The queen is the most powerful
piece in a chess player’s arsenal. The queen is unique in that it can move in
any direction. It offers a great deal of protection and security and generally
makes solving your opponent more straightforward. Players covet the piece and
try to avoid losing it at all cost. Having ones queen taken by an opponent
usually puts them in both a tactical and perhaps more importantly,
psychological disadvantage.
A queen sacrifice is the term for
a play in which the player purposely gives up his queen, expecting to win in
return either multiple pieces from his opponent or a winning position. There is
however, one celebrated instance in chess history where a chess master
intentionally sacrificed his queen for neither of the usual rewards. He had always
been renowned for his great creativity and resourcefulness, but on that day,
playing one of the most important matches of his life, he could summon little
of either. Then, for reasons no one at the time could fathom, he sacrificed his
queen. He had realized what his game was lacking, and knew there was only one
way to get it. It wasn't to be found in security. He had to be backed into a
corner, he had to be pressured, pressured to create a solution
when the most conventional means to do so were no longer an option and it
worked. He won.
. . . . .
. . . .
"What kind of stuff do you
see?”. Prior to our departure from Victoria, it was a question that I asked
many of my physician colleagues in the ViVa organization, all of whom had
worked in Vanuatu before. Common responses included pneumonia, abscesses,
tuberculosis, malnutrition, dysentery, burns and meningitis, not to mention all
the obstetrical problems that arise. After listing most of the usual suspects
they would usually pause and then try to somehow come up with a name for the other stuff. They were thinking of
all the things you would never see in the west, wildly advanced cases of cancer
or other diseases, weird manifestations of known illnesses, and stuff you just
plain couldn't make up. You couldn’t because even though as a
physician you might know the physiology of the problem, you could never have
foreseen the effect that the swirl of forces on this island would bring.
Our hospital is about 100 m from our house, both of
which sit on the top of a hill. On the way there’s a beautiful view of a lush valley
nearby. “Time to put on the old suit and tie”, I often mumble as I don my
Hawaiian shirt, surf shorts and flip flops to make the trek to work. The
hospital itself is a square, one level complex with a central courtyard. It is
undeniably a bit run down, and generally speaking, very far from the brightness
and cleanliness we are used to in the first world. This can be a little arresting when you first
get here but fades with time as it quickly becomes apparent that you are not in
Kansas anymore. I think that many
westerners that come to Vanuatu and similar places often carry a bit of white
man’s guilt when they see the discrepancy between these living conditions and
their own. Eventually you just get over it. It’s not your fault. You don’t have
to be conciliatory or try to act like a Ni-Vanuatu. Respect their culture and
their country but be yourself.
Usually there are lots of locals milling about the
courtyard. They are mostly the family and friends of patients. Almost nobody
arrives for treatment at Lenakel hospital without a large entourage. There are
no designated visiting hours, partly because we rely on the families to do a
lot of the care for their sick relative, and I think partly because no one
would accept anything that restricted family contact any way. Sometimes it’s
been the middle of the night when I’ve been called in, and when I arrive the
whole hospital and courtyard were abuzz, filled with people, cell phone lights
waving. It’s like I walked in on a rave. Then, the whole place turns to look at
me and it’s time to be the dokta.
There are about forty beds in the hospital divided
among 2 adult wards, a children’s ward and a well-used maternity ward. There
are about 4-6 deliveries per day on average here, the vast majority done by our
extremely capable and experienced midwives. We even have a small operating room
and a labour and delivery room.
By now I know all the nurses so when I arrive on
the ward to do rounds there’s always some good chit chat that happens first. In
fact not much gets done around here without a chit chat and a laugh to go along
with it. It would just seem rude to do otherwise. People on Tanna take a lot of pride in this
attitude and I think for them it comes down to this: given the choice, why
would you do it any other way?
The Life Wisdom Of Gene Hackman
So what’s it like practicing medicine here? Well at
first there is a hell of a lot to get used to. There’s a lot of stuff we never
see in Canada, the resources are a lot less, and the culture can throw a lot of
wacky roadblocks in your way. Then, I had my Gene Hackman moment. The film Hoosiers tells the true story of a small
town Indiana high school basketball team that comes out of nowhere to win the
national championship. It’s a story we’ve all seen a hundred times but
something about this film worked. There’s a great scene where the team arrives early
at the stadium for the first time in the tournament. The stadium is huge, the
stands are enormous, the roof is cavernous, and everything is so different from
their tiny gym at home. The players are feeling completely out of sorts.
Hackman, their coach, orders one of his players to use a tape measure to take the
height of the basket, then the measurements of the foul line and the key. Not
surprisingly, they are exactly the same as at home. The message was clear. The
surroundings might be different, but the game’s the same. Similarly, the bodies
of my patients here in Vanuatu worked just like the ones at home. Their lungs were in the
same place. Their hearts worked the same. I could examine them exactly as I
always had. They got the same kinds of aches and pains, colds and flus. They
responded just as well to a kind word or a joke to make them laugh. They had
all the fears, anxieties and personal strife as people do at home. It might
sound silly, but after spending over a year preparing for how different Vanuatu
was going to be, this realization actually surprised me for a second. The game was the same. It was just everything around it that was
different. And boy can it be ever be different.
How do you convince someone to take precautions
against giving their infection to others when they don’t believe in germ theory?
How do you convince a parent to leave their child in hospital to treat their
meningitis when they believe it’s caused by spirits. How do you go about
persuading someone that the brutally aggressive kastom (traditional) massage they
got didn’t help them, and in fact was responsible for the ruptured bowel that
almost killed them? Similarly, the traditional practice of kastom cuts to the skin around a problem area do not let anything bad get out, but when covered by a dirty
medicinal leaf, are a great way to get an infection.
