health policy work. And I didn't, I really didn't love clinical work after training in the US, I found it very tedious, very bureaucratic. And it disconnected me from like the heart and soul of what it means to be a healer. It just felt more businesslike and very punitive. And, but the moment I arrived on my first mission, I just, I just fell in love with medicine, because I felt like I was finally really doing it. And, and so what, what struck me so my first mission was a pediatric intensive care unit for children five and under, and we focused on severe malaria and severe acute malnutrition. So we would routinely admit babies to the unit. And what instantly stood out was that nobody knew what to do with them. If you had a newborn, nobody knew how to take care of them. If they were really under about three months of age, if there was any kind of feeding related issue, they didn't know what to do, getting an NG feet, we just didn't have anything set up for them. And there was little to no protocols for us to follow. I remember using there was this tiny, who Bluebook for field care, there's one chapter for newborns. How to Handle fluids, the most simple things people just didn't know. And we all just panic when there was a baby, especially if it was low birth weight or premature.

Ben: 6:47

And then, I mean, providers, you don't mean parents, providers?

Unknown: 6:51

No, no providers? Yeah. The International physicians, as well as the local staff, we just we were really panicking without the right equipment in place. And it just it was it was really traumatizing, actually, because I felt like we were losing children left, right and center for completely preventable and treatable reasons. We just didn't know what to do in a timely fashion. And then adjacent, what also really stood out was adjacent to our unit, we were on the grounds of a government run hospital. And they did all of the labor and delivery and there was no there was there was just nothing. There was nothing in the realm of resuscitation for babies. So you just saw them just being so mishandled there. And that was really traumatic to see as well just to complete lack. And this was in the hospital with trained providers, and they still had no, essentially no approach to newborn care. You either were healthy or you weren't. You know, you could either get through those first few days of your life with no assistance, or are you just passed? So I just thought, wow, like, how is this happening? Today, anywhere?

Ben: 7:54

It's so funny how we complain about you leave residency fellowship, your first attending job is usually so stressful, and so much pressure. And we have and we say this with the support of all the nice amenities of being in the US. I can't imagine when your first job is with Doctors Without Borders. Which which was that in was that that you started?

Unknown: 8:17

Yeah, this was in Schad. It was on the border of Central African Republic. So pretty remote, historically violent, but it was It wasn't an inactive state of conflict. So it was a it was a nice mission. And but I walked into this unit, it's 65 beds, intensive care with two two bed, two parents and two mother or two babies and two parents in the bed. So you know, we were often over 100 patients with two doctors around. And I just remember I walked in, and they're like, Oh, thank God, the pediatricians here, and I was like, I have no idea what to do. And yeah, I'm like, we're all gonna die, I'm gonna die the kids because that was my first few days. But within a week, what one thing that we do extraordinarily well is is trained people, we just know how to help them, get in and get trained. And it's just extraordinary how we can get things up and running with our organization. We've been doing this for a long time, and it was remarkably easy to come in and just learn a whole new system. So I'll just I'll never forget that first walking into that unit.

Daphna: 9:21

Yeah, you're right. Ben, you know, when you think back to your first few days as an attending, it's really nothing compared to be really out of the system entirely. So I mean, I really respect you for for making that leap. Because I there are, I mean, I'm still not ready, I think to go do what you did. I've been out a few years. So I think that's really tremendous. You You also said you know something that really struck me I mean, the care there is basically the opposite of what we do right? If we're were here in the in the states and well developed medical systems where we do everything If possible, or you know, anything potentially to keep life going, which you know, has its own ethical and moral challenges. But it's, it's, it's almost the opposite of what you faced there.

Unknown: 10:18

Yeah, so I've just feel like I've had the extraordinary experience of being on the true extremes of this profession, I worked in four of the countries that have the highest, they're all top 10 infant mortality in the country, and then I come back to the US. And we don't have the best infant mortality, we are in the top 20. But but we have the highest amount of technology, and absolutely the highest expense per baby. And the word futility comes up a lot in what we do, we will spend a million dollars saving a child with an incurable genetic condition simply because the parents ask us to will do ECMO, when we know the child is probably not going to survive. It's, it's, it's almost like I feel like I split into two identities. There's the me that that did the work in Africa. And then there's the me that comes here. And I try not to let them judge each other too much. You have to kind of keep things in the right context. But I think one of the benefits and the tortures of spending extensive time overseas is just living with the the memories of how unfair things were. And then you come back here, and it's, it's it's really hard. That's the biggest struggle that I think will always be with anyone that does global work.

Ben: 11:34

And can can you give us an example of that unfairness that you're that you're talking about, specifically? Because I think it's important for us to, and for the listeners to understand the magnitude of what you're talking about.

