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.

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.