Archive for January, 2011
I finally had the opportunity to go with our mobile med team to one of the communities this week. I arrived at the clinic at 7:30am and crammed into the backseat of a pick-up truck cab with 3 other clinic workers. The back of the truck was filled with metal cases containing our supplies for the day. It took approx 2.5 hours to reach Uratary. 1.5 hours of which were on a narrow dirt/rock road that weaved through the stunning vistas of the Andes.
Our arrival to Uratary was announced by some avid honking by our driver. As with most of the trips, someone lost the keys to wherever we were supposed to set up our clinic and we had to make due with just the truck. My “office” was on the left side of the cab and the internist’s was on the right. Our pharmacy was in the truck bed and the “triage” station was just beyond. The patients were triaged by our only Quechua speaking volunteer. After being weighed (adults had their BP checked as well) the age and weight of the child was written on the back of a prescription and handed to me. I saw between 8-10 children between the ages of 3 and 10 who all had one of 2 complaints: itching with rash or not eating/poor growth. Much like in the US, everyone expected a prescription. This wasn’t helped by the fact they were handed a blank prescription with their name and vitals on it at triage. In my arsenol of medicines to choose from for the rash/itching were oral antihistamines, betamethasone cream, and bacitracin ointment. As far as the “not eating, not growing” complaint, my only options was multivitamins. After seeing patients, we were invited to the community president’s house for lunch. We were set up in a 8ft by 6ft hut made with mud bricks and a tin roof. There were 2 small stools and a short bench all about 1 ft above a dirt floor. We were each given a tin plate with 2 hardboiled eggs and there was a central pot filled with boiled potatoes. It was as organic as it gets and delicious after hours of working in the sun.
From a medical provider’s standpoint, I felt a bit hollow after this experience. I’m not used to not having options (ie not being able to send labs for children drastically below the growth norms or select from a wider range of medications for dermatitis). If a child is sick enough in the community we would theoretically bring them back with us in the truck or drive them to the nearest hospital. I guess I’m looking for some elegant solutions where none currently exist.
Unlike many of the prior residents’ inpatient experiences, our ventures into global community health have been comparatively somewhat less intense (for which we are often thankful). Admittedly, a lot of clinic medicine in the States involves reassurance that one’s child is normal and Peru is no exception. While we have had our fair share of interesting medical cases (e.g. severe balanitis, ezcema herpeticum, labial fusion, congenital torticollis, constitutional growth delay), below are a few unique chief complaints we hear on a daily basis that often simply require some good old TLC to troubleshoot.
Chief complaint #1: Nocturnal bruxism + sweet tooth
A word about this interesting combination of “symptoms”. Despite the frequency with which we hear this chief complaint, Amy & I are still confounded. According to local culture, this is a slam-dunk diagnosis for pinworm infection (i.e. Enterobius Vermicularis) in children. First, bruxism is said to affect 20-24% of normal healthy children, peaking between the ages of 7-10 yrs old. Second, last time I checked, kids love sweets. My training has taught me to recognize pruritis ani (i.e. itchy butt), nausea/vomiting or even vulvovaginitis as symptoms of pinworm infection. When (and why?) did grinding your teeth at night and wanting to only eat sweets become pathognomonic for a nematode infection?
Chief complaint #2:
Parent: My child (9 yo male) doesn’t eat, doctor. He just doesn’t want to eat.
Olga: I’m sorry to hear that. When did you notice this change?
Parent: He has been like this his entire life. Doctor, why is it he only likes to eat sweets?
Olga: Well, we can see from the growth chart that his weight is on the 50th%-ile, as is his height. It appears as if he is growing great.
Parent: But isn’t there an appetite stimulant you can prescribe him?
Olga: No, I’m sorry, but he doesn’t need one.
Parent: Really? But can’t you just prescribe us something to stimulate his appetite?
For whatever reason, one of the primary companies that makes multivitamins for kids in Peru produces a concoction that contains cyproheptadine (periactin). The inside pamphlet contains instructions stating it is an appropriate therapy to stimulate an otherwise completely healthy child’s appetite, even toddlers. We have found that parents come to the doctor expecting a prescription for this, despite our efforts at reassurance with the help of a perfectly normal growth chart. Amy & I have not won this battle.
Chief complaint #3: “You know, doctor, I’ve noticed my child has smelly feet and sweats a lot. Is that normal?”
Cusqueñian children habitually don several layers of clothing. The weather in the Andes rapidly changes and accordingly concerned parents will dress their children in multiple layers. The problem is that they never take any of the layers off, even when the sun is blaring (remember, we are at 11,000 ft of elevation). Parents need prodding to disrobe their kids even when requested for the purposes of a proper physical exam.
