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.

Robbed!

                So it turns out that my 4 year old iPhone [that you have to push the central button 20 times before it acknowledges your efforts and that has a battery that runs out before the end of a normal residency work day] is worth $200-$300 (more than how much I paid new) in Peru.  I put my cell phone down for a second when I was on call because an emergency came in the door and then another.  When I reached for my phone it was gone.  Thanks to God and the video camera the thief finally returned my phone (though he denied it a million times, he was stuck when he, his mom, and his aunt were forced to watch the video of him stealing the phone).

                I decided this whole ordeal was God’s pretest for my Lent commitment of giving up self vengeance/ justice taken into my own hands.  So I gave my phone to the Lord and didn’t expect to get it back, and entrusted vengeance to the Lord.  I thought I did well, and then I realized that was just round one. The next day due to circumstances out of my control I had to take a bus to Cusco after 7 PM.  That meant we got into Cusco after 10PM. The Hospital security guard who had given me a ride to the taxi stop kept telling me that I’d get robbed if I took the bus.  With no other option I got on the bus and told him to pray for me.  He yelled back as the doors were closing to not leave the bus terminal on foot for any reason.  I spent the whole bus trip praying and rearranging my valuable so that the most important things to get out of the country (i.e. my passport, cards, and immigration document) where hidden closest to me amount my stuff.  Praise God I got off the bus and into a taxi which took me to my hostel without any glitches.

                So I made it to Houston, Texas where the Brinkleys live (my Texas family who the Lord provided me with as spiritual and emotional support while I was in Medical School in the DFW area).  It was a blessing to blend into the crowd and not be noticed for 4 whole days.  I was able to get a longer tourist visa when I came back into the country and I have my appointment with Immigration next week in Lima.

                While I was with the Brinkley’s they treated me out to the new movie “Son of God.”  It was wonderful.  It’s based on the format of the book of John.  Becky made the comment that she wished they’d not spent so much of the movie on the last week---a thought that had passed through my mind a couple times through the movie.  But I realized that though I didn’t like watching that part, that’s the part that challenges me the most and sets the best example for how I should act in hard situations.  Parables are nice cuz they don’t push you unless you let them.  Jesus walking through the last week with love for his killers and no desire for vengeance (if anything, his last prayer was that God would forgive his murders; which if that happened then God wouldn’t “remember” the incident and justice may not actually be given in the end) challenges me more and inspires me more, and makes it easier to make choices within his will than a million “nice parables” or even the sermon on the mount.

"Ari" is Quechau for "si" (yes)

My name is Quechuan and I didn't even know it.  I tell the hospital staff that my new name is "Sara" "Ari""Mana".  Sara means corn. Ari means yes.  And Mana means no.  I just started a Quechua class on Saturday mornings.  My goal is to be able to butcher their common greetings so that my patients better sense the love of our Lord :)
  Also a praise that I finally got my appointment for my application for Peruvian residency, March 26th.  Once I got to that appointment my application process has begun and in a matter of time I'll be a Peruvian resident (which means it only will cost me $5 to take a train to machu pichu instead of $200. ;)  Unfortunately or fortunately my Tourist visa runs out march 18th, so I have to leave the country and then come back in time for my appointment.  when I was having to decide where to go I was still pretty worn out from my trip to Machu Picchu and not excited about another tourist trip, especially not one alone.  So I sat at my computer and searched travelocity for flights to all the cities that people I like live in [:)] .  Houston won. It was the cheapest and shortest flight without any layovers.  So for anyone interested and in the area, I'll be in Houston from March 16th-19th (short but perfect :).  One good God has worked out of this hassle (other than the fact that I will get to see people I like) is that I'll be able to bring back some of the curriculum for the American kids since they were unable to ship it by mail (which means they'll get to have their curriculum when the start school next week instead of in a month when the next Americans come).
  The other big thing this week is the Diospi Suyana School inauguration on Friday.  Many of the people on the Diospi Suyana board in Germany are here for the inauguration.  There was a crate from Germany with a lot of supplies for the school that got held up in Peruvian customs last week, but thanks to God it made it a here the other day. :)

Girls Weekend Out! and Vengeance

I went to Machu Picchu via Cusco with Erin Morgan (a friend who’s now a 2^nd year resident at my residency program, In His Image), Konika Wright (an American and the wife of Nolan, who’s physical therapist at Diospi), and Luz (the Peruvian general practitioner—she’s in her interim year during which they work in a rural hospital before applying for residency programs).

