What's "Normal"?

                It’s easy to take for granted knowledge of what’s normal.  In the USA a lot of the practice of pediatrics involves knowing what’s “normal,” because parents are worried about a wide variety of things during the normal growth and development of their child.  Here I deal with that a lot too, but I also deal with a lot of things that make me laugh inside.  To me it seems obvious that the patients “symptoms” are normal, but when I really think about it there’s no way they could know it’s “normal.”

                For instance, I had a man in his late 30’s complain that his body gets hot at night for the last 7-8 years. Consequently his wife doesn’t want to sleep right next to him, because he’s so hot.  Upon questioning it turns out he’s been married for 7-8 years.

                I had a 23 year old male complain that his arm veins stick out (i.e. vasodialate) when he lifts heavy things.

                 I had a 30 year old guy tell me that when he walks long distances his body gets hotter and hotter.  The further he walks the hotter he becomes.  And he even starts sweating a lot.  Especially when he’s out in the sun.

                I had a 50 year old obese lady with 5 thick alpaca sweaters, 2-3 pairs of knitted wool pants/leggings, and 3 skirts on tell me that her body sweats A LOT! (I was wearing a polo shirt and a pair of pants quite comfortably in the same room).

                Everyone tells me that their hands and feet are warmer than the rest of their body and that they sweat more than rest of their body. 

                Everyone gets worried when their urine turns from clear to yellow (I guess they’re very well hydrated).

                All day every day everyone complains of low back pain.  On my way to the hospital today I passed by a field (farm). There were 5 adults (4 men and 1 woman).  They were standing with their legs straight, bent 170 degrees at their waist, (I guess) picking weeds out of the field.---My back hurt just watching them.

                The other issue that really wears on my and I need prayers for is their “old wives tales.”  The problem is that I can tell them they are not true, but they are things even the Peruvian doctors tell them.  For instance, working hard, physical labor, lifting heavy objects will cause you to tear your kidney or cause inflammation of your kidney (this is what some of the general practitioners tell them).  The symptom is back pain.  So when they come in from the chakara (the field/farm) with severe back pain they all want ultrasounds of their kidneys.  Some of my patients have even told me the doctors here did a surgery on the micro tears of their kidneys, but it didn’t help the pain.  The hard thing is when I tell them its not true 5 times, they’ll still come in the next day to try to see a different doctor who will order a ultrasound so that they can check their kidneys.

                The Peruvian doctors tell them that cholesterol causes headaches, dizziness and arthritis, so all the thin 30 year old women (and everyone else) want their cholesterol checked.

                The non medical tell the patients that sun damage/lentigo’s on your face are caused by a bad liver.

                The people also think that upper back pain is from bad lungs or water on their lungs (not from the fact that they carry their children, and everything except the kitchen sink on their back).

Seeing that God is with Me

                One story of the Bible that I really fell in love with this year is the story of Daniel (especially after seeing the rendition of his story as portrayed on the History Channel’s “The Bible”).  His country and people had been destroyed.  He was a million miles away from home forced to learn and work for people who didn’t serve his God.  Yet, Daniel knew on a frequent basis that God was with him, and with him strongly.  If you not only know the meaning of someone else’s dream but also the dream itself, you KNOW it’s because of God and you know that God is with you.

                This last fall I while I was working as a hospitalist (only several months out of Family Practice residency) I was talking with one of my friends, Sarah, who was in my same residency class and was also working as a hospitalist.  I had been thinking how great it’d be to be about to interpret dreams or to have some gift that you know without a doubt that God has empowered you to do something and is with you.  But I realized, and Sarah agreed, that we do indeed have that gift.  Some of the practice of medicine is learned in school and in books, but most of it is learned by experience.  Part of medicine is treating symptoms, but especially in the hospital setting where all the organ systems show evidence of a domino effect due to some trigger, the key is to figure out what started it all and treat that disease/condition/etc.  The ability to “figure it out” comes from experience.  But neither Sarah nor I had much “experience” yet we daily (and even hourly) saw God bringing the “trigger”/original order of sequence of events to mind.

                I had a similar experience a couple weeks ago.  I was on call on a Friday night.  I received a call from the nurses at 4 am that there was a patient with pelvic pain and urinary symptoms.  Pains hard, because overly dramatic patients make a huge display of a small bruise, whereas a stoic patient will come in calm and no apparent pain, but the context is the only thing that gives evidence of their pain.  I talked to the 50 year old Quechan lady, and through a translator found out she had had right pelvic and suprapubic pain since the day before. She had vomited at 11a the day before and hadn’t eaten anything since due to pain.  She came from a town almost 2 hours away due to excruciating pain that was worsening throughout the night. (Note: no one likes to travel in the night in Peru, especially from that far away because there are a lot of robbers on the roads, and poor Quechan’s don’t own vehicles.  They take public transportation, which doesn’t run after 9 or 10pm. Usually if any patients come in overnight it’s because they live in Curahuasi—the town the hospital is located in).  So this lady lay in “excruciating pain” on the hospital bed and you never would have known she was hurting by looking at her.  But the time of day and the fact that she hadn’t eaten since the day before made her automatically fall into my “stoic” category. 

                Stoic patients are the worse because you know something bad is going on or they wouldn’t be there.  And if you send them home to come back the next day, they will never come back.  So you have one shot to “figure out” what’s going on and they don’t give you a whole lot of feedback back.

                We checked her urine and there was a small “infection” versus contamination, but it didn’t explain her pain.  So I went to the pharmacy to look for a pregnancy test and had them set her up in one of the GYN rooms to examine her.  While in the pharmacy I was thinking about what I wanted to “rule out” before I would let her go home and follow up (i.e. what are the worse things she could have that required emergency treatment).  I thought: pregnancy..and then “torsion of the ovary” [a condition when the ovary twists on its blood supply which runs along the fallopian tubes. This tends to happen if there’s a large cyst or something heavy on the ovary. It’s a surgical emergency if they’re still in reproductive age, because you could lose the ovary if it goes too long without blood supply)   popped into my head…. I’ve seen torsion once or twice, but its not super common.  But I couldn’t shake it from my differential of more common things she might have.

                On pelvic exam she had no vaginal or cervical discharge (sorry Dave if you’re reading this—please don’t puke), was just starting her period, cervical motion tenderness, right adenexal (the area where the ovaries are) fullness and “severe” tenderness (i.e. she said “that hurts”).  On vaginal ultrasound I was able to see a large right ovarian cyst.  And I couldn’t find the button on the machine to check for Doppler—ie. Blood flow to the ovary (turns out that was because it doesn’t have one). 

                The pregnancy test came back negative (that rules out ectopic pregnancy which could cause a similar presentation).  So I debated for half a second whether to call Jens our GYN at 5am on a Saturday morning, but I was even more convinced that I had to rule out torsion before the patient could leave.  Jens came in a couple hours later.  Saw the same thing on exam I saw.  He put the Doppler on her and there didn’t appear to be blood flow to the right ovary, which was very visible due to the large cyst.  But Jens says torsion is still a clinical diagnosis (ie. Based on symptoms and physical exam.)  So to surgery she went.  And she ended up having a large mass on the  ovary with a torsion (the ovary twisted with blood supply completely cut off).

And I was reminded that God’s still with me. J

Praise: I finally had my meeting with immigrations and Interpol---so I’m in process of getting my resident visa.  Probably within the next 30-40 days I’ll have it.