As much as I might like to poke fun at some of the local neuroses, it is incredibly touching to witness how much Cusqueñian parents love their children and will do anything to help make their lives better than theirs were, no matter the cost. Even when parents deposit their children on somebody else’s doorstep, estranged family members will swoop them up and care for them as if they were their own. One of my patients, a 6-year-old jovial boy, is now being taken care of by his paternal grandmother after his father died from a cirrhotic liver (alcohol-induced) and his mother abandoned him. His grandma, worried about all aspects of his health, has brought him in to see me 3 times already. My heart sank when I found out that she spent more than $100 soles (around US$35: an obscenely large sum relative to what is reasonably attainable for them) to get a CBC and Strep probe that I had mentioned in passing might be helpful but was not necessary. Discussing his normal results in my office, she recounts her “desperation” at the idea that he may have had some unfavorable lab results.
I began to chuckle to myself as I read through prior global health blog entries. It both is, and is not striking how certain themes recur in so many of the residents’ experiences abroad. While attempting to process everything that has been happening here in Cuzco, it was reassuring to realize that my experiences thus far haven’t been much different. First, you succumb to complete chaos during the initial days of orientation to the new time zone, weather, food, language, geography, coworkers, protocols, charting (in a non-native tongue, nonetheless). Then there is the feeling of impotence and frustration that stems from a significant lack of resources necessary for quality patient care. Finally, you are overwhelmed by the humility that arises from the unavoidable confrontation with extreme poverty. I suppose this is what global health is all about.
The clinic where we volunteer is technically a “policlinico.” This is distinct from a “clinica.” Usually, a policlinico is a public establishment meant to serve mostly disadvantaged people with little or no resources to pay for medical attention. The quality of care is thought to be less than that of a clinica, mostly because a clinica is a private business with more “amenities” that serves a more affluent population. Our clinic is funded mostly by a local parish and is staffed with several hermanas, or nuns. Like Amy mentioned before, the diagnoses we make here are not terribly different from those we see at Kaiser (i.e. URI, herpangina, AGE, contact dermatitis), but there is a huge difference in the approaches to their management. Like in the States (but not nearly as bad), everyone wants a prescription for something (and local providers want to give it to them!), or they feel that they didn’t get their 5 soles worth (i.e. 5 soles=less than US$2 – this is what patients pay for a consult with us). Have a sore throat? Amox! Have a headache? Amox! Have vomiting? Amox! Amy & I are like broken records, explaining over and over the difference between bacterial and viral infections but the patients are so habituated to getting antibiotics (or antiparasitics) for absolutely everything it is difficult to convince them otherwise. Where I personally have stepped outside of my comfort zone is with the diagnosis and treatment of various parasitoses. Within days, we must have treated at least 1-2 dozen Giardia cases, several cases of Entamoeba Histolytica and a case of Ascaris Lumbricoides. Interestingly, patients are also being routinely treated for non-pathogenic ameba, which is something we are trying to raise awareness about.
There have been a few puzzling cases of rashes and congenital muskuloskeletal deformities that Amy & I discuss between ourselves but unfortunately we don’t have the luxury of referring patients so we make the best of it.
Today I traveled with our “mobile clinic” to the community of Accoracay. It is a very small town with only a few homes deep inside the Andean mountains over an hour outside of Cuzco. The winding dirt road up the mountain terrified me. The team consisted of myself, a young general practitioner, a nun/nurse and a pharmacist. As we drive towards the town we beep our horn and yell out the window, “Attention! Doctors are visiting! Come to be evaluated and bring your children!” We bring along some basic medications with us that we give out for free if needed (i.e. amox, cipro, paracetamol, diclofenac, vitamins, etc.) but you can imagine the poor medical stewardship that goes on. The most common complaint that parents have about their children is a lack or loss of appetite. This is secondary to parasitosis until proven otherwise (at least this is the thinking of many local providers). I did see an interesting case in Accoracay: a 7 month old boy with a a week long history of a huge neck mass and fevers. Sadly, there wasn’t much I could do for him out there but we educated the mother on how important it was that she go to Cuzco tomorrow to seek medical attention, most likely for an I&D. As you can see by the picture, she was hoping it would go away with the help of a medicinal plant she that affixed to the mass.
Having received the warm welcome that we did made acclimating to the clinic that much easier. According to one patient’s mother, the word on the street is that there are 2 foreign doctors working at the clinic that are very good. Stay tuned!
