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...

quiz #2!

Another quiz time...here are your hints

-This disease exists here in Peru (and in other South American/ African countries)

-Most people (80%) of the people who contract this disease have a mild “flu-like illness” and that’s it

-The other 20% of the people who get this disease turn yellow

-The scary part: 3% of the people who get this disease will DIE and there is no cure, no medicine to stop these deaths, you simply cross your fingers if you get it and hope you are in the lucky group of the 97%

Ok, instead of withholding the answer, I am going to show some pictures that give the answer away

the vaccine itself, dont worry: they write dates backwards, the vaccine expires on Mar 12th, 2014 

someone looks pretty excited for a shot

someone else looks a little more nervous

my lovely medical assistant Maren, preparing her father's arm with alcohol

all the supplies

more skilled prep-work by maren...Nancy was the first person to go for the vaccine, super brave

In those pictures, you can see a vaccine for the mystery disease. And you can see the sketchy drug injections that took place in our hotel when our parents arrived to Peru. The YF vaccine costs $250/person in the states. Here we were able to buy the vaccine for $25 (1/10^th the cost!). However, the clinic that usually administers the vaccines was closed on Good Friday when our parents arrived here in Cusco, and we needed to give the vaccine ASAP, since it needs 10 days to work before you go to place with dangerous mosquitoes. So…an  “almost-wannabe doctor” wound up injecting his parents and in-laws. I don’t think it was necessarily “legal” as the vaccine needs to be administered by a doctor or nurse (I am neither of those) and it needs to be administered in an “authorized vaccination center” (which I don’t think our hotel is registered as). Anyways, it was a pretty funny experience,  we could all rest assure that we wouldn't wind up in the “unlucky 3%” and when we visited the jungle. 

a break from all the medical posts

This past week, I was invited to share my testimony with a group of non-christian Peruvian medical students. A few of the doctors that work at La Fuente came to Peru with the vision of reaching out to peruvian med students, and one of the Physician Assitants here (Mark) has a group of second year med students over to his house for lunch, a talk and hang out time every monday. Mark has 5 kids and after a big lunch, Mark or a guest talks to the students about Jesus for 20 minutes, and then the students stay and play Wii, ping pong, etc. Its a really cool ministry and I felt really luck to get to share with these students. Mark asked me to tailor my message to include a lot of stuff about my medical journey, in order to connect with these students.

In the end, the exercise of giving a testimoney of how God has worked in my life over the past 10 years was very worthwhile on a personal level. It is helpful and important to reflect on the different events God has used to change me.

Below is is an outline of what I shared.

1. How I became a Christian

-        -  As a child I my parents went to church and the only time I thought about God was when I got scared of “going to hell”, I didn’t really know much about God

-         -When I was 17 I worked at a Christian all-boys wilderness summer camp and it was here that I felt like I first met other people my age who were really excited about Jesus, they made God seem real

-          At the time, there were two bible verses that I encountered that really made an impression on

o   1 Corinthians 10:13- no temptation has seized you except what is common to man. And God is faithful. He will not let you be tempted beyond what you can bear. But when you are tempted, he will also provide a way out so that you can stand up under it

§  For me, in HS, I was tempted to drink alcohol, use marijuana, look at pornography and try to be physical with girls…this verse, and God being faithful to fulfill his promise and his help with these things was “proof” of God's power

o   Romans 8:38- for I am convinced that neither death nor life, no angels nor demons, neither the present nor the future, nor any powers, neither height or depth, nor anything in all creation, will be able to separate us from the love of God that is in Christ Jesus our Lord

§  This verse is so exciting! I am more loved by God then I can even imagine

2. How I became a doctor

-       -  I didn’t know any doctors (none in my family/none of my friends parents were doctors), but I decided I really wanted to be a doctor when I was 10 years old and remained obsessed with that dream through middle school, HS, and college

o   I thought that being a doctor was going to make me important and make me happy and I made choices as young as 12 yo to make sure that I’d be able to get into med school

3. How I changed in University

-            - My relationship with God grew a lot during my time in university, I learned more and more about what Jesus really did for me (erasing my sins by dying for me)

-              -My faith in God grew from “a religion”, “a set of rules”, “a set of beliefs” to a way of life

-              -One really important verse for me was John 13: 34: A new command I give you: Love one another. As I have loved you, so you must love one another. By this all men will know that you are my disciples, if you love one another

o   I started thinking about what this verse might mean for my life, “loving other people” this is what was most important to God, and I started to question my goal of being a doctor