Unknown: 11:47

So like unfairness for babies, globally? Yeah, absolutely. Yeah. Well, I mean, you can look at some basic statistics in talking about newborn resuscitation. So UNICEF and who are two of the best resources and getting a sense of numbers, we're still looking at over 3 million preventable neonatal deaths a year, which is a dramatic reduction from a couple years ago. And they estimate less than 20% of children globally have a truly properly trained birth attendant in the room with them. I remember. So one of my missions was to open a neonatal unit in Ivory Coast. And so we partnered with a group that had already been there, these were experienced nurses and midwives. And when we tried to do a resuscitation course, not one of them could use an Ambu bag. And these were the skilled birth attendants. And, you know, they were trained for this, I vividly remember a midwife telling me not to disparage people's education, but just this is what it was like in the field. I remember a midwife who had been working for like 20 years. And she just said, they teach us how to take care of the mothers, but the babies, we just expect them to be healthy. And this is the woman that's present for the birth, there is no attempt at resuscitation, there was a dusty, dirty, Ambu bag on the wall. But no one would even attempt to you that they didn't even know how. So it was amazing to me, just the lack of prioritization of babies, that I saw, pretty much everywhere that I went, and I don't judge this, I don't want it to sound like these are bad people, they are faced with the impossible decision. They don't have enough staff, they don't have enough resources. So are you going to save the mother so that the other children can survive? Are you going to put it all towards the baby? Are you going to save the father, who's the provider and fix that unit? Or are you going to save a little baby who, frankly, you know, it's really not as big a deal if the baby dies. So that's the attitude that we've been fighting with for first, since the beginning of time is that it is worth saving babies, that is worth doing. Because they have value. And that you can fold this into a medical system, even if the resources are poor. But that's that's the biggest struggle is that the baby's not good to go from the beginning, then they're just not meant to be here. And even now, in the modern age, we're still fighting with with that opinion, and it's due to circumstance. It's not due to malice. I think it's important to see it that way. as sort of a long winded discussion, but the injustice is just, I mean, I was shocked that we had to convince people that this work was worth doing in the first place.

Daphna: 14:15

Yeah, and what about the kind of kind of cultural and societal you know norms around kind of death and dying and, you know, infant and childhood mortality?

Unknown: 14:27

It was very different than what I was used to here. I mean, hear if a mother dies, the hospital shuts down. It's such an anomaly to lose the mother. If a baby dies up. Same thing I remember in residency, it was just if we lost a kid in the PICU, it was just this big deal. When a kid dies, it's a rarity. You can go through an entire pediatric residency and only lose a handful of kids in three years and really same with Nikki does have a slightly higher mortality overall, but even then, I mean, Ben, I think you and I can count the number of infants we We lost during fellowship, and

Ben: 15:02

I know them by name almost. I mean, I totally do.

Unknown: 15:05

Yeah, yeah. And we could sit here and extensively talk about their stories, because there were so few of them. So, but you know, over there, and I remember I remember when I left for my first mission, the Medical Director, I was in the office in Paris, and he just said, Just be ready, you know, it's normal for children to die, where you're going. And those were the words, it's normal for children to die. And that probably sounds really callous, but it is just statistically Correct. You know, the birth rate, or the infant mortality rate in the US is around 5.7 out of 1000 babies, and I went to a country where it was at, so almost 10% of infants die, and in the first 20 days, and so just adjusting to that reality was just pretty amazing. experience, it really is, it's normal, it's a way of life, they still tell women in many parts of the world to have twice the amount of children that she wants to have because up, you know, half of them could pass away before they reach adulthood.

Daphna: 16:06

And, you know, I'm sure there's still, you know, trauma and so much grief in you know, the people who lose babies, they're her see so many losses. But I I imagine it's even more complicated feeling like, but I could do something about it, you know, and they're still dying, even though, you know, I had the training, but we needed the resources, you know, to make it work.

Unknown: 16:33

Yeah. Yeah. So a cultural attitudes about death vary tremendously. You can tell in places where it's more normal. They certainly would grieve, but they would do more. So privately, very few. And it was interesting in three of the countries I worked at, when we would lose a child, the family would usually just, I would explain what happened, they would sell them cry, they would just take the child and walk out of the unit. And I remember being like, why aren't they upset? It was, it was really shocking, they would just be a notable exception to that was I was I ran a refugee camp Hospital in South Sudan as my second mission. So violent warzone and field hospital, kind of the classic MSF setup. And it was a different culture. And those parents would have a very emotional response when the children died. And I just remember, the first time we lost it was a two year old, the mother reached over and hugged me, as she was sobbing, and I just couldn't handle it. It was just too much. And then it was Warzone to have these emotions playing out. So visibly, it really shocked me because the three other missions, everyone was so stoic in the face of death, it was really hard for me to, to handle the visible grief process that I saw in South Sudan. That was that was just absolutely terrible. And we lost about five kids a day on that mission. So it was a huge problem. We actually had to build a separate facility just for the families to go and integrate together. And so it was it just varies, it varies based on where you are, but you definitely see there's there's just more of a sense of normalcy. You know, in the US. One thing that was easier, and it's strange to say that, but because it was more normal, we were never blamed for it. There was never, there's no malpractice, there's no Inquisition, there's no more morbidity and mortality, we would do meetings to discuss deaths just to make sure we hadn't done anything incorrectly. But here, there's often a sense of accusation, there's litigation, even a child who is not supposed to survive when they do die, there will still often be a big whole scene about it and litigation and all of that. And so that was I remember just getting really angry about cases where parents, it just seemed unreasonable. And we'd have kids who had severe genetic conditions, and they were still shocked when they when the child passed away. And so I found that in a way harder to deal with when I'm here, I get angry at what I consider to be a lack of reason on the parts of families, when we lose children.

Ben: 18:58

You mentioned a bit earlier, the work that you started doing with MSF, trying to train midwives and providers to to help babies in the first few minutes of life. I am baffled by by the courage that it takes to do this, because I think my my experience has always been that sometimes the work that needs to be done is so overwhelmingly large that you have no idea where should I begin, what should be our next step, you feel like you're so far behind, that you're never going to catch up. So I'm wondering how do you approach in a very pragmatic and constructive manner, a place that is not just having low resources, but almost nothing? And you say, Okay, this is this is what we're going to begin. And how do you construct a plan to make effective change over significant change over the time that you have a lot of data as well because you're not going there on these missions for an indefinite amount of time. You know, your time is limited. So how do you tackle which How do you pick the issues? How do you tackle them, and how do you try to make your or stay there as meaningful as possible.

