Life and Death

Dad says I need to write more positive things and less negative things in my blog.  So I wrote the previous two stories first and I’ll end with this one, which is only half negative.  The problem is that medicine is caring for people, and a lot of times life, death, and pain are involved.  The great thing is that’s when you see God the most.

                So this hospital is more technologically advanced than the rural hospitals I moonlit in.  Usually the equiptment and meds aren’t the limiting resource.  We do try to be good stewards of cost.  Usually it’s the doctors and specialists who are limited.  Here’s an example of the level of care we’re able to give here.  I admitted a 55 year old male with hemoptysis (blood in sputum with cough) and pneumonia—the left lower lobe of the lung was whited out on the chest xray with some infiltrates in the left upper lung as well.  He also had a huge (~5cm) cyst in his liver probably [Ecchynococus is common here.  It’s a parasite spread by dogs and causes huge cysts in their liver, lungs, pancreas, etc.  Treatment is albendozol for months, though usually they need to be removed surgically].  He improved and then worsened and went into septic shock (low blood pressure that doesn’t respond to fluids due to infection in the blood).  The old CT scan broke (a new one is due to arrive in March or April), so we couldn’t see exactly was going on in the chest (whether there was a lung cancer [he had a history of tobacco and alcohol abuse] or lung abscess or what), but the entire left lung was whited out on repeat chest xray (though he was moving area better).  With the major help of the visiting anesthesiologist from Germany he was intubated, placed on the vent, started on Norepinephrine, Epinephrine and eventually doputamine and Amiodarone drips to maintain blood pressure and protect against arrhythmias. These meds and the ventilator are something I’ve never had access to before in all the mission hospitals I’ve ever worked in.

   He eventually went on to be with the Lord.  But on a good note, I got to wake up at 2:30 AM two days ago when I on call and over see Alex, the Peruvian OB/GYN visiting resident, deliver a beautiful, healthy baby girl.  I asked the mom for the name of the girl.  She said they were still deciding between two names.  Alex says in Peru they don’t have to have a name before they leave the hospital and sometimes they take up to 9 months to choose a name.  I told the mom she should name her Ria (which is from the verb “to laugh”), because she kept crying and crying and crying…which is acceptable only at one’s birth since it helps open the lungs up. J

To Be “Good Enough” to Be Saved

I give lots of “you need to lose weight” talks every day.  After one of these talks, after the patient left the room my nurse who helps me order labs and imaging and helps me write prescriptions and helps me educate my patients as well starts talking to me as I’m finishing up writing my note.  Maruja was the name of the nurse who was with me this particular day (I have different nurses every day , if I get one at all).  She starts talking about how she wishes she was content with what she ate “like I am” so that she could be “thin.”  I talked to her about the book I’d read, “Made to Crave.”  How the root of most of our problems with food is we eat to fill our emotions and pain and emptiness and not just for nourishment.  That’s why we eat what taste good.  That’s why we have such a great and bad problem in the USA.  Our food tastes good even when you’re not hungry.  I talked to Maruja about going to God to be filled and that self control is a fruit of the spirit.  Something that is a product of letting God and the Holy Spirit have more and more reign over our lives.  Maruja then said that she was raised Catholic and had only been baptized as an infant.  I asked her why she didn’t give her life to Christ now publically in baptism, since from talking to her I could tell commitment wasn’t the issue.  She was already trying to live for Christ, she’s just human.  She said she was waiting until she was ‘a little better,’ a ‘little’ more faithful at attending church, praying and reading her bible.  Sounded familiar.  That’s how and what I thought when I was 11-15 years old.  Until I finally gave my life to Christ publically in baptism at age 16.  Yes I was living for him before then, but here’s the 100% true retrospective statement.  I was trying to be “good” and live for Christ from my own strength prior to my baptism.  After my baptism, looking back I can see the initiation of the fruits of the spirit in my life: self control, love, peace, etc.  Especially self control/discipline.  Goodness is a product of a relationship with Christ, not what earns us the relationship.  Please pray for Maruja and her faith.

All Things Come in Threes

One saying we have in medicine is that all things come in threes.  That means if you admit someone with pneumonia, you can expect two more are on their way.  To me this “coincidence”, which has happen numerous times throughout my training, is actually the providence of God.  Because after you’ve seen a medical condition present three similar but different ways, and you care for all three patients at the same time, you’ll never forget ever again.  One of these “providences” actually occurred this week for me. A condition that occurs commonly in Peru for whatever reason is rheumatoid arthritis.  I’d yet to have diagnosed this condition—though I found lots of osteoarthritis due to patients age, long history of manual labor, and being overweight. 

                My first lady was in her 40’s, had be diagnosed with “maybe arthritis” two years earlier at a different hospital and started on Prednisone (an oral steroid) 5mg twice a day, and was suppose to follow up with that doctor.  The Prednisone worked well for her so she continued to take it for two years.  (Two issues here.  Number one, patients don’t need a prescription to buy medications here, or at least not new ones.  Number two, prednisone is a very dangerous medication to take chronically, even when you have a doctor monitoring side effects and weighing risks and benefits of the meds in light of your particular situation/medical condition.)  Her rheumatoid factor came back 250ish (normal is less than 14).

                Later the same day I saw a 42 years old lady who looked cachectic and chronically ill.  When she took of her three pants and skirts to show me her knees that were hurting her I saw thin “chicken legs”, especially the left leg, with huge swollen, warm, painful to touch, knees.  She walked with great difficulty, much pain, and a limp. Her fingers were also painful but not as noticeably swollen.  I ordered some labs to evaluate for chronic illness and xrays of the knees.  Her left Knee joint was literally bone on bone.  Not even a millimeter of joint space.  The right knee joint had 1-2 mm in a couple areas of the joint.  The labs all came back normal except for her rheumatoid factor was 4500ish.