-              -Until that point, I had only wanted to be a doctor because of all the things it would do for me: give me a secure job, lots of money, respect in the community, it would interesting and fun

-             -I eventually realized that I needed to be willing to not follow my dream, if it was not the way God wanted to use me to “love others”

-             -During this period of considering giving up my dream, God wound up changing my motivation for becoming a doctor, but not changing the dream itself

o   Matthew 25: 34-40: Then the King will say…come you who are blessed by my father…for I was hungry and you gave me something to eat, I was thirsty and you gave me something to drink, I was a stranger and you invited me in. I needed clothes and you clothed me. I was sick and you looked after me. I was in prison and you came to visit me. Then the righteous will say, “ Lord, when did we see you hungry …when did we see you sick?” The King will reply, “I tell you the truth, whatever you did for one of the least of these brothers of mine, you did for me”

o   Psalms 37:4: "Delight yourself in the Lord; and He will give you the desires of your heart."

4. The story of how God has made my life look different in Medical School

-             -I have been able to pray for and with patients, I love the fact that as a doctor I can offer “physical healing” and as a Christian I can also offer them “spiritual healing”

o   This is the style of ministry that Jesus did, there are lots of stories where Jesus went to a town and he miraculously healed the blind, the crippled, the deaf the lepers, but at the same time he preached to the people about God and he told them about eternal life with God

-            - Being a Christian has also change the way that I look at patients- I try to see people the way God does (he loves them all the same)

o   For me, that has meant withholding judgment to a person who is an alcoholic or obese

o    Jesus showed love to the most evil people in his world, tax collectors who exploited the poor and prostitutes

-             -Even my choice to be in Peru right now, I believe that I followed the voice of God here, as a trial period to see if God wants to use me as a doctor not to make a lot of money or be impressive in the USA, but rather to use the gifts he has given me to serve others and tell them about Jesus

teaching about diarrhea

In one of my older posts, I talked a lot about an amazing trip Maren and I got to take to “el campo” with PROSIM. Under the same umbrella of PROSIM is a different ministry of the Mennonite Church here in Cusco. Once every month a “health representative” from each of the 12 Mennonite churches in the Cusco region comes to the city of Cusco (for some this is the same 8 hr bus ride we took to go to their towns). These representatives receive basic health training in a lot of different areas, and then they go back to their communities and act as community health workers providing things like basic first aid, basic medicines, hygiene education, and nutrition education. It’s a way for the church in those areas to help other people in their communities.

At the most recent PROSIM health representative meeting, I got to give a lecture on DIARRHEA. It was pretty fun preparing for, and ultimately really fun to present, as I taught the lesson in Spanish. Since I don’t think the majority of my readership speaks Spanish, I am not going to share with you the entire lesson, but I am going to make one quick plug for diarrhea.

Did you know? 2 million kids die from diarrhea (dehydration) every year in this world. That’s the #2 cause of death in kids (18% of all deaths under 5 yrs old) and those 2 million deaths are more than HIV/AIDS +TB + Malaira + Measles COMBINDED cause in a single year. But, only 5% of global health aid money/research is focused on diarrhea.  And here is the really frustrating and sad thing: The treatment to stop these deaths costs about 40 cents to create. 40 cents!!!!! With 40 cents a mother in a remote village can create an Oral Rehydration Therapy consisting of water, sugar and salt. This simple concoction can effectively prevent the vast majority of these preventable deaths from diarrhea.  OK, done my rant.

It was really cool to see “public health” in action at this meeting with these workers. The other lessons for the day were about drowning and choking.

See below some fun pictures from our day of teaching the health representatives

Dr. Derek Brubraker (our main host here in Peru), teaching about drowning

me 

everyone learning the Heimlich maneuver, very funny

we had two volunteers make the Oral Rehydration Therapy , and then we all drank it, it was not tasty

