A final blog post about la fuente

This is my LAST WEEK OF MEDICAL SCHOOL!!!

I am working three days this week at the clinic and then we fly out of Cusco on Thursday morning.

When I walk out of the clinic tomorrow, it will be my very last time wearing a short white coat. Also, at least for the foreseeable future, it will be my last time seeing an adult patient.

I have loved medical school, as it has been the culmination of a lifetime of dreaming. Ever since elementary school I have wanted to be a doctor…at times my obsession was self-serving (I wanted to do something impressive and make money) and at other times the dream felt impossible (when I started off college with mediocre grades). The Lord was gracious to change my heart and to help me get accepted to Tulane. Now that this much anticipated chapter of my life is going to end, it feels surreal. It’s not that I don’t want it to end (believe me, I won’t mind not receiving another grade for the rest of my life), but I do kind of get emotional realizing the thing I wanted so badly, for so long…it will be over in 11 days. Or should I say, just beginning.

There have been many highlights along the way, but for sure my 2 month Family Medicine rotation here at La Fuente stands out as the single best learning experience of the past 4 years. The doctors here are true examples of what it means to serve/love your patients and I hope that I can adopt their compassionate approach to patient care.

Here is an excerpt of the things I listed at "the strengths" for my feedback evaulation for my Intl Family  Medicine rotation

-The number one strength was the dedication to compassionate care the physicans exemplified. I was literally in awe of the capacity to serve, listen, care for and be patient that the doctors showed.

-The doctors LOVE teaching and it’s a charity-based clinic, so there is no rush to see patients to make more money. When there wasn’t a line out the door, the doctors loved taking time to discuss differentials for basic complaints like  “abdominal pain” or “headache”. I felt very challenged to be thinking critically with every patient

-I got to see active cases of Leishmaniasis, Tuberculosis, yellow fever, acute altitude sickness, a host of rare parasites, and life-threatening diarrhea (all diseases I never got to see in New Orleans).

-I got to see the differences between the American hospital system and the Peruvian system. I left feeling that despite the brokenness of the US system, it could be a lot worse and we have a lot to be thankful for.

-I was forced to use my Spanish for hours, every day, a challenge that I eventually found to be fun.

-You really feel like you are a part of something special, from the nurses to the cleaning lady to the doctors. Everyone who works at the clinic believes in the mission of serving the poor in Peru.

a few nurses and a dentist during one of our staff devotion (we met for 15 mins of bible reading and prayer every AM)

Dr. Derick Brubraker (my precepting Doctor)

Dr. Wilson on the Right (my favorite pediatrician!) Working with a 3rd yr peruvian medical student

Nurse Nancy....working at her triage desk

a view of the clinic

another view of the school...dentistry and pharmacy to the Right

Blog post about the craziest patient ever

As one of my other recent posts noted, I am in my last week of medical school. And fate had it that the single most fascinating/wild patient encounter of my 4 years of medical school occurred this week!

A 20 yo girl came in today to discuss her 1 month of “stomach pain” after drinking soda (which she drinks 5 days/wk, despite realizing the connection between these drinks and her pain). We talked about this subject, as well as her shortness of breath, induced with exercise for the past few years. As I do with all patients, I followed our conversation with a physical exam. Everything seemed normal (lungs were clear/ eyes reacted to light/ heart beat was normal), until I had her lay down for the abdominal exam. At first glance, her abdomen just seemed really large to me (out of proportion to the rest of her body). I started pressing on her protuberant abdomen and felt something similar to a mass in the lower-half of her abdomen. At this point of the visit…I panicked, left the room, and told her I’d return with the real doctor!

In my mind I thought, either she was a really strange sort of FAT or she was PREGNANT! I started replaying our conversation in my mind, I had asked her about her periods and she stated they were normal (5 days of blood) and regular (came every month), and her LMP was on the 25^th of April.

I left the room and said to my precepting doctor, “she looks and feels super pregnant”, but she has normal periods and didn’t mention anything about being pregnant. I should have asked her more questions after my exam findings, but I was too embarrassed (as I didn’t want to imply she was pregnant if she was simply overweight). While discussing the patient, we had the nurse obtain a urine analysis looking for an infection, and a urinary pregnancy test (the main reason for the urine analysis was to have something to tell the patient as we asked her for the urine sample).