Unknown: 20:02

So yeah, that's a great question. So going back to the core of our organization, we we have a policy of 9010 90%, local staff, 10% international staff. So it's not just a group of us flying in for a short term mission, the idea behind all of our missions is that we are employing and paying health care providers, which is often the only work that's really fear. And I mean, South Sudan, when I flew in all of the doctors and nurses we hired Well, there weren't any physicians to hire, but all of the nurses and clinicians, clinical officers that we hired hadn't been paid for about six months there, they were government employees, and they just had not been paid. So we provide critical, you know, resources. And then more importantly, working with us, we're providing training and experience. So teaching and training is really the foundation of what we do. And using clear, reasonable protocols is also the foundation of what we do. So whenever we open an issue, so it's just, you know, how do we approach neonatology? So I'll go over kind of the key strategies of how we like how do you open a NICU in a war zone. It's not, it's not as bad as it sounds, it was actually very reasonable. And our success was extraordinary. Just going back to some general like broader principles, if you look at who there was a great who report in like 2015, that came out, and it estimated that a good 70 to 80% of neonatal mortalities are completely treatable, treatable and curable. And so really, the idea is that most of the children that are dying, just do not have to die. And the interventions, the problems, what we're talking about the interventions for the vast majority are very low cost and very effective. So it's, it's very reasonable work. What you need to do, though, the key challenge, especially with the utility is that you need to properly train people to do it, they need to actually know how to take care of a newborn. And then the harder part is that there just needs to be the right equipment and resources presents. So that's the thing, you know, in an area that's heavy, heavy hit, and just very resource restricted. Even the cheapest medicine, having penicillin on board, having IV supplies, that's where you often run short. But for us on our missions, what we do is we hired 90%, local staff, we extensively train them before they start clinical duties, they go through weeks or days, days to weeks of training with our specific protocols, we have everybody on the same page, we're treating the patients the same way we're running the unit the same way. And, and so yeah, the teaching and training has become just the cornerstone of what we do with our neonatal project. So we just started this, my timing in the field was was perfect, because we only wrote this neonatal protocol in 2015. As I was finishing my first mission, we wrote our first actual neonatal Field Guide, there was one chapter in the obstetrics book, that's what we had been using previously. So lucky for me, I finished my first mission, then I went to South Sudan. And then my last two missions, I was one of the first pediatricians in the field to actually start and operate this neonatal protocol. And it covers everything that you could be doing for a newborn in the field. And so it was just really easy to read, it was really easy to use, it was really easy to teach to other providers. So looking at kind of what we what we were doing. The key elements were just having everybody on the same page, the training, the teaching, and then hygiene was huge, just so first of all, the physical separation of babies, it, it sounds so simple, but simply putting babies in a different space than the other kids. Even if you just find one tiny little room, even if it's like a closet, if you could just put the babies away, that alone cuts infections, and, and then having dedicated providers for them. So that's like number one. And you can do that anywhere, you can clear space for babies anywhere, and you can take one or two nurses and just dedicate them to the babies. So giving them sort of a different separate status was the first thing. So just physically opening NICUs not having them mixed in with other kids and other infections. So that was kind of one of the big things that we would do. And then as far as interventions and pathology is one of the biggest issues was prenatal intervention. So it's hard to run a good NICU if you're not helping with the moms as well. So whenever possible, you try to approach the moms as well as the babies because if you don't get to the moms in times, you're gonna have a lot of preventable problems happening. So just working on prenatal monitoring, picking up on preeclampsia, blood pressure issues, infections before birth, helping to prevent a lot of preterm births. And then most importantly, being in the delivery room. It is really easy to teach resuscitation I know that that seems like the hardest thing to do but that can be done anywhere. And it's very effective. So we used we started using the helping babies breathe doll years ago I apps I use it for my US residents to teach them I think it's better than it was like $20,000 Sim, sim babies You fill it with water, it's very realistic for chest compressions. And it's extremely realistic for, for positive pressure. So really, if you can use the Ambu bag on the stall, you can use an Ambu bag on an actual baby. So the kids are free. This is one thing I really like to highlight helping babies free. So it's from the AAP. It's a branch of it. And it's a project, it's I think it's one of the best interventions of a low cost, but extraordinarily effective global health intervention that has ever come into creation. You can apply for kits, they have training tools, you can get things to hang on the wall in the clinic, it comes in multiple languages, and then most importantly, you can get the doll and it comes with an Ambu bag. So it's a usable, Ambu bag. So you can actually use that in the clinic, you can clean it in between uses, and then you can teach with it, you teach with the mannequin and with the equipment. So so we use that it was the most effective way to teach people and within one hour, I had every single person doing proper PPV, which I would later see them doing properly in the room. So as far as you know how to get there, just start teaching people, the most simple thing you can do is resuscitation training. And that is always worth doing, you are instantly saving lives if you can get that person ready to identify that the golden minute and getting positive pressure. Right? I mean, that's what babies need. If you need an intervention, like how many of them actually are full Cozzi with epinephrine and all of that it's a fraction of a fraction of a percent. What the average baby needs is airway clearance and positive pressure. And you can teach just about anyone to do that. So when I was in Ivory Coast, I think we had over 100 people trained when I was there, and they still give that course, you know, regularly. So that's a perpetuating gift that that is extremely easy to do. So just start with that, that alone, teaching people how to resuscitate automatically shaves off a whole bunch of infant mortality. So you know, you begin with reasonable things. Maybe you can't operate a full, fully functional NICU, but you can always do basic things like resuscitation, herding. So don't lose harpin. There's always similar.