close up, more practice for what to do when a person is choking

John Jacob and John Isaac: an anecdotal hospital comparison

After an hour of being at the clinic, Dr. Nathan (see older post about this awesome doctor) was seeing a pair of 1 month-old twin brothers. Like a lot of twins, they were born prematurely and started life with “lung issues”. These two boys were born to a mother who lives far out in “el campo”, but she was luckily in Cusco this week for a training with her church to be a lay leader. Thus, on Wednesday when they initially came down with colds, they came to La Fuente. Dr. Nathan saw them on that day and was cautiously optimistic they’d be alright, but told the mom to return if they seemed worse to her. Two days later they seemed worse. At intake, John Isaac’s oxygen saturation level was 74% (normal is 94-100%, and at Cusco’s elevation it is 88-94%) So 74% means that his Red Blood Cells were carrying only ¾ the amount of oxygen that they have the potential to carry, and it means his brain, his heart, his kidneys, his hands, and his feet were only receiving ¾ of the amount of oxygen they need to receive. Plus, when you are sick, it’d be nice to have MORE oxygen than usual, not less. A quick physical exam confirmed that they were both really struggling to breathe (their noses were flaring and their bellies were retracting with each breathe). Think: the way you and I breathe after we finish exercising, except they were laying on the backs resting.

Needless to say, this was an emergency. I picked up the “less sick” twin John Jacob, and we called a taxi to come pick us up at the clinic. A nurse from the clinic (Nancy), the mom, me and the twins got in the taxi. We drove to the ER at the public regional hospital and my initial first impressions were actually quite positive. The building looked like a nice hospital and within 5 minutes we were talking to a triage nurse and maybe 10 minutes after that we were in a consult room with an actual pediatrician. (Impressively fast in comparison to what I’ve seen in the states).

However, this is where the “impressiveness” ceased. After an initial assessment by the pediatrician both kids were deemed to be worthy of hospital admission and a discussion of exactly how old they were began, as kids under 30 days go to the neonatology wing and kids over 30 go to the regular pediatrics area. These twins were 32 days old. Scarily, John Isaac’s oxygen saturation level was around 60-65 while in the pediatrics consult room in the ER. To all you none medical folk out there… if a baby is having trouble breathing, at baseline has lung problems and a machine is confirming that 1/3 of this child’s lung function is missing…would you think that maybe this child should be given supplemental oxygen? If you're wondering how long it took for this child to be given oxygen, the answer is atrociously too long: 4.5 HOURS!!!! 4.5 hours AFTER arriving at the hospital he was finally put on supplemental oxygen. In all honesty, I think if you wanted to make an argument to intubate the child and have a machine be breathing for him- you probably would have been justified.

At one point, I was looking at John Isaac and thought he literally might die while I was holding him in my arms. After hours of breathing at a level much lower than is normal, his extremities, face, belly and lips started to turn blue (a later sign of cyanosis). Also, his breathing rate (which should have been elevated above normal to try and compensate for his lack of oxygen) was actually lower than normal, another really scary sign that his body was tiring out from the increased work of breathing. I asked the doctors and nurses repeatedly when they were going to bring this child some oxygen? When are you going to start performing the 10 or so other orders the original pediatrician wrote for: lab tests, antibiotics, oxygen, etc. And I never could get a solid answer.

Another crazy/annoying thing about this hospital is that family members must take orders from the doctor and go to another part of the hospital to BUY supplies for the doctors/nurses. I understand the hospital doesn't have a lot of money and needs families to help pay for treatment, but as a baby is in an ER on the brink of death, this doesn't seem like the time when they should suddenly remember: “Oh, I need a piece of gauze before I draw this blood…Mom, go buy some!”. I counted 9 separate trips to buy various supplies and medicines during the 4 hrs we were in the ER. Maybe once, MAYBE once, I’d understand a pre-printed list of things the family needs to pay for before treatment commences, but not 9 times!!! And it is crazy to me that these supplies are not actually found in the ER treatment rooms themselves. Why waste precious time having someone go wait in line and buy these supplies? It was maddening, the inefficiency and dangers of this system.

True story. There was a tourist who had clearly had a bad night or some bad luck, as one quick glance revealed his hand was bloody. I heard him speaking in English that his money was back in his hotel, and they told him he’d need to leave, go get the money and return if he wanted basic bandaging or xray to see if it was broken. ARE YOU KIDDING ME!??!?!

