24: Che

Dr. Jesus Bonifaz Q. was kind enough to provide his office for our use. The office wall contains scriptural quotations (the name of the clinic is “Christian Jerusalem Clinic”), flow charts for diagnosis/ treatment of H1N1 flu, pregnancy stages, and... a poster of Che Guevara.

At the bottom of the poster is an ad for a multinational drug company. Che se da la vuelta na tumba!

P.S, I asked our Ecuadoran translator what people think of Che: “He’s a hero.” A hero to some, Castro's executioner to others.

23: Donde le duele?

Riobamba turned out to be mostly outpatient, a little disappointing, maybe, but okay. Here's a summary from one day:

12 patients, including two men. All 12 spoke only Spanish (I could begin the conversation and understand much of what was said, with an excellent interpreter filling in the gaps).

Abdominal pain: 3
Symptomatic varicosities: 2 (I had brought with me compression stockings for surgical patients, ended up using almost all of them for outpatients)
Enlarged uterus: 1
Bladder prolapse: 1
HPV: 2
Worried well: 2
Persistent yeast infection: 1 (also sees Ecuadoran doctor; I reinforced his recommendations)

The three abdominal pains included:
1. prior abdominal surgery that lasted "15 horas", using an incision from sternum to pubis to remove what I assume was a benign tumor, which has apparently returned and appears to be wrapped around and may slowly osbtructing the bowel; I could only recommend returning in February when MMI returns with a general surgeon.
2. a "7 hora" vaginal surgery that left has left the patient with chronic abdominal pain and some difficult bladder issues.
3. pain associated with an enlarged uterus, heavy bleeding, and stress urinary incontinence which adds up to a sound indication for surgery--pt initially accepted surgery but then returned, and cancelled; it appeared that her husband didn't want her off work for several weeks.

22. Blogging at 9,000 feet

In Ecuador for my 7th overseas medical trip, some words about the previous six (nb, dates are approximate):
#1 Montalvo, Ecuador 2004. Blankets hung over ropes for exam rooms, major gyn surgery in an OR previously used only for cesarean deliveries, real questions about risks and limits of overseas surgery. An evangelical group (mmint.org) with three goals: medical care, support for the local church, and a spiritual experience for the participants, many of whom came with no medical skills or background. These goals were at times in conflict, but don’t be mislead by my habitual second-guessing; a tremendous experience.
#2 Accra, Ghana 2005. The organizer could not deliver on his promises so no real medical work, but whoa, what an amazing place. We stayed with a local family, met with government and church health system administrators. African art came alive.
#3 Chengdu China 2006. A first hand view of modern Chinese medicine (at least as practiced in large cities) . Should Western medicine feel complimented as China hurtles towards a Western health care system? Yes and no.
#4 Vietnam 2007: A medical exchange; I lectured with a bust of Uncle Ho looking over my shoulder; tried to assist with a hysterectomy, only to have language prove to be an unsurmountable barrier; listened to medical students explain why thy chose medicine, a mixture of filial duty and personal, usually negative, experiences with the medical system.
#5 Mozambique 2007: Sounded like a perfect setting: a rural Methodist-funded hospital with two ORs a couple of anesthesiologist, and no local gynecologist. Ii even knew some Portughuese! Though hindered by the absense of any prior screening, I helped with some deliveries and confronted the most difficult hystectomy I have ever done. And an unanticipated bottleneck: the small autoclave (sterilizer) couldn’t keep up, so some cases cancelled simply because there were no sterile drapes/gowns. But also an opportunity to appreciate the perspective of local chronically overworked operating room staff: I came wanting to do lots of surgery; but for them, I just represented extra and uncompensated work.
#6 Guayaquil Ecuador 2008: A group from Phoenix with a local connection to provide access to military hospitals and almost completely self-sufficient (no want of sterile drapes/gowns). In 8 days I saw 50 outpatients and performed 12 major surgeries and a couple of minors. My fingers were literally sore from tying so much suture. Finally.

21. Flu Stories

The distribution of theH1N1 flu vaccine has been unpredictable in terms of both timing and quantity; when our clinic received its first small batch, an email went out advising staff that they were high priority and should go to the injection room to get their vaccine. A few minutes later, a second email arrived: "Make sure if you come up to the fourth floor injection room check in, that you are quiet as to why you are here. Patients are told we do not have any flu vaccine in our clinic. Thank you."

Two public servants in Alberta were fired for having provided the flu vaccine to members of a professional hockey team, disregarding established priorities. The team doctor who ordered the vaccines, and the team manager who concocted the scheme suffered no repercussions.