Daphna: 26:54

And that's here, you know, there are, you know, like, they're just providers who may interface with neonates who just don't have the training. And that's something we can extend.

Unknown: 27:07

Yeah, I work a lot with community pediatricians. We're a transfer center in Massachusetts, and this is their number one thing is that, you know, they always panic in the delivery room and forget their skills. So constantly re emphasizing training with anyone is huge. So teaching resuscitation is as important here as it is overseas. So

Ben: 27:23

let me let me take a different a different let's let's take this interview in a different direction, because we've talked about so many serious things. I'm curious when you are on the field, what does a typical day look looks like? And I don't mean, in the unit itself. I mean, like, what time do you get up? When are you expected to like check in? And how do you unwind? After a day, the kind of days you're describing? Like, you're not going on your couch and turning on the TV? I'm just curious as to what is what does it look like day to day to be an MSF physician around the time of your of your shift.

Unknown: 27:59

So it depends entirely on what you're doing. We work in very different contexts. So the traditional context would be like an active war zone and you're in like a tent. And I did a mission like that. So settlers in South Sudan, it was very violent, it was very dangerous. You always live with your colleagues, you're never allowed to go on your own. So you're in a locked compound. So we found an abandoned hotel. And we just like took it over. Yeah, we got a generator, and we had running water. But yeah, I mean, it was just like, lock us out. And we had 7pm curfew. So I would wake up, I was the only doctor on the mission. All of my colleagues worked in the office. So we had a compound in office and then the hospital. So I would get driven by myself 45 minutes across this city. I go through three armed checkpoints, one with South Sudanese soldiers, and then two UN peacekeeping checkpoints to get to my hospital. And I would

Daphna: 28:57

get myself to go glamping so

Unknown: 29:01

yeah, yeah. So I'd be there. From like, like 730 in the morning, and then we would leave at six to make curfew at night. And I just spend the day in the tent with the kids, whatever came through the door, and then it's exhausting. So I mean, I was you're often the only doctor and you'll always be the only pediatrician. So I was I knew that I would have the phone at night and they would call me for any questions. I wasn't allowed to be there at night. It was too unsafe to drive there at night, but I would kind of talk them through things if they came up when I was when I was in the compound and that was seven days a week. So that was you know that's that's just exhausting. Some of the missions are extremely physically arduous and draining but my other three missions were you know, they were they were post conflict or non conflict zones and you still live on the compound but you know, you'll we will do a full clinical day you'll go in and you wake up the rooster wakes you up. You have breakfast with colleagues and And then you go to the ward, some words you would do in Mali and Chad, I would do night call some time. So it's either day shift or night shift, and then you just be there for the children. And always as backup, if you were the pediatrician, long and difficult days, and then as far as unwinding, you do whatever you can, I mean, you're with usually a group of like fun people. So all of the options, there were just cool people. And you unwind in any way that you can. So I would try to like meditate, it didn't always go very well. But that's where I got really into yoga and meditation as a way to escape from it. And I would dream about kind of being home and the life that was going to come after the missions. And it's funny, because I kept when I was in South Sudan, which was really, really bad, I would, I would visualize myself walking on a beach. So I was locked in this cell. And I just kept seeing myself walking on a beach. And then when I was applying for fellowship, I ended up ranking Miami first because like, I have to live on a beach. So I've been seeing this for years. So that is how I ended up in Miami.

Daphna: 31:09

Beach, during fellowships,

Unknown: 31:12

I got a permit, to fulfill that that dream that I had had, yeah. And then just connecting with family whenever we could, like whatever you can do, we watch movies, unfortunately, I mean, with the level of stress, a lot of people like drink heavily, we had to watch that you saw a lot of people unwinding in ways that were unhealthy. So that can be an issue. It's a way of dealing with the trauma and the sadness that you're seeing. So trying to unwind in healthy ways is always a challenge. They require us to take a vacation, which is really a mental health break. If you're in the field for three continuous months, you have to leave for at least 10 days. And they they take you somewhere else that you can rest for a little bit. And I remember thinking this is so wasteful, like how can we do this? These are this is like, you know, donor money. I can't take that for a plane ticket. But by the time I had hit three months on my missions, I was like, Yeah, I need to leave. Can we? When we started doing that we actually our attrition rate skyrocketed. Billy people were able to finish their missions, because they were actually resting a little bit. So that's kind of how we unwind.

Daphna: 32:18

Yeah, well,

Unknown: 32:19

I'm still working on fully unwinding from all of this any day now. With that four years. Anything.

Daphna: 32:25

My question? Yeah. How is your kind of reintegration back to the States?

Unknown: 32:33

Yeah, you know, it just wasn't easy. i In retrospect, going into fellowship ICU fellowship was maybe not the right thing to do. I although maybe it wasn't the right I was so busy in fellowship, maybe that was what I needed. But it took about three and a half years for the daily kind of flashbacks to go away. I just kept reliving painful moments and memories and dangerous situations. And honestly, I that it was I realized, now it's kind of stopped. how prevalent it was, in my mind at all times, just the worst of the worst moments, I just kept reliving them, and everything would trigger them. There's just no part of your life that doesn't somehow connect to something over there. And whether it was professional or personal, I'd walk through a grocery store, I'd had a patient die. Everything just connected back to these, these these painful memories. So it was it was a very, very difficult reintegration process. And I didn't really recognize it as such, because I just kept saying, Well, I got to come home. I'm so lucky. I have no right to complain about any of this. So kind of realizing now what those three years were like.