The urine pregnancy test came back POSITIVE, as this point we didn’t know “if she knew, and was simply assuming we knew” or “if we had some big news for her”. I went back into the room with my supervising doctor, and started with a bunch of repeat questions. Asking specifically about her period in January, February and March confirming she had her normal cycle for the past few months. We also asked her if she had a male partner or boyfriend, her response to this question included an alleged “I have never had sex before”.

Normal periods for the past few months and a virgin--the news that she was pregnant was obviously not going to be expected. So much so, that she even denied its possibility after we showed her the pregnancy test results. We then got out the Doppler ultrasound machine and were able to auscultate the baby’s pulse (which was around 140 beats/min, compared to her pulse of 70 beats/min). We asked her to listen to the noise and she still maintained that it must be her pulse making that rapid noise. We measured her fundal height, which in centimeters roughly correlates to weeks-gestation: 26 weeks pregnant!

That’s 6.5 months pregnant, if she delivered today, the baby is old enough to survive…and yet she had no clue she was pregnant. On so many levels this case amazed me.

In talking with the doctors at the clinic, this was the first time any of them had heard of a pregnancy being diagnosed via “physical exam”. Most (all) people find out they are pregnant many, many months before a doctor would be able to touch their abdomen and palpate an occupied uterus.

Maybe she was lying about her periods and her history of no sexual activity (and she suspected the pregnancy), but if this was the case, she was an incredible liar. I honestly believed she is in complete denial and really believed that being pregnant was impossible. Whatever the case: Immaculate Conception? Honest obliviousness? Lying? It was a really good reminder to me why I must always do a physical exam on every single patient! 

she thought that the baby's heart beat was her own pulse

A blog post about a dream coming true

I had a lot of expectations about Peru before we left in January, and most of them have been met or exceeded. However, I had one specific dream before coming here that had yet to be fulfilled in the past 4 months: I wanted to play a legit game of soccer with Peruvians.

This past Sunday, a group of Peruvian medical students invited me to play in a mini-tournament of 6 medical student teams. I immediately said yes, and even went out and bought brand new soccer cleats.

I arrived 20 minutes early and started stretching, my anticipation was high as my dream was finally coming true. My team arrived a few minutes later, but 70 minutes later…we were still waiting for our game to start (bad sign #1). Then we started playing and I was the lone player they had sit on the bench to start the game (bad sign #2). Then half-time passed with me still on the bench (bad sign # 3). With 10 minutes left in the game, they subbed me in and I got to play…I made one mistake and basically didn’t get near the ball again before the game ended. After the game, the captain told me I’d get to start in the other game they were playing that day. We waited another hour until our second game, only to find out the other team wasn’t around and had to forfeit…hence no game #2 (bad sign #4).

At this point, I had been at the soccer field for about 3 hours, had my new shoes on, but hadn’t really gotten to fulfill my dream. A few players on our team packed up their stuff and started walking off. I was trying to laugh about the situation, but the comical randomness of the situation was not making me feel much better.

Finally, somebody suggested we go play a pick-up game on our own. We set up for 5 on 5, with smaller goals and started playing soccer. We played for the next 90 minutes without taking a break and I had a ton of fun! My team won 10-7, and I scored 3 goals. Although I was nowhere near as good as some of the guys, I felt like I held my own (or at least didn’t suck that much, which would have been pretty bad considering my new cleats are neon green and call a lot of attention to myself).

Anyways, it was a great day and it rekindled my love for team sports (hoping to find some time to join an adult soccer league once we move to Tacoma). 

our team! captain was the goalie. I missed the memo on the MAN U jerseys. Also, notice my lime green shoes

natural medicine...working through my bias

I was not given a ton of instructions or guidelines about what this blog had to consist of to obtain credit for my international family medicine rotation, but at one point I was told to “reflect/process”, not just record what happens to me here.

This post is an attempt to process the things that I have seen related to healthcare that are quite different from western medicine.

