Benjamin Telsey in Peru (Intl Family Med): 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.