Ben: 33:40

It's almost it's interesting, because it's almost survivor's guilt, right, even though

Unknown: 33:43

Absolutely, yeah. You shouldn't

Daphna: 33:47

you know, Ben and I have it, we're, uh, we're opening a NICU, and we feel like that is hard. But listening to what, you know, you you went through, really makes ours look like a real a real dream in the park for sure. Like Disneyland, honestly, all the bureaucratic stuff. I

Unknown: 34:09

mean, it's, it's extraordinary. To think about, I think about a lot how in this country, you know, do you? Well, us in our field, we were a little bit different. But how many people know or even know of a woman that died in childbirth, and how many families have actually lost a child under the age of five? This has never happened in human history until really the last like 50 years, that we can live a life of so much comfort, and just such assurance that we and our children are going to be okay. So it's, yeah, well, I'm grateful I wake up every day and I think about how grateful I am for that. So that's the benefit of coming in. So work I do have painful memories, but I have an incredible sense of gratitude and joy, to be here and to be safe and I don't think that's ever good. That's only gotten stronger as the longer I've been out of the field. So that's, that's the emotional benefit of doing this work.

Ben: 35:00

I'm not sure if you read this book, but I can only recommend the book called a good time to be born by Perry class, which basically goes over sort of the history of child birth and, and pediatrics and shows how basically it was the norm, every family was expecting until very recently to lose a child. And the expectations that we have today that you're going to have kids, and they're all going to survive is a very modern feeling. And so if you haven't read the book, I highly recommend it. And we're most likely going to have a book club with her as well. So yeah, I

Unknown: 35:30

want to address here, because I hear a lot of like, what you just said is, I have no right to complain, because you've been through something worse, like, don't minimize the stress that you feel here. It's very real. It's just mirroring what Ben said, it's not normal for a baby to die here, which creates extraordinary pressure on us as physicians, because we know that no matter what we do, there are going to be some moms that don't make it and a lot of babies that don't make it. And the fact that society just does not get that it just makes it so hard for us to do our job. So we're under this stress of needing to be perfect. And that is an extraordinary form of stress. And it's it who's to say that that's any you know, that that isn't as bad as the stress, I feel. It's just different. But they're they're both very genuine and valid forms of stress and pain as providers.

Daphna: 36:17

I wonder to some of the, like you said some of the bureaucracy here and in medicine and you know, the patient physician relationship. I you guys are doing so much in so little time over there. I wonder what it's like to come back to the states where even a simple policy or protocol change can take meeting after meeting months after months, when you guys are building entire units in that that same timeframe. So like you said, a different kind of strap.

Unknown: 36:52

I mean, it was amazing, like people like how could you round on 60? Kids? I'm like, because I didn't have to do any of the other shit that I have to do here. Yes, I swear, can I swear on the podcast? Yeah. I have not. We weren't computers, we was a handwritten up in the chart. And yeah, paradoxically, I felt like I spent way more time with my patients there, even though I rounded on like three times, three to five times more of them. Because all I did was direct patient care, anything that wasn't important was just cut out of it. So minimal meetings, minimal paperwork, it was like just go and save their lives. And that's why I said that, like that's where I fell in love with medicine, I actually felt what it was like to take care of patients. And coming back here, it's definitely frustrating to come back to the bureaucracy. But I still they're still there. They're still patients, and I get to take care of them. And I still take that, that sense of connection with me. And it's here. And I'm just so grateful to my time with MSF. Because I don't know if I ever would have found that if I hadn't actually gone and connected with medicine in that way. Easy to get resentful when you're wasted.

Ben: 38:05

How do you re up for these missions? I mean, what what you're describing is so it's so gruesome in terms of what you're not have the workload, but the trauma you're exposed to what? What drives the decision to say one more, and in your case, it was not just one more like four missions. So how do you explain to us what, how does that work?

Unknown: 38:29

And it's almost like from addiction. Nothing. It was an adrenaline rush. But one thing that I loved was as I got better at it, I got more comfortable. Once I really knew the protocols. It was really fun. And once I felt comfortable teaching, it was just so fulfilling to do the work. So I loved it. It was it was a joy to go back.

Ben: 38:50

How did you how did you navigate

Unknown: 38:51

just you get used to it the first two missions. When I left for Chad, I didn't know what to expect. And I know post traumatic stress, I had pre traumatic stress. I was visualizing my death. Before I left I was like envisioning headlines like, you know, plane shot down six minutes. Like I had vivid dreams about how I was gonna die and how it was gonna traumatize my family. And my sister had just given birth and my, my brother had just given birth. So I was leaving these three month old babies behind, and I just, I was like, Oh my God, you know, I'm gonna die and they're not going to remember. And I thought it was crazy. But it was so upsetting before I left, and I had no idea what to expect. And CEDS has a pretty violent place. There's like Boko Haram activity and I had no idea where I was going or how violent it would be. It was fine. I had a great time. But like, and then before my second mission, South Sudan that I was flying towards, and they had extensive counseling about how dangerous is going to be so I was also very kind of strapped like pre traumatized before I got there. My final two missions after South Sudan like Everything's just fine. Nothing can compare to that maybe Afghanistan but but honestly after that mission The final two, I was like, Bring it on, I'm fine. And then I was just kind of fun to go. And I was really ready because I'm just excited to teach and but and I mean, I would have stayed longer, but I, I signed on for fellowship, so it was just time to come home. When course they tell us not to do more than two years in the field, they advise us to kind of stop either take an office job with spontaneous sporadic missions, or it's just time to do something else. But they say more than two years is just not really healthy.