                As I was about to go home after seeing my patients for the day, I got a call from the hospital floor.  I was on call and a 26 year old male had just arrived to be evaluated for knee pain.  I took one look at him in a wheel chair with thin legs, huge swollen tender knees that hurt him even as I lifted his feet to pull his pant legs up.  Third time’s a charm.  I gave him a Toradol injection and a lab slip for the next morning since it wasn’t enough of an emergency to call the lab people in.  The next day his rheumatoid factor came back 300ish.

                I talked to both Kirsten and Dr. Martina and confirmed their recommendations with UpToDate when I got home and had a slightly faster internet connection.  Methotrexate is the mainstay here.  A Prednisone taper and Meloxicam are what you given to work immediately and make them love you and trust you. UpToDate says to consult a rheumatologist before starting Meloxicam….I guess we’re rheumatogists now. 

                P.S.  I saw a Juvenile Polyarthritis the next day.  Eleven years old female with warm painful ankles and elbows.  And with pain in her fingers as well. Treatment is similar.  Start Methotrexate early.

THE SYSTEM

When I first got here I wasn’t expecting the level of medical care that the government provides the people.  If you have a job you have one type of insurance, if you’re poor you have SIS (another type of insurance).  If you have cancer and have SIS you can go to a hospital in Lima and they’ll cover your chemo/radiation and all treatment costs.  The poor have access to the other specialties as well.  When I realized all this I questioned the need for Diospi.  But in no time I’ve seen the problems in the system and why the lines for Diospi continue to be long even though more and more doctors arrive.

                Yesterday I was working the ER and a 39 year old lady came in complaining of pain all over and breast pain.  She showed me her breast.  It was red, warm, deformed and hard with cancer.  I began to question her about her medical history, what treatment she’d had for her breast cancer, who was taking care of her and why she’d come to Diospi if she was receiving free care elsewhere.  She’d been diagnosed with intraductal malignant breast cancer in 2011.  They’d done a lumpectomy and a lymph node dissection (the lymph nodes were positive for cancer).  They’d given her 20 rounds of radiation therapy and she was still currently taking Tamoxifen. Evidently it was “gone” after all this treatment but then “came back” in August 2013.  She just managed to get an appointment with her hematologist in Lima (a 28 hour bus ride from Cusco or a 45 min flight if you can afford a plane ticket) a couple weeks ago.  They took a biopsy of the recurrent breast mass, gave her a follow up appointment in March to discuss the results, and told her maybe they’d have time to remove the mass for palliative care in July or August.  She also had what appeared to be a pathological fracture (ie the bone broke with little force or trauma because the bone was weakened by cancer eating away at it---likely metastatic cancer) of her clavicle on the right side of her chest as well that occurred in August 2013.  They’d sent her home with over the counter Tylenol/ibuprofen for pain control.

                I ran her case by a couple of the doctors here that know the system well in order to know how I could best help her.  She’d come to Diospi for a miracle. She’d come to Diospi because patients are treated and care for as individuals and not a just another symptom or problem.  Unfortunately, her best resources were in Lima.  Through her insurance and current care plan she had access to hematologist, plastic surgeons, etc.  All I could offer her was the love of Christ, pain medicines, and encourament.  She told me she had a strong faith in Christ, but I could sense her desperation and desire for hope.  I tried to fill this need with words reminding her that Christ is with her through this even if he doesn’t cure her and that we’re his hands and here to help her be comfortable and walk through this trial with her.  I think we’ll never truly know the impact that anything we say or do has on the lives we encounter, but I took her tears and a sign that she felt at least enough comfort to let her emotional guard down.

                You can definitely be praying for Mrs. Consuelo and her family. She’s only 39 years old, married with 2 or 3 children.

Why’s a Baby Shower called a Baby “Shower?”

This was the question that one of the German missionaries here asked me.  Evidently baby showers are American in origin.  Baby Showers don’t exist in Germany.  But due to the new American presence here in Curahuasi, the second ever Baby shower was thrown Monday.  It was for Tabea and Annett.  Tabea is the wife of Stefan (the hospital administrator) and is due soon with their second child. Annett is the wife of Michael (the maintenance administrator) and just had their 4^th child (1^st boy).  It was the first baby shower either of them had ever had.  At the end as they gave their thanks to everyone who came.  Of note, Tabea (deeply moved) told how they’d just moved just prior to the birth of their first child in Germany and had had very little if any help and support. 

                It was funny to watch the baby shower. It was hosted by an American (Alison, Dr. Will Caire’s wife) and a German (Demaris, Dr. Jen’s wife).   The majority of the crowd had never been to a baby shower before.  So when it came time to open presents, initially everyone came up all at once to give their gifts and Tabea and Annett opened them at the same time without showing them to everyone (there were about 30 guests total).  Alison tried to gently instruct them on “proper Baby Shower etiquette” J i.e. showing each gift as its open so everyone can enjoy it, and finally managed to somewhat succeed.

                Nearly everyone staying in the apartments at the hospital together made a Quite Book out of material, buttons, zippers, Velcro, etc for each baby.  Even one of the Peruvian tile layers who’s working on the school right now and the uncle of one of the volunteers at the Hospital who’s visiting for a couple weeks helped out.  When some of the ladies in charge of the school saw the books they asked us to make 3 more.  We all responded the same: no, thanks. :)  Each of us made one page, and each page is so intriquet and takes so long to make because of cutting out pieces and sewing, especially at the end of a long day of work, that though one page was fun to make, we were glad to be done :).