Somehow our clinic in Federal Way received more vaccine than it needed. Tacoma was short. No problem, we said, just put some in a box and bring it to Tacoma. Nope... it seems that vaccines can’t cross county lines.

20. Priorities

A 28-year old in her 26th week of pregnancy is in the ICU, near death. The pandemic flu. A story repeated across the nation.

Meanwhile in the clinic patients are dithering about whether to accept the vaccine, especially the preservative-free vaccine, which was available first.

19. Whatever Works

I complemented A. on her well-behaved daughter, quietly sitting in a chair during her mother's antepartum exam.

"Oh, I just told her she was getting a shot."

18. Twilight

J. delivered on Halloween, naming her baby girl Bella. I don't know whether the Twilight series will have much staying power, but if it does, then in about 15 years her daughter will either think that her mother was awfully clever or had a misdirected sense of humor.

J., though, is clueless: "Twilight what?" she says.

17. And the Answer Is

Link from Zelda

16. Multiple Choice

One of those everything-went-according-to-plan deliveries yesterday, a girl to be named Adelaide. Their first child is Link.
I asked the origin of that name. What do you think?
A. One of the leads in Mod Squad
B. As in link to a website
C. protagonist in Legend of Zelda
D. Short for Lincoln.

15. DV

Domestic Violence yesterday
1. R. raped by some one she knows; won't tell his name because she's afraid of reprisal.
2. S. is pregnant; her estranged husband threatens to come to the hospital with a loaded gun to take the baby.
3. J. was kidnapped by her husband, driven around while deciding how to kill her (so he said). She quietly dialed 911. A dutiful dispatcher kept the line open and with GPS technology the police rescued her.

Why this local epidemic of DV? Must be the threatening storm of gay marriage

14. Calling Dr. Ruth

Dr Ruth (still going strong at 81) told us to call it like it is: vagina, penis, cliterus, scrotum and so on. An honesty is the best policy approach. My patients are seldom so forward, though when they talk about "having sex," or being "intimate," the message gets through. But today S. would only allude to, "when my husband and I do adult things." You mean like drinking, or voting maybe?

13. Someone Famous

There are 9 of us in the department, and when a new patient makes an appointment, she has the option of first looking at our photos and a "bio."

T. said she picked me because I looked like someone famous, in this case Dr Zorba from Ben Casey. She is not the first patient to have made this connection. Other patients have mentioned Billy Crystal or Dr House. I like to think that I have the authority of Dr Zorba, the bedside manner of Billy Crystal and the medical knowledge of Dr House. Though I wouldn't mind if I just brought Ben Casey or George Clooney or even Matthew Fox to mind.

12. Who's Paying the Bill?

The Mirena IUD embeds a hormone inside a plastic T. Inside the uterus the hormone both suppresses the uterine lining and thickens mucous in the cervical canal, while the "T" triggers an inflammatory response. A three-act contraceptive, good for five years. At about $500, that's $8 a month for very effective birth control. So L. has a Mirena inserted, paying just a $15 copay for the office visit. Three months later she and her husband decide to try for another child and has the IUD removed. The IUD of course is discarded. How will health care reform fix this?

11. It's Not About the Money

After the delivery, I returned to the ER: J. is 34 and childless, with two weeks of pain and fever and a large pelvic cyst which is probably a tubo-ovarian abscess. With antibiotics and the cyst drained, she'll be okay. She just can't pay a hospital bill that may reach $10,000, which the hospital will just pass on to its insured patients, leaving J. with a bad credit rating. So? It's not like she's in the market to buy a house. But let's say that health care reform would give her access to outpatient health care. Would she have gone in earlier? Would earlier invention have protected her fertility, which I expect is now non-existent? Health care reform is not about money, it's about health.

10. I Think So

Down in the ER admitting a patient (more to follow), and a young woman is brought in on a stretcher, obviously in labor. Not my patient, but hey, I'm there, so I check her--complete dilated and ready to push. Just like on TV: straightaway we wheel her towards the elevator, grabbing a "precip" pack on the way (the basic instruments for a "precipitous" delivery). We manage to avoid an elevator delivery, but just by a few minutes. Afterwards, someone asks a pretty obvious question (I think they were working up to something more): "Were you in labor at home?" Her reply: "I think so." Well, yuh.

9. Bizarre

Remember the 50-something who came in with what she thought was a labial wart (and knew that genital warts are STDs)? It looked looked like a wart but sounded like herpes (itching, tender); biopsy showed herpes; so I tested her herpes immunity which suggested exposure in the distant past. I explained (trying to be as discrete as possible) that this could have been the result of a peck on the cheek from a cousin with a cold sore, that found its way down south. Granted this is unlikely, but the appearance of a herpes lesion is no reason to reevaluate a marriage. Dirty socks on the floor, yes; recurrent herpes, no. Her reply? "Bizarre"

8. Will the Real Father Please Stand Up

A. is a 20-something Asia-born dealer at a casino. And pregnant. Soon after breaking up with a white boyfriend, she started going with a Cambodian and is not sure who is the father. She's okay with not knowing: "they're both good guys."

