The interesting cases continue. We had a 70-year-old woman come into the emergency room the other day complaining of 3 months of feeling like her entire left side was amortiguado (numb). On exam, we weren't entirely convinced that she was actually numb or if she was having paresthesias or just decreased sensation, so the attending came in to confirm the story. He pinched her, used a tuning fork, and finally poked her with a needle, drawing blood without reaction, confirming that she was in fact numb. Although MRIs are not readily available here, she had had a normal head CT, so she probably had a small lacunar stroke that didn't show up on the head CT that left her with hemianesthesia. She was complaining of also having pain, and apparently one can get a delayed central pain syndrome after a unilateral sensory loss. Since gabapentin is not readily available, we started her on amitriptyline and had her follow up as an outpatient.
Another case that will stick with me is the previously well 4 month old baby boy who came in with severe pneumonia. He progressed to intubation and was being managed on our vent but was requiring high pressures and had worsening chest X-rays and we were unable to wean the oxygen requirement. It looked like a picture of juvenile respiratory distress syndrome, and when he did not improve, we tried to transfer him to Quito but were unable to due to a severe storm. His mother stood by for days, watching her baby's swollen body fight with the vent and periodically asking us when she could breastfeed him again.
For those of you who are non-medical, white in the lung fields is bad. Our baby started out with a pneumonia (top left), progressed to respiratory distress syndrome (mid right) and then improved to nearly normal a few days after our prayer.
The day the transfer couldn't happen, we went into the room and talked with the mother about his poor prognosis. At the end of our talk where we confirmed that he could die from this (and I was thinking he probably would), the attending asked if we could pray with her. She agreed, so the three of us stood around the bed with the struggling little body and prayed. My heart was heavy as we walked out. The next day, however, against all odd, she came off the ventilator and was switched to CPAP. The following day he was on nasal cannula oxygen and that was rapidly weaned down. He remained in the hospital several days after his oxygen requirement had finished to finish his required days of IV antibiotics, smiling at everyone as his mother carried him around the halls, but he went home today. His story is part of the reason I want to work overseas. I want to see God do miracles. And I can honestly say I think I just did.
I have gotten to see a good bit of obstetrics here. We had a delivery the other day for a 44-year-old woman whose 10th child this was. I have to say I don't think I've ever delivered someone with quite so many G's (pregnancies) and P's (births). For the most part, OB is similar, although little things are different, like how they hold their hands to try to avoid tears during delivery, a practice of cleaning everything around the birth canal before the baby is born, the routine use of intermittent fetal monitoring (about every 2 hours until pushing and then often after only every few pushes). The complications are the same, though, and there was a shoulder dystocia a few days ago (although not on one of my deliveries) and an external cephalic version today of a breech baby. One of my deliveries there was more blood loss than expected, and it turned out to be a cervical laceration, which I had never seen. The patient had gone from 6 cm to 10 cm (fully dilated) in 40 minutes, much faster than expected even for her second delivery, which is a risk factor for cervical lacerations. The attending repaired the laceration, and it was good to get to see how to do that.
I've also seen some routine things I hear about in the States but just hadn't seen yet. One of the few overweight children I've seen, a 10-year-old girl, came in with difficulty walking for past week and severe pain with any movement of her right hip. It turns out she has a slipped capital femoral epiphysis (SCFE - the top of the long bone in the thigh essentially gets shoved off to the side), so one of our surgeons took her to the OR for a fixation. Based on an ultrasound, clinical history with irregular menses, and infertility, I diagnosed a patient in clinic with polycystic ovarian syndrome (PCOS) and started her on metformin in hopes of increasing her chances of getting pregnant. I had a 7-year-old girl in the outpatient clinic with diarrhea who turned out to have both amebic dysentery and giardiasis.
I'm on call again tomorrow, so I'm off to bed but hope to write more soon about how it's going with Spanish and about what life is like here.
Another case that will stick with me is the previously well 4 month old baby boy who came in with severe pneumonia. He progressed to intubation and was being managed on our vent but was requiring high pressures and had worsening chest X-rays and we were unable to wean the oxygen requirement. It looked like a picture of juvenile respiratory distress syndrome, and when he did not improve, we tried to transfer him to Quito but were unable to due to a severe storm. His mother stood by for days, watching her baby's swollen body fight with the vent and periodically asking us when she could breastfeed him again.
The day the transfer couldn't happen, we went into the room and talked with the mother about his poor prognosis. At the end of our talk where we confirmed that he could die from this (and I was thinking he probably would), the attending asked if we could pray with her. She agreed, so the three of us stood around the bed with the struggling little body and prayed. My heart was heavy as we walked out. The next day, however, against all odd, she came off the ventilator and was switched to CPAP. The following day he was on nasal cannula oxygen and that was rapidly weaned down. He remained in the hospital several days after his oxygen requirement had finished to finish his required days of IV antibiotics, smiling at everyone as his mother carried him around the halls, but he went home today. His story is part of the reason I want to work overseas. I want to see God do miracles. And I can honestly say I think I just did.
I have gotten to see a good bit of obstetrics here. We had a delivery the other day for a 44-year-old woman whose 10th child this was. I have to say I don't think I've ever delivered someone with quite so many G's (pregnancies) and P's (births). For the most part, OB is similar, although little things are different, like how they hold their hands to try to avoid tears during delivery, a practice of cleaning everything around the birth canal before the baby is born, the routine use of intermittent fetal monitoring (about every 2 hours until pushing and then often after only every few pushes). The complications are the same, though, and there was a shoulder dystocia a few days ago (although not on one of my deliveries) and an external cephalic version today of a breech baby. One of my deliveries there was more blood loss than expected, and it turned out to be a cervical laceration, which I had never seen. The patient had gone from 6 cm to 10 cm (fully dilated) in 40 minutes, much faster than expected even for her second delivery, which is a risk factor for cervical lacerations. The attending repaired the laceration, and it was good to get to see how to do that.
I've also seen some routine things I hear about in the States but just hadn't seen yet. One of the few overweight children I've seen, a 10-year-old girl, came in with difficulty walking for past week and severe pain with any movement of her right hip. It turns out she has a slipped capital femoral epiphysis (SCFE - the top of the long bone in the thigh essentially gets shoved off to the side), so one of our surgeons took her to the OR for a fixation. Based on an ultrasound, clinical history with irregular menses, and infertility, I diagnosed a patient in clinic with polycystic ovarian syndrome (PCOS) and started her on metformin in hopes of increasing her chances of getting pregnant. I had a 7-year-old girl in the outpatient clinic with diarrhea who turned out to have both amebic dysentery and giardiasis.
This was our little girl with SCFE before and after fixation of her epiphysis. You can just barely see in the picture that her right epiphysis ends lower than her left.
I'm on call again tomorrow, so I'm off to bed but hope to write more soon about how it's going with Spanish and about what life is like here.
glad to hear your stories and that you're getting to see interesting cases and learn how to deal with things you haven't dealt with before. sounds like you're becoming an even better doctor all the time!
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