  Machu Pichhu is a 25 minute bus ride up a 1,500 meter altitude change from the touristy town of Agua Calientes.  We spent a night and part of two days in Agua Calientes, and half a day at Machu Picchu.  They’re so beautiful because they’re on the east (ie Amazon) side of the Andes mountains---so it was junglely and just a little bit humid and about 70-80 degrees.  Machu Picchu was pretty because when we first got up the mountain at 6:30 am, the surrounding mountains were covered in clouds. But as the morning wore on the clouds burned off and displayed the awe-inspiring surrounding mountains and peaks.  I know that what makes Machu Picchu so famous is the fact that they were about to cut and shape the stones so perfectly and get them to the top of the mountain without modern technology----but as the pictures I posted on facebook reveal, I think the view was the most beautiful part of the whole trip.

After we got back from our trip we planned to be in Cusco for Sunday, which ended up being a mistake.  Cusco is evidently very Catholic, so the month of February and evidently at least part of the March is the “month of the Youth.”  Kids, adolescents and even 20 year-olds throw water balloons at each other all month (guys vs girls).  But this Sunday was a million times worse.  You couldn’t walk through any of the plazas without getting drenched and covered in foam.  From talking to the Peruvians it sounds like Cusco and Lima are worse than the other cities because they have less respect for those not wanting to participate.  Also its common for them to cover innocent passerby’s with shoe polish and colored paints.

Lent started today. I’m not Catholic, but Jessica Skidmore got me in the habit of “giving something up” for Lent.  I participated last year with the intent of not ever picking back up the bad habit.  This year I’m participation again.  After getting pretty angry and frustrated last week and weekend at the Peruvians I decided I needed to give up my spirit of Vindication/need for seeking out my own “justice.”  It started with one of my poor Quechan patients (The 25 yo girl I’d diagnosed with mixed Type1/type 2 diabetes a month ago) presenting with severe left eye pain, near blindness in that eye, and a fixed dilated pupil—very concerning for acute glaucoma, which is a medical emergency in the USA.  Our ophthalmologist just went on a 6 month furlough so I spent all afternoon trying to get her a same day appointment with one of the ophthalmologists in Cusco, but failed miserably.  Finally, with Dr. Martina’s help I sent her to Abancy hospital that has 2 optho on call at all times.

                There’s two classes in Peru: the very rich and the very poor.  And the very rich consistently screw over the very poor.  I got frustrated again during the weekend because you can’t trust Peruvians.  They don’t even trust each other.  They all look at any money you hand them very closely to make sure there’s no tears and its not counterfeit.  When I bought our Machu Picchu packet there were all other of details I was later caught off guard by. For instance, we arrived at Hydraelectrica (a city just before Agua Calientes) after a 9+ hour car ride and told that we had to walk 2.5 miles to Agua Calientes carrying all our stuff.  If the lady who sold us the package had said anything about walking (with I had no memory of), she must have not mentioned the 2.5 hour walk with luggage part of it, but that’s not something you miss very easily.  So my second frustration wasn’t just that they exploit their own poor, but that they even exploit those who come to help their poor.

                I was talking to Dr. Martina this week.  She says the problem is that there’s so much bureaucracy in Peru.  And a lot like the Pharisees they care more about their rules than they do about their people.  Unicef (a well known international relief agency) sent the hospital a crate of Hepatitis B vaccines. The Peruvian government held the crate up so long in customs that all the vaccines spoiled at the expense of the lives of their people (Hep B is super common here in Peru and many people are dying from it).

                So rather than letting myself get madder and madder at the Peruvians, for Lent I’m letting God right these wrongs and I’ll heed the Lord’s words, “If they ask you to walk one mile, walk two.  If they sue you and take your jacket, give them your coat. Do this so that you’ll look different from the rest of the world who is nice to those they love and who are nice to them first.” (my paraphrase).

                Please pray for Dr. Klaus.  He’s in Lima right now trying to get a crate through customs that contains materials and things needed for the inauguration of the new Diospi school in the next week.  Also pray that my 25 year patient doesn’t lose her vision.