Transcriber: Dimitra Papageorgiou Reviewer: Chryssa R. Takahashi
(Greek) Good Day Thessaloniki
and thanks to TEDx for this invitation.
The summer of 1982,
I was stuck in the middle of the Israeli invasion of Lebanon.
At one point, I found myself in a large public hospital
that had been abandoned by its personnel
and had then been occupied by about five thousand civilians.
Entire families who went into the hospital thinking that since it was a hospital
they would be safe there from the bombing and shelling.
They were mistaken.
With me, there were two general practitioners and six nurses
and we received tens and then hundreds of wounded.
The operating theaters were located on the fourth floor
and too exposed to shelling to be safe to work,
so we operated on the ground floor.
Literally on the floor.
For anesthesia we used Ketamine.
Ketamine is a wonder drug.
You can have full anesthesia and do any sort of operation with it.
You don't need a special apparatus, it's given by injection.
Either in the vein, or in the muscle.
You don't need an extra oxygen supply.
The 20% of oxygen in ordinary air is sufficient --It's a very safe drug.
It's difficult to kill someone with Ketamine.
Which means, you don't need an anesthetist.
Now, as a surgeon, I appreciate anesthetists.
I love a good anesthetist.
But what happens,
when there is no anesthetist present?
Ketamine.
So we'd give an injection to patient, we would wait a few minutes for it to work
and then I would start operating
and before I finished operating, a few minutes,
I would tell the other doctor to inject the next patient,
I would hand over this one to a nurse to do the bandaging,
and we went on like this in a sort of an assembly line of surgery.
Ketamine is an old drug. It's more than 40 years old.
And it is still the best anesthesia, if you're working after an earthquake
or in a war zone.
It's better if you do have an anesthetist
and although it's not used very much in industrialized countries,
it is still the basic form of anesthesia used in most of the rural third world.
Now, I am a general surgeon by training, and war surgeon with 35 years experience,
I have worked in difficult situations, dangerous circumstances
with limited resources.
And I become used to this. I'd probably find it difficult to work
in a modern hospital in Greece, in an industrialized country.
But that's fine.
In my professional career, in my lifetime,
there's been tremendous change in the practice of medicine,
in general surgery in particular.
There's been an introduction, well, I love technology.
In 1966 I was operated on my knee, I spent five days in the hospital,
I had the same operation in 2007, I left the hospital the same day.
In 1983, I had my gallbladder out, -- Cholecystectomy.
And for five days in the hospital I had tubes coming in and out
of various parts of my body.
Today with Laparoscopic Surgery, the patient drinks the same evening
and leaves the hospital the next day.
It is perhaps in diagnosis that we've had the greatest advance in technology.
CT Scans, magnetic resonance imaging, ultrasonography,
very sophisticated laboratory analyses,
and this is good.
So we've had all of this.
The mastery of this technology, however, has become a challenge.
Now, in spite of all the advances,
alleviating suffering,
prolonging many, many lives, not all is progress.
And the gap in progress, when compared with medical technology
is best exemplified by the training of young doctors
who tend today to become medical technicians
and no longer, physicians.
They look at images, and numbers in the laboratory,
and forget to look at the human being,
the patient.
Technology can be alienating.
Now it is not alway thus
and there is another way of practicing medicine.
When I was a young intern, in Cairo,
we had a consultant
and we had a particular patient with a very difficult diagnosis.
Aches, pains, fever, this, on and off.
We put him in a room on his own,
and on grand rounds we asked the consultant
to come and examine the patient.
He opened the door, stopped:
"I smell typhoid fever."
Here's a man for 30-40 years of medical practice
that smelled his patients.
Now, I have not learned to smell typhoid fever
but the pungent odor of Cholera, yes.
The stale, urine odor of kidney failure, yes.
The musty ammoniac odor of liver failure, yes.
The fecal shitty smell of E. coli infection --
and I have learned to distinguish the good, bad smell of a clean war wound
from the bad, bad smell of an infected wound.
During surgical conferences on trauma, it's very often an exercise,
they present a case: Accident, person is bleeding, etc,
and they tell you,
"The blood pressure is 96 over 62, the pulse is 112."
Obviously to have such specific detailed figures,
somebody has read them off a monitor.
I ask, "What was the character of the pulse?
Was it strong and bounding full or weak and thready?"
Nobody can tell me because nobody felt the pulse.
They read it off the monitor.
Now, there is a difference when the body reacts to hemorrhage, heavy bleeding,
having a full pulse, or a weak pulse.
You cannot put the fingers of a doctor, into a machine.
The physician must practice what I call the eye, ear, nose,
and ten finger whole body scan.
You look at the patient, you listen to the patient,
you (inhales) smell the patient, you palpate the patient
from top to bottom, there is a laying on of hands.
It is an intimate act, and it creates intimacy
between the doctor and the patient.
The patient tells the doctor intimate things:
"Doctor it hurts, here."
Pain is an intimacy not to be betrayed.
It has been said that medicine is an art as well as a science.
The art is much like storytelling.
I sit down with the patients, and I listen to them.
To what they want to tell me
about their lives, their fears, their desires, their pains.
They tell me a story.
It's only then that I look at the images and statistics and say,
"Well, what's going on?"
and that storytelling is important.
I am not the only surgeon who goes in to the operating theater,
and thinks that the body on the table is a slab of meat.
I can then cut into flesh, it's not, not a human being.
And that's normal for a surgeon.
It allows you to cut into human flesh.
It allows you to go from deathbed to operating table and still be efficient.
It's only afterwards, during rounds, that, that slab of meat
becomes a human being again
with desires and hopes and human dignity.
And it is during those rounds that if I can make an amputee to laugh
then I consider that my day is a success.
