Clinic Tales

I am not as good as Amy at this whole blog thing. Almost every day in clinic presents me with a new story to tell...but I procrastinate. So you will have to forgive me if this blog is longer than some and full of fewer (read: "no") pictures. If you need to read over a few days...no problem (I usually have a rule myself about not reading e-mails or blogs longer than a paragraph). But there are a few stories of patients that I would like to tell. I don't think that HIPPA applies to Cusco, but after about 17 "compliance tests" at Duke, it is drilled into my brain; therefore no names will be used. But the stories are all true.


Senor D

Every Monday morning the clinic the team starts out the week with a small Bible study and prayer time (this week, I had the pleasure of leading my first one...in Spanish of course, but that is for another story). Last week, Margarita (one of the nurses) led the time and she told the story of "Senor D." Senor D has lived in the jungle for many years, working in the mines. He is now 84 years old and was still working up until a couple of weeks ago. He had been in good health until that time when he began to experience swelling in his legs and difficulty breathing. He knew that he could not get good care in the jungle so he rode a horse to Cusco (a journey of who knows how many hours, but consider that it takes about 5 hours by car) and rented a house here in Margarita's neighborhood. Somehow, Margarita met him, took one look at him struggling to breathe and barely able to walk ,and took him to the hospital. However, there they told him that he should be admitted, but there were no beds in the hospital. So he went home (though they did give him some medications). We prayed for him.

Little did I know (she probably said this, but I still only understand about 50-75% of what is said when people are talking fast), he would show up at clinic that morning to see me. He weighs 68 kg (~150 lbs), but probably at least 10 kg of that is edema (swelling). He was breathing about 40 times per minute (normal is ~10-12). Bill and I tried to do an echocardiogram on him (though neither of us really have an idea how to do that) and we think that it looked like his heart was not functioning well. I will spare you the rest of the medical details, but suffice it to say, I found myself trying to treat this man, who should be an inpatient, as an outpatient...and with all the same difficulties in obtaining tests that I have alluded to previously in this blog.

Margarita has really taken him in. She is feeding him all of his meals, giving him all of his medications, bringing him to clinic, and she told me today that he is now sleeping at her house. She had never met him until 2 weeks ago. I am treating him for heart failure, and he is improving (though slowly), but I am not sure what his ultimate outcome will be. Please pray for him.


Senora M

Later that same day, I met another octogenarian that I am afraid is on death's doorstep- Senora M. She was brought in by her granddaughter (it seems that, though she has several children, her young granddaughter does the best job in caring for her). She weighed 38 kg (84 lbs). Her chief complaint was "total body pain." She had been losing weight and had no appetite. She thought that she had been having fevers. She had a cough.

She is a lady that would get thousands of dollars worth of a work-up in the US; I had to boil that down to about $30. I still don't know what is wrong with her, though some of her tests have come up abnormal and worrisome. I have come to the point that the next steps in work-up would be either extremely expensive or even not possible in Cusco.


Senorita N

OK, this one actually didn't happen at the clinic...but I feel compelled to include it nonetheless. On Monday, I was at home having Spanish tutoring, when there was a ring of the doorbell. Amy answered. The person on the other side was a lady whom I have had some contact with, as she works at the tienda (store) next door, but that is all. She was able to relate (and Amy able to understand) that there was an emergency across the street, where she lived, and asked if I could help. (I have no idea how any of my neighbors are aware that I am a doctor.)

I ran over to their house and found a 16 year old girl unconscious on the floor. She was breathing and she had a pulse. Over the next few minutes, she was able to wake up enough to answer questions. She was able to tell me that she had never had a seizure before, nor did she take any medications. She had no health problems. She did not drink or take anything. The only person who witnessed the event was a young girl of about 6 years and she was little help. I thought, "she needs to get to an ER," but how was I to get her there? I have no car and I have never seen an ambulance here. I decided to call Bill.