In the end, both John Jacob and John Isaac were admitted to hospital beds and what seemed like a fairly competent staff of nurses and doctors assumed care of these boys. I haven’t heard anything yet, but I do believe they are going to be ok. But it is very scary to think of “what could have been”. The mom of these boys is very poor and surely could not have afforded to pay for the treatment they received in the PUBLIC hospital. Dr. Nathan, as we were pulling out in the taxi, handed Nancy the equivalent of 150 dollars. Also, we had “runners” who could go back and forth from the ER to the store to buy all the stuff the nurses/doctors kept forgetting to ask for. What if you are alone and sick- who can go and buy your supplies? Also, we had Nancy who was a godsend on two levels: 1) she speaks Quechua (local Incan language) and the mom didn’t speak much Spanish, so she would have not had any way to communicate with the staff at the hospital. 2) Nancy is a nurse and she understands the system. She was able to demand what we needed (it still took us awhile to get the oxygen). If just one of these things was missing: money, translator, runners, advocate, or if the family had been 8+ hrs from a hospital in their rural home….I honestly don’t think John Isaac would be alive right now, it was that serious of a situation. So in the end, I do believe God was working in this situation and the boys are going to live, more so in spite of the ER, not as much because of the ER.

Two other crazy things I saw in the ER: 1) There was wet blood on the floor in the middle of the hallway and during the 4 hours we were there, no one stopped to clean it. 2) There was a 1yr old girl in status epilepticus (seizures that last more than 15 minutes without stopping) and the pediatrician tried the first medicine you give for unceasing convulsions, this medicine didn’t stop the seizures, so they needed to move on to the second medicine. However, this required the doctor to write a prescription, then the mother had to leave her convulsing daughter and go wait in a line to purchase medicine number 2. Ten minutes later she returned with this medicine. With status epileptics, SECONDS are precious, as each moment the seizures do not stop, there is an increased risk for brain damage. The fact that there was a 10 minute delay between the second and third doses was infuriating for me. To me this that was a situation where you act as fast as possible, and then ask the family to pay for the medicine a few minutes later.

our "ambulance", aka a taxi

2-3 hrs after we arrived, some nurses started doing some things, finally

the mom and John Isaac, waiting at triage

the pediatric hospital wing, finally!

a little too close, but this is me and John Jacob waiting for the taxi

Dr. Nathan setting up the oxygen, in hindsight, i wish we sent the oxygen  with us to the hospital

John Isaac...waiting...waiting...waiting..

xray time

a pretty normal xray

time for a quiz!

-2 million people in the world have this disease, but today was the first time i ever saw someone with "active disease"

-medical history: cough for "a while", lost 12kg in the past 3 months, and he saw some blood in his cough this week, and thus he came to the city to see a doctor...he lives 10 hrs away in the jungle

-and you biggest hint...some xrays:

one note about the xrays: if you look the "L" side of the image doesnt show the heart shadow, but its simply mis-labeled and the R is actually the L side, we confirmed it wasnt a rare case of dextrocardia bc the gastric bubble is on the R, too, so that confirms its just mis-labeled...wanted to explain that, but dont get caught up on this detail, it was nothing to do with the case

I will post the answer (in case some doesnt get it right, in the comments section)

I will also post come extra comments about the case and some reflections about it, after yall have time to guess

A great day with a great Pediatrician

So, I know that writing 2x at once and then not writing again for a while (my habit with this blog) isn’t the best way to keep an audience, but we have sporadic internet access so I got to get them in, when I can…and after today’s work in the clinic, I really wanted to share with you a really exciting day I had.

A little background on the clinic I am at first: I have been working at La Fuente Health Clinic in Cusco for the past 2 weeks. It was a clinic started 10+ years ago by the Mennonite Church. The doctors we connected with via Dr. Mayes (my favorite/best professor from UR) are Mennonites and have been working at the clinic for the past 6 years. About 2 years ago, a team of 5 families came to Cusco to join in the work here at the clinic. 1 ophthalmologist, 1 pediatrician, 1 dentist, 1 pharmacist, 1 Nurse Practioner, 2 physical therapists and 1 physician assistant. They all went to the same Presbyterian church in Augusta, Georgia and all signed up to be a missions team together. Combined they have 15 kids under 10 yrs old, and their connection back in Augusta had been with a ministry called “Medical Campus Outreach”, where doctors/dentists reach out to med students. They came to Cusco with the goal of replicating this ministry with medical and dental students here in Cusco.