Ben: 40:29

Do you have one cool, peculiar story from South Sudan that you could share with us? About how did you like something that happened that was that where you felt that Oh, my God, what is what is what? Where am I right now in terms of something happening that you didn't expect or anything like that? Not just with patients, I mean, with the context of it being a warzone, you being in a hospital, because it's the stress of the patience, the stress of being a provider, like you said, stressing about your well being, and then suddenly, the war zone enters the hospital. And I don't know.

Unknown: 41:03

So the word did enter the hospital one day. It's hard to talk about, I'll see if I can get through it. But there was one morning where we had finally gotten up and running. It was like two weeks, in two and a half weeks, the tent was up. And we had trained everybody and we were rounding and it was the first day we like got through rounds, and it was great. And we only had like 10 patients, so it wasn't that bad. And I remember being like, alright, team, we did it, you know, we're like knocking it out of the park. And I got a call from my mission head who said, you know, I need you to step outside of the tent, we have to talk about something. So I was like, shit, like, in South Sudan. That's not what you want to hear. What's going on, and he was like, the general is coming to the hospital. He's demanding to see it. And so it was the general, you don't, you didn't need to say who it was. There was one general that was kind of responsible for this crisis. And he was an extremely violent man. He had been wonderful war crimes in the Darfur crisis somehow ended up as one of the main generals in one branch of the South Sudanese army, and he was just wreaking havoc. And so my, my boss basically says, he's, he's coming. He's and He's almost there. You have to let him in. He's demanding to see the place. And I'm just like, why is he called me? What is he doing? And he said, I don't know. And I said, are we in danger? And he said, I don't know. And so I took the staff aside, we had five nurses, and I just said, you guys can leave if you want to, you can run to the UN base. And they just said, No, we're not going to leave. And, you know, it ended up being like, nothing. My boss got there in time. And he ended up talking to him, but I just, you know, in your mind, like, what could have happened, and I write

Daphna: 42:57

well, and what's right, your whole team, really brave people who are putting, you know, the work before themselves. It's incredible, really, that people are out willing to do it. So thank you for that.

Ben: 43:12

And it's and it's such a I feel like we experienced that a little bit ourselves as well. Right, Kate in Israel, when when we were in bear Sheva, and there were all these rockets falling on the hospital and as a provider, you find yourself in this moral dilemma of what am I supposed to be right now? Am I supposed to protect myself and my, my abandoning the patients? What is what is the right thing to do? And, and unfortunately, the situation never gives you the time to ponder the question and you find yourself thrown into this crucible of pick something just you have to you have to handle the situation as best you can. And, and it's it's exactly right. It's I just

Unknown: 43:55

remember like, yeah, you're right, your wound into it, and you have no no time to process it. And, and I just remember

Ben: 44:05

that was gonna say, thankfully, it for for us at least it's worked. Worked out, okay. And everything is okay. And but then, like you said, you wonder, holy crap. What if What if x had happened? What if y had happened? How everything would have been different? Like literally your whole life takes a whole different path? And it's it's a scary road to look down? Because yeah,

Unknown: 44:27

yeah. It's just like, it was like nothing happened. And yet this is a memory that I get clearly early. This reliving. Yeah. I mean, like, probably 10 times a day, I would relive this and it just stopped like, a few months ago. Wow.

Daphna: 44:45

I wonder like, you carry those, you know, those things with you, you know, how does that shape you know, your clinical practice, you know, on a day to day basis, you know?

Unknown: 44:58

What's funny, one thing I A kind of as a joke is when the shits hitting the fan and the Nikki's busy. I say no one's shooting at us. That's right. That's right. That's all relative joke. It's a joke, but I actually mean it. And it goes back to that. Or I thought that he was gonna kill the children.

Ben: 45:16

Right? Yeah, that's, that's frightening. That is frightening. We might have to reshoot this segment.

Daphna: 45:23

You're doing great.

Ben: 45:25

You're doing fine. But let me let me ask you this question on a more on a more personal on a more personal note, I know you told us that you're into people's health care.

Unknown: 45:35

I've never spoken about this publicly, actually.

Ben: 45:38

But I think it's important for people to know about this, right? I think I think we tend to live in our silos. And like, Daphna was saying just earlier, we tend to complain about stuff. And we don't realize what it truly means to be aware of what's going on around us. Because we assume that our situation remains an anchor for what other people are experiencing when it truly doesn't there's a drop off is, is it's a precipice? And yeah, the toll that people have to pay for that is excessive. So you told us that global health came because you stumbled upon this article. But I'm wondering if there's anything that you could tell us about how you were raised, and I'm sure that in your family, sort of some of the values that you grew up around that sort of, consciously or unconsciously steered you toward a career and in basically doing good, right. I mean, beyond being a physician, your career is your you're a DG, right? You just do good around you. Yeah. And that defines you. So anything that that you could, that you could share with us on on