After Bill picked up the phone, Senorita N passed out again and this time she stopped breathing. I handed the phone over to Amy (who had come over, too, at this point) and started to go into BLS mode. The lady who had summoned me from my house started to do chest compressions, though I stopped her becuase she still had a pulse, though thready. Praise the Lord, as I was about to perform my first mouth-to-mouth, she started breathing again.

"Amy, what did Bill say?" I asked, hoping that the answer was that he was already en route to pick us up.

"He said, 'Call a cab.'"

"Are you crazy??"

"That's what he said."

So I got into a cab with this barely conscious teenager and two other men. (Neither of them, by the way, were family. She is from el campo [the country] and is here to work for this family).

We arrived at Regional, the public hospital, in about 20 minutes. Senorita M was getting more lucid, but was very weak, so we put her in a wheelchair and rolled her to triage. The ER was just a long, dingy, dirty hallway with doors on either side leading to small rooms where different types of patients were seen. One patient was intubated, but there was no monitoring, as best I could tell.

We rolled her to the triage line. At this time, she was told me that she had to go to the bathroom and was actually able walk to the bathroom by herself. Unfortunately, as others had seen this feat, someone then came up to us and asked if they could have the wheelchair because it was the only one in the ER and his patient needed it more than ours. We acquiesced.

In a few moments, she was brought into the triage room. Her vitals were all ok (though I had to ask them to do a temperature, which is relatively important becuase if she had a temperature, it might mean a spinal tap. Additionally, they had no way of doing a finger stick glucose, which is not a "vital sign" per se, but should have been in this case). We were told to wait in another line in front of another door at that time.

I am not sure if this was a good thing or a bad thing, but the next thing that happened was that Senora N passed out again...in front of a doctor. This got her immediately seen and in a room. The doctor asked about 2 questions, did not examine her, and said that she was being admitted (which I was thankful for, especially as Bill had told me he thought that they would just send her home without doing any tests once she got better, though a little more evaluation by the physician would have been nice). I will say, the work-up and treatment that he had planned (including a head CT, which was the most important thing in my opinion) was good.

He gave the guys that I was with 2 pieces of paper, one with the labs that he was ordering and one with the medicines he was ordering. He told them to go and pay for it. I thought that this was a little strange, but understandable. I was not prepared, however, for the fact that when they returned, they were literally carrying a bag full of her medications and supplies (including the IV and bag of normal saline).

(When I told this to "the other Greg," whose wife, "the other Amy" is pregnant, he was not surprised, and quipped "That is why we are not delivering at the community hospital. I do not want to have to go and buy the doctor a new pair of gloves during the delivery when one breaks.")

I stayed around for about another hour, during which she did not get any labs or medications, but rather these two men ran around to different places paying for different things and talking do different administrators. However, as she was continuing to improve, I felt comfortable leaving at that time.

Yesterday, I went over to her house to check on her. She is doing fine. But it turns out that she did not get the CT, because they could not pay for it. Their working diagnosis (as is mine) is seizure from neurocycticercosis (a parasitic brain disease, the most common cause of new onset seizures here), but rather than diagnosing by CT (the proper way), they are using a blood test (a far inferior test). Nevertheless, she is doing well, and I had an exciting introduction to the public hospital here.


Senor J

I will try to keep my final story for the day shorter. Senor J is in his 50s, and lives in a Christian homeless shelter for former alcoholics. He developed appendicitis about 2 weeks ago and went to Regional, where he stayed for about a week. He couldn't relate the details, but it sounded as if all did not go well, as he developed perotinitis and left the hospital a week later with a colostomy and minus about 20 kg. He now weighs 49 kg (108 lbs) and is around 6 feet tall. As concerning as that was, it was almost more concerning that the hospital had not given him any bags for his ostomy, meaning that he had intestinal contents continually spilling out onto his shirt. I think the best thing that we did for him was to buy him some ostomy bags, and hopefully gain back a bit of dignity.


Needless to say, treating these patients in these conditions is an incredibly humbling experience. I realize daily how daily how weak I am, and how much I need Him to heal these patients. I think the best thing that I do every day is to get down on my knees to pray for them...would you consider doing so too?