In Peru there is a type of Tea for every single specific medical ailment. Take chamomile tea for upset stomach. Take black licorice tea for headaches. Take coca tea for altitude sickness and for digestion problems. Take lime tea for heart problems. Take peach tea for kidney problems. (Take a combination of 5 different teas to help with sleeping issues). It’s not that I dislike the emphasis on tea…I find it tasty and warm and soothing when I have a sore throat. But, my western-medicine brain finds it very hard for tea to solve these problems on a physiological level. How is lime-flavored tea going to reverse the pain of angina? How is peach tea going to treat a kidney stone? In the end, it seems semi-harmless to address all of these problems with teas, but what if drinking tea means someone stops taking their blood pressure medicines and their kidney failure worsens? Not so harm-less in that case.

Along the same lines, but a bit more absurd to me is the conversations I have had about “the herb de cancer”. Supposedly, if you have been diagnosed with cancer, you can use an herb (eat it or drink it in tea) and your cancer goes away. One time I was told a story about somebody’s aunt. She had been told she had metastatic breast cancer and only had 6 months to live. She refused surgery and chemotherapy and only drank the “herb de cancer” tea 3 times a day. And now she is still alive, 20 years later.

Great story, and I hope it’s true, but I highly doubt it. I’d like to see a control study where people with cancer drink “herb de cancer” tea and others drink black teas and a few years later we see whose still living 10 years later.

Now I know this makes me sound arrogant, quickly trashing these herbal and tea-based treatments because they are not scientifically proven. I know that there are many things that natural medicine remedies treat quite well, but in a society that relies so heavily on this approach to serious diseases, it’s hard not to be suspicious and concerned. This internal struggle I’ve had while witnessing a heavier reliance on natural approaches than I’ve seen in the US has reminded me of an amazing book I have read twice: “The Spirit Catches You and You Fall Down”. It is a very enlightening book that deals with a lot of the flaws that a western medicine approach has when it comes to treating patients that come from a vastly different cultural background.

At the end of the book, the author consults a Harvard Anthropologist about what he might have suggested the doctor do, to avoid the myriad of frustrations that developed....

Kleinman’s Eight Questions for Cultural Assessment 

1. What do you call your illness? What name does it have? 

2. What do you think caused your illness? 

3. Why and when did it start? 

4. What do you think the illness does? How does it work? 

5. How severe is it? Will it have a short or long course? 

6. What kind of treatment do you think the patients should receive? What are the 

most important results you hope the patient receives from this treatment? 

7. What are the chief problems the illness has caused? 

8. What do you fear most about the illness? 

These questions have been a good source of guidance for me...

The bottom line is this, there will always be things that I feel comfortable saying are right and wrong, regardless of how culturally sensitive I strive to be. 1) rubbing fecal matter on a wound is not a good idea. 2) bathing in urine doesn't do much 3) herb de cancer isnt all its cracked up to be (the secret would have gotten out by now) 4) depression is a real illness 5) child abuse (physical and sexual) is evil 

it was a crazy adventure

First off, I need to apologize: this will not be my most interesting post. Last week, I went on a 3-day trek with Clint Barnes (one of my closest friend’s older brothers) and two new friends. Due to a set of complicated circumstances, we needed to do the “Salkantay trek” a commonly done route…in the opposite direction. Usually most paths are walked in two directions, but this hike is not one of those.

Why? The normal direction consists of a difficult Day 1 with 700m of elevation gain to the pass, followed by 3 days of going downhill. Our route consisted of 1 day of relatively flat hiking, followed by 1.5 days of 2600m of elevation gain (over 8500 ft), finished with a few hours of downhill.

-In total we went uphill about 4x more than most people do when they do the Salkantay trek.

-We also carried our own packs, something we did not see a single group do (the tour companies use 10-12 donkeys to carry all the gear/supplies)

-We also did our hike in 3 days, instead of the allotted four days to go the easier direction

In spite of being the single hardest physical activity of my life…it was an amazing trip!

The group dynamics were great from the start, and I truly feel like I made 3 new friends. Clint and Aaron had been in Lima the week prior to our trip, as they work for two different NGOs that do development work in Peru. Clint works with starting savings accounts for people in areas that usually don’t use banks and Aaron works for an organization that gives out loans/grants to private Christian schools in developing countries. Beyond the work they each do, they are just really genuine guys that I grew to look up to as the trip went on. If I could summarize why I found these guys so unique; it would be their openness and their ability to reflect and analyze themselves. I have heard many times that ‘knowing thyself’ is a very important thing. At times I have had bold friends and a patient wife who have had the courage to help me see the things in my life that I couldn’t see, and I know this has been helpful in avoiding sin and maturing. Anyways, being with Clint and Aaron was a refresher on how attractive it is to be around self-aware people.