Unknown: 46:42

that? Um, no, I mean, I grew up in like a standard middle class, suburban Boston. Nobody in medicine. But I grew up. So I'm Catholic, and I, we went to church regularly. And I just remember hearing like Jesus, taking care of people, not judging people taking care of children. I remember, I liked that. And so I mean, not to denying the terrible things the Catholic Church has done. But there was a beautiful message that I always heard in all of it. And so I just liked the idea that, you know, you do good work, and you do good things for people. My grandfather was heavily involved in the oil industry, but he was very involved in the Jesuit branch of Catholicism, which is about service and education. And I think that really rubbed off on me, I met a lot of missionaries. I don't agree so much with religious missionary work, but they would run hospitals, and the only hospital in a rural area of Peru, and I remember going to some of their presentations, and it was extremely inspiring. And so, ya know, that was definitely the, the, the start of it. And then the other important thing, yeah, the seat. And then I was also given I had an absolutely phenomenal education, I went to Wellesley High School, which is just a great, great school system in Massachusetts. And we had early language exposure, which I credit with a lot of, really with changing my life. Excellent, excellent language teachers. So I studied French and Spanish. I think the reason I got the job with MSF was because I was a fluent French speaker. So I can't emphasize enough how important early language exposure and training is, if you want to work abroad, I always tell people, like anybody that I mentored was, like how many languages you speak, and they're like, what I'm like, you want to do something with it, we're global in it, and you never thought to learn another language. It's kind of an American thing. We don't value it. But I because I just had such a great foundation to work with the languages led to travel, which kind of compounded all these interests. So everything kind of combined together. That's why I think access to good education is probably the greatest privilege that and surviving your neonatal period are the things I can ask for in life.

Daphna: 49:01

Well, I know we're nearing the end of our time, but we talked a lot about, you know, resource poor communities. And that's, you know, using the term loosely, but I wonder what intervention did you see overseas, that you think we could do more of

Unknown: 49:24

overseas?

Daphna: 49:25

What did you see there that we we don't do enough of here or you know, that we that you integrate into what you do?

Unknown: 49:42

Well, I guess what I've taken back, which I touched on earlier, is I spend more time with the patients, even if I have paperwork like I maximize time with them, and I minimize time away from them as much as I can. Because I learned to really love that. And so just just making every effort to connect with them and with my colleagues I, what I found that was so interesting was we all worked so closely together, we had daily meetings. And one thing I really loved was doctors, nurses, patient care assistants, and our hygienist, which is like, to us, that's the most important that we take for granted how clean our hospitals are. But we know torso hygiene is like the foundation, we clean it, we wash our floors twice a day, I remember we had a visitor once he said you can eat off these floors. And so we really are hydrogels were as important as anyone else. They were always in our meetings, we always work together, and there was a different level of collaboration and collegiality. And I wish I could see more of that it. Definitely I try to like connect with everyone I see in the unit, that person is emptying the wastebasket. It's like the most important job in the unit. Learning how to see them as as much your colleague as someone else. I try to keep that, you know, because we're all working together for the kids. It just I guess I felt more of that when I was in the field.

Ben: 50:57

That is definitely the podcast highlight right there.

Daphna: 51:02

Thank you for sharing.

Ben: 51:04

Absolutely. I mean, the right, we've laughed.

Unknown: 51:07

We've cried to cry on your podcast?

Ben: 51:12

I think so. But this is this is one this is I think this is one of the best podcasts that we've recorded. So this is very exciting.

Daphna: 51:22

No, I mean, we appreciate you being you know, open and honest with us. It can't have been easy for you. So we're so we're so grateful for your experience and for you being brave enough courageous enough to share it with us. Yeah,

Unknown: 51:38

I harder than I harder than I thought to talk about. But yeah, it's good. It's good for me to talk about it.

Ben: 51:44

I have two more questions. The first question comes from, I guess, people who are interested in global health, I think the biggest challenge in the US is that there's all these tracks, right? I mean, you're on your College Track, then you go to medical school, and then you go to medical school, and then you go residency, and if there's no break, or there's not supposed to be any break, and none of these tracks often incorporate the global health. So what would be your advice to a college student, a future medical student, a medical student who is interested in global health? What are the concrete steps that you think people could take in order to explore their interest?

Unknown: 52:23

Yeah, so just taking it as seriously as any other step is what I would say, taking real time and dedicating it to that. And don't let anybody tell you that you can't do it. That's bullshit. And I had people tell me, it's not good for your academic career. You should go straight, go straight through don't take time off the all of the best things I've done in my life where the gaps where I did something special. So go out and explore things take a year take two years, what did it? Did it hurt me in any way? No, it's the foundation of my life. And, and I got incredible interviews for fellowship, because everyone wanted to meet the MSF doctor. Like everybody loves that you're the MSF. So it makes you more interesting person, it makes you more skilled. So just do it you have the time and do when you're young. Extensive fieldwork cannot be done when you have children, you know, or if you have a partner, so you have to give a lot and sacrifice a lot if you want to and you don't have to as life goes on, you might find that it's not a reasonable goal to leave for two years. And that's absolutely fine. You can support global health in different ways. But if you're serious about field work, you need to take it really seriously and treat it like a job and dedicate some real time to it.

Ben: 53:36

Let me let me ask you, because you also have you have an MPH. And I think many people believe that, oh, if I if I'm interested in global health, I get to first get the mph. Do you think that this is an essential step to get out into the field? Or how do you view the MPH sort of option or track in the context of a potential career in global health?