How do you get a husband to stop hitting his wife
and children when many males have traditionally seen this as part of their role
as a husband and father? How can I assess a potential psychiatric patient that
tells me they are a victim of spirits and curses, and that they feel insects
crawling all over them when in fact many of the island’s populace believe in
similar supernatural phenomenon and I pick ants off myself most of the time
when I’m in our kitchen. The list goes on. I don’t mean to sound dismissive of
these things. They are simply some of the realities here. In fact, frequently
brushing up against beliefs in magic and spirits has given me a new insight
into what life is like when it’s so influenced by such things. It’s really not
as big a mental leap as you might think, and there certainly are some great
things about it. It can be pretty comforting to believe that the spirits of
your ancestors roam the bush outside of your village and can be called on for
help. The world literally becomes a magical place.
Often it is the simple, mundane things about the
job that can be the most confounding. For example, nurses at the hospital, many
of whom are quite capable and do very good work, might not call you though when
a patient is critically ill because they must use their own cell phone to do so,
and no one wants to use up their credits. In general, nursing competence here can
vary widely. Some are great and some can be exasperating and bewildering in
what they do.
Most people don’t seem to know their age, or really
care for that matter. This somewhat indifferent attitude towards the passage of
time can also make it vexingly difficult take a history from a patient, or
determine when a problem actually began. Bislama, the main language here, is a
kind of pidgin English that initially developed to allow communication with the
English colonials. It doesn’t have an extensive vocabulary, just over 2000
words. While this makes it easier to learn, it doesn’t allow for a lot of
subtlety when describing something. Consequently, a patient will generally
describe a pain or a problem as either, ”bigwan (literally big one)”, or ,”smol
(small)” and nothing in between. You just have to roll with it, and above all,
phrase every question for a yes or no response.
The keeping of records in the country, medical or
otherwise, is generally quite poor, if they exist at all. A person could have
their name spelled differently at different times. Sometimes the father’s first
name is used as the patient’s last name and sometimes not. This can make
tracking charts and records a nightmare.
Patient privacy is practically nonexistent. You
might try to close the drapes around a patient’s bed to shut out the twenty
other people and family members in the room only to realize that a dozen others
are peering in through the windows, which of course, have no blinds.
People here have a very different attitude towards
illness and death. I guess when you see it up close a lot you accept it more as
a normal part of life. They are however;
by and large tremendously appreciative of whatever we do for them, even if
sometimes it’s really very little. A walk through the town usually draws at
least a couple of shouts of, “Hello Dokta!” followed by warm handshakes from
folks, often ones I haven’t even met before.
Beds of Nails
What do we have to work with to treat these
patients? Obviously, a heck of a lot less than we do at home. There is vastly
less equipment, available tests, medicines and just fewer options in general. There’s
no physiotherapy, no rehab, no social work, no mental health medicines or
programs. There is even less at the remote medical outposts that we pack up and
drive to on a weekly basis. In a way though, it’s cool to have to rely so much
on your clinical examination skills and judgement. The common algorithm is that
you formulate a list of potential diagnoses, and then you cross off all the
things you can’t test for, and then cross off all the things you can’t treat
for and see what’s left over. If there’s more than one, then treat for all of
them and hope for the best. Here, expectations of what can be done are very
realistic. No one expects you to know everything and be right all the time.
Generally, even if you don’t get it right people are better off than if you weren’t
here at all. The surprising thing was how liberating this situation can be. It
was like taking off that wetsuit that is a touch too small and then realizing
you weren’t breathing in fully all day, or that little hitch you never knew had
crept into your baseball swing, only feeling its absence when you were no
longer afraid of striking out.
Often something like abdominal pain, or shortness
of breath, symptoms that make a doctor consider numerous possibilities at home,
get treated repeatedly as one of a short list of things that we can actually do
something about. It always reminds me of an old saying: when all you have is a hammer everything starts looking like a nail.
Some days I feel like that’s all I have on the wards, beds and beds of nails.
. .
. . .
. .
The ViVa project has been going on for over 20
years, supplying the sole physician for Tanna island. When Andrea and I signed
on we were expecting the same scenario but two months before our arrival, a
husband and wife physician couple were suddenly posted here by the Ministry of
Health. He is an ophthalmologist (eye doctor) and she an obstetrician. He was actually
born on Tanna and they plan to live and work here permanently. This has significantly
changed the experience for us. We had been expecting to have to handle surgical
and obstetrical cases to some degree but now they would deal with the bulk of
these patients. It’s nice, and they are great to work with, but a small part of
me regrets not being as self- reliant as we had envisioned. Of course that’s
only in the quiet times. When the shit is hitting the fan then I’m thanking my
lucky stars I’ve got a surgeon nearby, even if he has done only eyes for the last
eight years. Still, they do leave the island for days or weeks at a time and
Andrea and I are left on our own. She handles most of the obstetrical calls and
she’s good at it. It’s been great seeing her reclaim these skills. I’ll then
handle most of the procedural and trauma related things. I’ll admit I do love getting
a chance to say, “Prep the O.R. I’ll take him to the theatre.”
Honestly, I can’t say I like that kind of pressure, but ultimately it is one of the main reasons that I came here. I knew what that
pressure would do. It would demand some things that I haven’t had to produce
working at home. There’s so much support there that it’s hard for that to
happen. It always makes me think of that famous chess match. I would have to
give up that support, give up my best tools, just as he sacrificed his queen,
in order to see if those things really are there to be given. I’d like to think
they are, even if ultimately I don’t want to have to use them every day of the week.
With two months left to go here it’s still too
early to claim success yet, but the endgame is looking good. My pieces are well
positioned, the chess board is a lot clearer, and when the game is over I hope
to be looking back without regret, at my queen sacrifice.
Sean