I didn’t bring our nice camera on the trip, so I am hoping that some cooler/more impressive ones show up on facebook soon…but here are a few I took with my point/shoot

a millipede...gross/awesome

first day was flat and along the railroad track

clint barnes...crossing a sketchy bridge

travis, cool guy from austin, tx

brutal sun, big packs...

aaron roth, balancing across another sketchy bridge

JIMMY!!! the hero of our trip, jimmy was our guide on the inca trail 3 weeks ago, and he was the first peruvian in 2 days that gave us reliable advice! 

SALKANTAY!!!

the top...with my life in the fast lane t-shirt

Blog post about parenting and a child at an orphanage

Last week I was working with Dr. Nathan Wilson (pediatrician from Georgia, see older posts) and the patient flow was a little slow. We began to discuss the role of a pediatrician with regards to parenting. I usually cringe when someone gets on their soapbox about disciplining children (mostly because my brothers and I were certifiable terrors as little boys…and we all turned out decent). However, his opinions and perspective on the matter were valuable, so much so, I am going to share a bit of what we talked about. 

First off, he strongly believes that Pediatricians have a major role to play in assisting parents in the job they have to raise children. He thinks that one of the boldest and bravest forms of loving a child is by being willing to discipline them. Essentially he was saying that leading children towards God (through discipline) is a necessity for any Christian that has the chance to interact with kids, especially a Christian who is in the position to provide advice to malleable parents.

Duet 6: 1-2, 5-9

These are the commands, decrees and laws the Lord your God directed me to teach you to observe in the land that you are crossing the Jordan to possess, ² so that you, your children and their children after them may fear the Lord your God as long as you live by keeping all his decrees and commands that I give you, and so that you may enjoy long life....⁵ Love the Lord your God with all your heart and with all your soul and with all your strength. ⁶ These commandments that I give you today are to be on your hearts. ⁷ Impress them on your children. Talk about them when you sit at home and when you walk along the road, when you lie down and when you get up. ⁸ Tie them as symbols on your hands and bind them on your foreheads. ⁹ Write them on the doorframes of your houses and on your gates.

“so that your children may fear the Lord”

“impress them upon your children”

A big theme he centered on was the sinfulness of disobedience, which cannot be excused simply because a child is “a kid”. This is something that I had a hard time easily swallowing. Sure, if I see a 4 year old kid in a mall yelling bad words at his mom and throwing a tantrum, I might lean towards judging such a parent as failing at some point along the way…but even still, my natural inclination is to extend lots of grace to that parent and simply assume there is more to the situation then I realize. In my mind, there is a good chance the kid is just really nuts. To open up my mind a bit, he shared this passage with me…

Ephesians 6: 1-4:

 Children, obey your parents in the Lord, for this is right. ² “Honor your father and mother”—which is the first commandment with a promise— ³ “so that it may go well with you and that you may enjoy long life on the earth.”

⁴ Fathers, do not exasperate your children; instead, bring them up in the training and instruction of the Lord.

The call to children is to obey and the call to parents is to bring them [their kids] up in the training and instruction of the Lord. I am obviously not a parent, yet…but up until this point, I would have been completely ok letting this passage remain between parents and their kids. Not really wanting to get involved as a Pediatrician, but what Dr. Wilson argued is that when there is obviously a clear lack of anything resembling an obedient child, it is very important for a trusted Pediatrician with an established relationship to speak a word of wisdom into the situation. Remind the parent that their children are to be subject to them, not vice versa. Remind the parent that discipline/punishment with explanation is a loving act.  

I mostly wanted to write this post as a way to process/reflect on one man’s opinion. I also wanted to remark that it was surprising to me how universal and easy it is to recognize a child who never hears the word no and who lacks respect for their parent. Even in Peru, I’ve seen parents promise toys, just for letting me shine a light in their 5 year old son’s mouth. I don’t exactly know what sort of application I might take with me from this conversation, but I do know that it is a topic worth exploring as the topic of parenting will be unavoidable as a Pediatrician and hopefully very personal for Me as a future Dad (in a few years, hehe). 