M. is a 30-something former exotic dancer who supported a deadbeat husband and three kids for years until she decided that she couldn't keep on dancing for much longer. She decided to become a security guard, which requires some course or certificate which she duly earned. In the process of this mid-course correction she also kicked out her spouse--but not before having sex with him one last time. A week later she was in bed with his brother. Now she's pregnant. I'm not sure if current DNA testing can tell who's the father. But that's the least of her problems. She's pregnant and looking for a job as a security guard, wondering how she's going to support her family.

7. Thinking Clearly

At 46, M. has a problem list that one would expect at 86: heart failure, liver failure, diabetes, morbid obesity. So she takes seriously the living will that every hospital admit is encouraged to discuss. "If there is a problem with the surgery," she says, referring to a relatively simple excision of an ovarian cyst, "and I don't wake up, then just turn everything off. I don't want to be on all those machines if I'd wake up and not be able to think clearly. But if I'll still be able to think clearly then do everything you can." I like M. Dr. House wouldn't, but I do.

p.s., she did wake up, the cyst was benign, and her thinking is quite clear.

6. ER

24 year old, mother of two and now 16 weeks with a third. Bipolar. Her doctor told her to stop taking her antidepressants (the kind of doctor who would tell her she'd go to hell for drinking a glass of wine during pregnancy). She complied (most of us like to think of ourselves as not needing to take any medications). Depressed moms don't make good moms. Now suicidal and infanticidal, she was seen hitting herself on her abdomen as hard as she could. Tackled by police as she tried to leave the ER. I was consulted regarding the need to hospitalize her against her will to monitor for possible placental abruption. No bleeding, no cramping, normal ultrasound; I said no.

5: HSV or HPV

Remember the 54 yr old matron who was concerned about the appearance of a genital wart and her concern that it was an STD? Well, I biopsied it, and it turns out it was not HPV but HSV: herpes! I've yet to reach her but can offer her some immunity testing that will tell us whether this is a newly acquired herpes or a reactivation. Will she accept or leave well enough alone?

4. The Clock Is Ticking

A's mother died a few months ago after a brief, unexpected illness. Current boyfriend "is the best yet," but they have been arguing lately. So no surprise that her cycles have been off-kilter lately. Helpful friends tell her she may be entering menopause which is frightening because she still wants to have a child--just not now. I reassured her that at age 37, menopause is unlikely but acknowledged that the clock is ticking and she shouldn't wait too long

3. Deadlines

Really needed to leave clinic by 5pm (usually I leave at 5:40 to catch the 5:50 bus). Down to the wire: at 3:30 I'm waiting for an Implanon insertion (subdermal contraceptive), having caught up on everything else. There's a 4:00 new referral and a finally a 4:30 checkback. The 3:30 showed up at 4:00 so I asked that she be rescheduled, something I do about once every 5 years. At 4:15 she's in the waiting room crying, so I said, okay I'll see her, but she has to wait for the others. The 4:00 was late and complicated, 54 yr old with vulvar wart wondering if it is an STD. My reply evasive. I started with the 4:30 at 4:55. She had lots of questions; finally finishing around 5:30. So I finally meet Ms Implanon. She looked like she just came out of a Vermeer painting. How could I have been so mean to her? We talked and decided to go for an IUD instead, which was done by 6:20; one last but important phone call; made the 6:40 bus.

2. Miscarriage

An email from a patient who recently experienced a miscarriage:

"But for now to get over what a failure I am I will have to bury myself in my school work and work as at least these are two things that I am not a failure and do have some type of control over."

1. The Living Fields

Heng is a community call patient, meaning either no insurance or no established relationship with a local specialist. Her employer offers insurance but she didn't understand how to sign up. She is Cambodian and though speaks good English I can understand how such issues would be difficult. But her daughter will help and in a few months she may be able to have her enlarged uterus removed, a uterus responsible for bleeding that has left her with just half the blood volume she's supposed to have, prompting the ER visit an my interview.

 The same daughter who was born in a Cambodian field as Heng and her father fled Vietnamese bombs. As she told the story I could see her reliving the fear of that day. "Run faster," her father pleaded, neither of them understanding that she was in labor. Finally she had to stop, and attended by her father with only a pocket knife, gave birth.