Ok….back to my awesome day…today was the first day I got to work with Dr. Nathan Wilson, the pediatrician from the Georgia team. I’d met him a lot of times, but working with him was one of the more inspiring days I’ve had in med school. I was equally challenged today to strive to excel academically in the practice of medicine as much as I was challenged to really love my patients and their families like God does. It is rare that these seemingly different (by no means opposite) roles of a doctor are so well exemplified in one person. I will try to elaborate on this…

-Today we saw a little boy named Saul, Saul is 4.5 yrs old, but is the height/weight of a 2 yr old, most of his specific health issues are related to the fact that he has Down’s Syndrome. Saul and his mom live in the one of the towns we visited with PROSIM (8 hrs away), they were able to get a free ride back with us on Sunday so that he could be seen by a doctor, and they came all the way to Cusco for a “check-up”. It was his first actual doctors visit in his life (despite the fact that he has a major medical condition!) We did a very thorough exam, as children with Downs are prone to tons of other health problems (congenital heart defects, thyroid issues, intestinal issues, failure to thrive, leukemia, early-onset Alzheimers)…but what Dr. Nathan spent even more time doing was encouraging Saul’s Mom. He shared with her a story from John 9, when Jesus is asked, “Who sinned, this man or his parents, that he was born blind?” and Jesus replies “neither..this happened so that the work of God might be displayed in his life”. Dr. Nathan told me that he spends a great deal of time talking to all parents with kids with severe disabilities because they need to know that the world promotes a lie, the lie is that their child is worthless. Instead, he tells them that their child, and whatever problem their child has (cerebral palsy, MR, downs, etc) is also a gift from God, and that their child and the way they care for that child is an opportunity to bring glory to God. I think here the idea that the parents must have done something wrong, and now they are punished with a child with Downs is very pervasive and this encouraging message can be life-changing for these families.

-Before we even saw Saul, I saw a 18 yr boy with the complaint of “abdominal pain”. Gastritis is extremely common here in Cusco and we diagnose 2-3 people with it every single day. I took the boys history (I worked up to 3 patient visits in Spanish today!) and came back to Dr. Nathan to present the patient to him. Over the past 2 years of medical school, the number 1 thing I've been graded for has been my ability to “present a patient”, no one expects the med student to know exactly what is wrong or to know exactly what meds/tests the person needs…but they do expect the med student to “present the patient well” so that the objective information is clearly communicated. When I went to present this boy with abdominal pain to Dr. Nathan I totally botched the entire thing. I was rushing, I was skipping around the presentation telling him random things “out of order”, and basically failing to follow the standard format of presenting a patient. Over the past 1.5 wks as I’ve been working with the other doctors here, no one has commented on my “sloppy presentations”, in fact, as Dr. Nathan later stated, “I've probably stooped to the level of organization/professionalism that has been expected of me”, but he said that he expects much more from me and will not accept a disorganized presentation. At first I felt embarrassed and dumb…(I know what to do, I know the right way to present), yet I was talking to him like a 2^nd yr student who doesn’t know any better! And in 2 months I am going to be a “doctor”! How could I be presenting so haphazardly? My gut reaction was to tell him I am good at presenting, I know what to do, but instead I resolved to do better next time, to prove to him (and myself, more) that I am capable to “talking/presenting” like a doctor. My next few patients were a bit better, but overall it was a very humbling “failure” and a good reminder to do my best even if I am only being asked to do “good enough”.

Finally, Dr. Nathan shared with me two “pearls of pediatrics”

1) “Continuity is a powerful tool”. He contrasted primary care with the emergency room, and reminded me that we can see the patient the next day if we are worried about sending them home. We can try something, and if it doesn’t get better, try something else in 2 weeks. We have the benefit of not having to waste money, or order extra tests, with the fear we’ll never see the patient again.

2) “Always listen to the parents”. He said that when a parents tells you there is really something wrong with their child, you need to believe them. They know that child a ton better than you do. He said almost every story he knows of a pediatrician being sued or a child dying unexpectedly/suddenly starts with the parent saying something is seriously wrong and an arrogant doctor saying everything’s fine. Not that it isn’t commonplace to calm worried parents by explaining the relatively benign nature of a viral infection…but that you should still trust a parents judgment when they are seriously concerned

------
Now for 5 "old" pictures that should have been in the previous post about PROSIM, but these are more "health related" pictures so I split them up and put them here

This is what the nurse drives to work...about a 1 hr trip on a dirt road...hardcore!

This is the clinic/ health post in the small village...and in the picture is the ROCKSTAR public health nurse, Huana

I found this picture to be terrifying/awesome...its a vaccine schedule, but then they show these horrific pictures of kids with the diseases that could be prevented: measles, mumps, rubella, TB, diptheria, tetanus, etc...a bit gory for most moms, but maybe it works?

I just really liked this sign instructing women to eat 3 meals a day while pregnant. Isn't 3 meals standard always?

This is the view from the clinic, not a bad view from "work"