On the flip side, I am going to describe the situation of a little girl that I saw in the clinic twice this week. A story not really dealing with the nuances of parenting/discipline, but rather a story about what happens with a complete lack of parenting all together. 

Arlet is 3-ish years old, her mom was abusing alcohol during the pregnancy and while breastfeeding. Last week she arrived at an orphanage here in Cusco. This little girl weighs 8kg (average 3yo: 15kg, 3% for 3yo: 12kg) ....8kg is the 50% for a 7 mo-old. So more than 50% of 7mo-olds weight more than this 3 yo girl! 

She also only can eat liquid foods, not because of something physically wrong with her mouth/jaw, but because she has never LEARNED how to chew. It's a habit she was never taught. 

She has had diarrhea ever since she arrived at the orphanage and she does not speak, not even words like mama or papa. 

As sad and heartbreaking as this girl's situation is, the two caregivers from the orphanage seem very loving and attentive, AND the little girl herself is a happy child. She likes to play, she laughs and she smiles. I wonder if God has gifted her with this disposition to weather these first few rocky years of her life, or maybe the joy on her face is a new development since arriving at the orphanage. Either way, it warmed my heart to see her so happy. 

I am thankful for the work of two orphanages here in Cusco who are connected with our clinic, they are vital places in this broken world. 

a few symbiotic reflections

Maren asked me the other day, do you know of any western doctors who have come to Peru and are working within the peruvian medical system?

The questioned stemmed from both the awful ER experience described a few weeks ago  and from the fact that the doctors with the lowest test scores coming out of medical school are assigned to the most remote/improverished health posts. On the flip side, it is nice that the Peruvian government sends Doctors to these remote health posts (locations I am sure no Doctor really desires to live), but its still hard to think its a good idea to have the lowest qualified doctors working in the areas where people are at-risk for many serious conditions and are hours & hours away from hospitals.

So, back to my answer: I don't think so. I feel bad saying this, but after those few hours in the public hospital's ER, I realized that it wasn't the competency vs incompetency of the doctors/nurses....it was the inefficiencies of the system. I understand refusing to work within this corrupt/broken system means that I have little chance of being apart of the solution, but I would find it utterly too frustrating to order an urgent medicine or a test, only to wait hours for the order to be carried out.

I've asked myself, if my goal/motivation for even considering being a doctor in a place like Peru would be to help poor/vulnerable people, then shouldn't I be willing to take an active role in changing the healthcare system for the better. And the answer surely should be YES, I believe every physician should play the role of advocate for their patients in the public/political sphere. However, I could much more easily see myself following in the footsteps of some of the American doctors I've worked with here, who are working in their own charity clinic, but also are actively engaged in training/mentoring/teaching local Peruvian medical students. Demonstrating a compassionate AND efficient patient care environment could go a long way to effecting the system as a whole, because these students they are working with are the future doctors of Peru, both in the remote areas and in the public hospital ERs.

This whole mental exercise lead me to broader reflections concerning one of the principal questions I came to Peru wanting to explore: What would it be like to me a missionary doctor? This past week I finished the same book that Maren read (and blogged about) a few months ago: Gracias by Henri Nouwen. This is an excerpt from a book that really convicted me to consider my heart when it comes to missions work.

the two most damaging motives in the makeup of missioners seem to be guilt and the desire to save.  Both form the extremes of a a long continuum, both make life in the mission extremely painful. As long as i go to a poor country because i feel guilty about my wealth, whether financial or mental, I am in for a lot of trouble. The problem with guilt is that it is not taken away by the work, hard work may be pushed underground or a while, but it can never really take it away. On the other hand the desire to save people from sin, from poverty, from exploitation can be just as harmful, because the harder one tries the more one is confronted with one's own limitations. If you depend solely on the success of their work, they would quickly lose their sense of self-worth. 

Although a sense of guilt and desire to save can be very destructive and depressive for missioners, I do not think that we are ever totally free from either.

Thanks for reading yall...