Now, I spoke to you about Ketamine and there are a number
of other basic and rudimentary techniques that have been used
and are still used in many places of the world.
And it's a simple technology.
And this is where human imagination comes into play.
You invent, you improvise, you adapt.
Recycling of surgical gloves.
After the operation, you wash off the blood
with a chlorine solution
you then wash them with water, you dry them, you put in powder,
and you re-sterilize them, and re-use them.
Sometimes you have to do a skin graft.
You take skin from one point of the body, to cover another part of the body.
And you want to mesh it so that it increases the surface area.
Pizza-cutter.
Serrated edge, much cheaper than what you usually find in the market
and in modern hospitals.
Plaster of Paris, -- (Greek) gypso-- is very old technology.
And you don't have to be a specialist to put on a bridge cast.
And this is a locally made bridge, made in any automobile workshop.
And with this, you don't put anything into the body of the patient,
you can have access to the wounds to change dressings, put in a graft,
and the patient can walk about.
You have to fight something called hypothermia.
People who have undergone trauma or burns, lose body heat.
Carton box, to preserve the body heat,
create a cushion of hot air around the patient.
In many hospitals in Africa, they make their own intravenous fluids.
Intravenous fluids are sterile, but it's salt and water.
Sugar and water.
And it doesn't really make much sense, to transport tons
of sterile salt and water,
hundreds of kilometers over an African road.
So they distill the water, they sterilize etc, they make their own.
And if you don't have enough blood for transfusion,
you can recuperate the blood from the chest and the abdomen
and give it back to the patient.
Now, this is sort of a throwback to a simpler way of doing things
but it is also, a throwback to another way of dealing
with ones patients.
This is when medicine was a vocation and a calling
and not just a profession or a job,
and another way of making a lot of money, or gaining social prestige.
And I am not alone in thinking this.
Dr. Mohamed Hadeeb is a general practitioner
in the Palestinian refugee camp of Shatila, during a major battle.
No hospital, no equipment, not a surgeon, and he had many wounded.
The only treatment he had, in the sweltering summer's heat
for his patients, was to fan them and speak gently to them as they died.
Dr. Abouhassan is a Syrian surgeon in the city of Aleppo.
Earlier this year, working in an underground hospital
he spent 48 days, without seeing the sun.
Dr. Denis Mukwege is the director of the Panzi Hospital in Bukavu,
Democratic Republic of the Kongo.
He is a gynecologist, and amongst his patients
are thousands of women who have been raped
some quite savagely and they have obstetric fistula.
And they tried to assassinate Dr. Mukwege a couple of years ago.
He had to leave, continue his therapy, he returned,
and today his defense, in his hospital, is thousands of women.
A human shield.
These people demonstrate empathy and solidarity.
and technology will not solve their problems.
Now, in medicine, the humanitarian will to alleviate suffering
and protect human dignity, is the goal.
It is the solution.
Technology is only a means.
And sometimes, this reality only becomes apparent
in extreme circumstances.
But you don't need extreme circumstances
of war or earthquake to prove the proposition.
Working with limited resources, doesn't occur just in earthquakes and war.
It is the everyday experience of many doctors and nurses
around this globalized world
where sophisticated technology is simply not available.
And that's when you go back to your imagination,
improvising and inventing.
Now, don't mistake me. I am not a Luddite.
I don't want to smash computers and mobile telephones.
Sometimes I do want to smash mobile telephones. (Laughter).
But I've written several books using a computer,
and I've used the Internet,
without which I could not have done the necessary research.
But I am not a slave to the technology.
I am its master.
I use modern technologies in my professional work
and my everyday life.
But I remain in control and I don't allow the technology to determine me.
I've talked about the role of technology in the medical sphere
and said about the great change that occurred
and we've heard today about the mobile revolution
and supposedly we have great rapid changes.
All true, but we've had rapid changes for the last 200 years.
It's just the industrial revolution.
Think back:
Steam power, internal combustion engine
airplanes, electricity! The first people who saw electricity!
We had then telegraph, telephone, radio, television,
nuclear weapons and nuclear energy.
We talk about a globalized world today.
Well, today we are only reaching the extend of a global integration
that the world already knew in 1914.
The emergence of China and India.
In the year 1800,
75% of all manufacturing in the world, was done in China and India.
What is new? What is a beginning?
It may simply be a continuity, or a repetition.
And we may think that there are very rapid changes today,
and this is different, but this may be a western perception.
There are still several billion people in the world
who do not have access even to a mobile telephone.
That will change, but we are not there yet.
Now, technology must be appropriate
and our response to technology must be appropriate.
We must not allow it to alienate us,
to create distances between people and between peoples.
We must remain the masters,
and not the alienated slaves of material progress.
Someway this has always been the case.
Here there is nothing really new,
and our perceptions of newness may simply be misapprehensions.
No beginning, no end, only a continuity
or what the writer Tom Bissell once called:
"Deep cyclical changes embedded in natural processes."
We human beings are blessed with imagination.
We invent new approaches to old and new problems.
Sometimes we re-invent the wheel.
We use old ways of doing things
but if the result is possitive then so be it.
Imagination creates intimacy.
It creates solidarity.
Imagination creates humanity, community.
And in fact, perhaps, our capacity for imagination --to imagine,
is what best defines us as human beings.
Defines what it means to be human.
And we must maintain our humanity.
The challenge is how to harmonize our lives
with this technology.
The challenge is how to maintain our humanity,
when faced with a new technology.
And that has been the case, since Prometheus.
Technology is neither the problem nor the solution.
We human beings, we citizens,
we are, and have always have been the problem.
But we humans, we citizens, in the richness of our imagination
in the diversity of our humanity, we are, and must be the solution.
I thank you.
(Applause)