Unknown: 53:59

It's, it's not something you have to do. It's a nice option. I did it before medical school. So it kind of framed my medical training nicely. I was able to do some I got a great internship with the CDC, which was the division of global migration and quarantine, that was my real introduction to refugee management. So you can certainly get a lot out of it. But it's not in any way required to to do global health work. Try not to pay for it too often covered in certain tracks. I spent a lot of money on it. And I kind of wish I didn't have that additional debt. But it was it was fun, but it wouldn't, I wouldn't say it was like essential. You're seeing more and more like year long tracks or things that are kind of folded into something else. So that's kind of a nice way to do global health training. You can do it any way you want. You really can there's the sky's the limit, but it's just fun. This could sound so judgmental, but I break global health into kind of two categories. There's the people who really do expensive projects and then there's the ones who say Oh, I I spent a week in Haiti. And it was the best like week of my life and like that, no, no, that was a vacation. I'm sorry. Maybe you saw some patients, but like, let's be real. That's the only thing that now that might be the first step. But don't mistake that for a real, like a real global health, career or experience, you gotta do a little more than that. That might be all you can do in the moment, when you're in college, maybe you can only get a week away or a month away. And certainly in residency, you have to dedicate yourself to like residency training. But yeah, it's just funny. Well, it's hard, it's hard, it's hard to integrate it in. So

Ben: 55:35

I'm going to ask my last question, I'm going to let Daphna have the last words, I guess. Any books that you recommend either a book that you particularly like related to global health, or just even two books, one related to global health, and one that you enjoyed reading while you were on the field, if you've got any recommendations.

Unknown: 55:55

So in the field, I tried to avoid anything, like triggering, I didn't want to read about war, I could just look outside my window. So it was a lot of fluff. And like yoga and meditation, but coming back, so I study this now, academically, yeah, like more in medicine. And so a great book is it's called governing the world. And it's a really extensive overview of kind of historical events that lead up to the current state of human rights and international health and how those things come together. So governing the world, I would highly recommend that understanding the historical context of global health and wars like what are the Geneva Conventions and things like that, I think it's really fascinating. I think everyone should know about them. Understanding how the great wars World War One and World War Two shaped current events, how the UN works, what they're doing, how all the agencies work, there is such a lack of knowledge. In the average person, I've given a grand rounds that goes over just the historical timeline of how the humanitarian world works. And everybody's just like, I had no idea any of this stuff happened. I'm like, I was talking about World War Two. You don't know what were to happen. Like, Well, I heard of it. But Jesus. So it's just so important to know, what has happened and what is happening. So any anything that covers that, just learn about the world learn about global diplomacy. And I don't know it's, it's fascinating. Another great book, shake hands with the devil by Romeo Dyer. He was the general at the Rwandan genocide. I think that's an excellent book. And he talks about how they approached that and then mournfully, how you could potentially prevent something like that from happening. Again, I think that's a really good book for global disasters. And there's a couple books out with a for MSF one is called an imperfect offering. And it was by a former head of MSF. And he's very candid about the challenges we face, how imperfect, the work is trying to provide the care that we do. So that was a really good book as well. I think yeah, there's lots there's lots to start with.

Daphna: 57:51

Yeah, you've you've I think, partially answered my my last question. And I think education, just learning about what's going on in the world is one way that we can affect change. And I will probably add those books to the show notes. But for those of us who are not brave enough to go to go out into the field, you know, how do you think is the best way to get involved to support the effort? If if we can't get out there? can't or won't?

Unknown: 58:22

Yeah, just you know, anyone can support it. These organizations really do function off of private donations. So join the $20 a month NSF donation club, you can sign on for like an electronic thing. And we we entirely self funded through private donations, we accept zero government funding, and we raised like $1.6 billion a year and we run 700 800 missions at any given time. And it's entirely the average donation is only a couple $100. So we just we do it, because millions of people around the world believe in this work and support it. So it is it is a movement of the people and for the people. We didn't wait for Bill Gates to get us started. We didn't need the US is money. We do this ourselves, which is also one of the reasons why I think it's such a cool organization. And you know, like UNICEF, just find something that you like and support them just it's small contributions, but they add up to $10 a month for the rest of your life. That's 1000s of dollars, by the time you die, and you will have made a you will have made your bit of difference. And then just just learn as much about it, know what's happening. That's the way to respect the people who are who are going through it. And it's not a lack of bravery. You know, it's very normal to not go and do these things. It's fine. But yeah, just try it, try and support it in any way that you can. I would not recommend this work for most people. I know hundreds of doctors and there's about five of them that I think should go and work with MSF. It's not for everyone. A lot of people would be absolutely miserable or their circumstances just wouldn't allow it. It's there's no such a shortcoming on your part. It's just not meant for everybody to do but everybody can see afford it in some way or another? Perfect, you can be as happy and well adjusted as I have if you

Ben: 1:00:10

That's great. Well, okay, thank you so much. Again, we'll have all the different things that you mentioned in the show notes. And, and I guess if please, to all the listeners leave us feedback. I feel like I have so many more questions that we could have gone to this, this potentially could have been a two hour episode. So thank you so much, Kate, for taking the time. I know you have a busy clinical schedule as well on top of everything else that you do. And thank you. Thank you. Thank you.

Daphna: 1:00:43

But I delight Kate, it's a pleasure and an honor to have spoken with you this evening. So thank you so much. Ben is always love seeing.

Ben: 1:00:56

I'll see you tomorrow.

Unknown: 1:00:58

Good night, everybody.

Ben: 1:01:04

Thank you for listening to this week's episode of the incubator. If you liked this episode, please leave us a review on Apple podcast or the Apple podcast website. You can find other episodes of the show on Apple podcasts, Spotify, Google podcasts, or the podcast app of your choice. We would love to hear from you. So feel free to send us questions, comments or suggestions to our email address NICU podcast@gmail.com. You can also message the show on Instagram or Twitter at NICU podcast. Personally, I am on Twitter at Dr. Nikki spelled Dr. NICU. And Daphna is at Dr. Dafna MD. Thanks again for listening and see you next time. This podcast is intended to be purely for entertainment and informational purposes and should not be construed as medical advice. If you have any medical concerns, please see your primary care practitioner. Thank you