Although the clinic divides the available medications into two categories (donated and non-donated), I’ve placed the medications I have available into the following three:
1. Familiar medicines: ie., amoxicillin, metronidazol, prednisone
2. Strange mixtures of familiar medicines: ie., a cream called Radskil (pictured below) which is an odd combination of clotrimazol, dexamethasone and gentamicin. This is the only cream we have that has any sort of anti-inflammatory component. It is often prescribed for diagnoses that include tinea corporis, dermatitis nos, and vaginitis. Thankfully for our tinea patients, we have just a clotrimazole cream.
3. Medicines I’ve never seen or heard of: ie., Isoprinosine. It had been prescribed at another clinic and my patient’s family had no idea why. According to my pharmacist its indications are: viral infections, immunodeficiency, facial herpes, and panencephalitis. Versatile, no?
Unfortunately, I was rained out of my “community” experience today (Tues 1/11) so next Tuesday will be my next chance to visit the remote mountain villages. Judging by the number of accidents I saw on my ride to clinic- this is probably a good thing. The dirt roads were surely in worse shape than the paved ones I take to clinic. The team that was supposed to go to Pancarhuaylla (one of the many mountain communities) today included an Internist, a nurse/herb specialist, an assistant who speaks Quechua and myself. Olga will hopefully be able to go on Thursday- weather permitting.
Today’s rainy weather was brightened by a donation of toys from the local health department. Who wouldn’t love to give a life size “Dora la exploradora” doll away?
Greetings from Cuzco, Peru! Olga (aka Leonor?) and I were shocked to find the above flier plastered all over the clinic building on our first day. Normally the clinic is not staffed with pediatricians so the children are seen by whoever is available (internist, surgeon, OB, med student, etc). Despite the publicity, our first day was fairly low volume-which worked well for us as we needed to get oriented to the clinic. By the second day, we found ourselves with 9-12 patients each, per half day, with promises from our patients’ that their siblings would be coming soon. We’ve also been seeing quite a few of the staff’s children, who seem like they have been saving up questions for a specialist for years. There is no limit to the number of children we will see, so the coming weeks should be very interesting. As you can see by the flyer, we are scheduled to work from 8 am-noon with the caveat that we see all the children who arrive before they close the clinic doors. A cook was hired to provide lunch, dedicated time in which we discuss our morning cases (in Spanish) with our preceptor and other clinic personnel over home cooked Peruvian food. Delicioso! The clinic re-opens at 2:30 pm until the doors close at 6pm, with a review of our cases again at the end of the day.
Thus far, the age range of my patients has been from a 1-month to 1 17 ½ -year old and the chief complaints are not so dissimilar from what we see in our urgent care clinics back at Kaiser Permanente in Oakland. Infants with vomiting/diarrhea/dehydration, rashes, poor weight gain, pain with urination, etc. Stay tuned for a more comprehensive analysis and discussion of our cases as we gather more information. What is strikingly different is the level of poverty and the amount of creativity needed to get patients the medications and services they need. Next week we will begin going out to the rural Andean communities with the mobile clinic twice weekly. I can only imagine how much more complicated providing care will be without a pharmacy and lab (the Policlinico has both in the building).
Much more to come…
Kaiser Permanente Oakland serving a global health elective at Benh Vien Hung Vuong Maternity hospital in Vietnam).
When I was interviewing for residency programs, I always said that I was grateful for having many international experiences in medical school. Of course, I learned most things in medical school, but I refined my skills and emulated those whom I admired, and most of those mentors, I met while traveling around the world. I attributed my bedside manner to a midwife that I had worked with in Belize, I attributed my physical exam skills to an intern that I had met in Kenya while on call, and I owe my openness to a Tibetan professor and monk. We all practice medicine differently, and we all have different cultural norms and expectations that we are expected to meet. I understand that. And I have loved my experience here in Vietnam. But I have to say, that I am glad that I learned the standard of care and how to practice obstetrics and gynecology in the United States. I understand that this may be due to my expectations as an American. I know that we have a healthcare system that usually enables a family to stay together during labor and delivery, and to share in the miracle of birth. I know that these are not the expectations of other people in other parts of the world. But I am so proud that we are able to offer our patients that shared experience.
I have had the great privilege of working with some wonderful Vietnamese teachers, who have gone out of their way to help me to understand their system, and the reasons behind their practice. I am grateful, and I am reminded of the wonderful faculty and staff that I have in my own residency program who go out of their way to ensure that I will be the best, most caring, responsible doctor that I can be. And I feel honored to be part of that system.