Sex, Drugs, and Public Health

November 4, 2017

Orthopedic Team to Ecuador

Filed under: Uncategorized — cbmosher @ 4:09 am

Here’s how it works. We arrive at the hospital in Cuenca on Sunday to find a large crowd of people hoping to get surgery by the North American orthopedic surgeons. The surgeons screen them (translators needed) and then refer them all to anesthesia, where I work.

We obtain histories, nurses check B P etc. and the anesthesiologists determine whether each kid is safe to go under. Most of these cases are complex and / or risky, so the Gringo surgeons will teach advanced techniques to the Ecuadorian surgeons in the O R.

Case # 1: Jordy – he broke his tibia at age 5 and has undergone four surgeries over the past seven years, but the bone never healed.

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He hasn’t walked in seven years. His mother has placed her hopes and faith in the North American surgeons (a bit of a cultural problem, as it can undermine faith in the local docs). On the morning of surgery, the team of five Gringo doctors, two Ecuadorian doctors and I (as translator) stop at his bed. The ortho docs pull out X-rays and discuss them while the patient and anxious Mom watch.

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“We shouldn’t be doing this case,” one surgeon shakes his head. “He has congenital psuedoarthrosis – it’ll never heal. What he needs is an amputation.”

The head surgeon begins an intense discussion with the surgeon who proposed this change of plan. Meanwhile, an Ecuadorian doctor tells the mother what has been said. Her mouth falls open in shock. Then tears overflow onto her cheeks. The doctors move on to the next bed.

“Señora,” I hold her hand as I trail the docs, “I’ll be back and explain this to you. Don’t worry.”

Rounds over, while the surgeons change into scrubs, I return to the floor. The mother is in the hall, listening to an intense young Ecuadorian.

Good, I think, some physician is explaining things to her.

 

I start work with another patient in a room, then hear loud yelling in the hall. Not just once – over and over.

What the hell?

I look out and see the young man gripping Jordy’s mother and yelling for Jesus to come down and heal something. The mother convulses in sobs.

I hurry down to the OR, get the head surgeon and implore him to come up and go over the issue with her. He assigns a different surgeon to go up with me.

Patiently, we explain to both Jordy and his mom that it was likely he had a condition which would prevent his tibia from healing. That the bone would remain in two un-united pieces. That this fifth surgery might fail, too. But it is their decision – they can go for repeat surgery, for amputation and prosthesis, or to go home and live with the crutches. But we stress that, even if it does someday come to amputation, his life with a prosthesis would probably be better than a life on crutches.

Mom is not ready to consider amputation. Surgery goes forward with these results:

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In the Recuperación Room, Jordy smiles as soon as he is awake, and doesn’t complain of pain. His mother is grateful and happy.

Upon hearing the story, one of our nurses offers to speak with the Mom.

“About what?” I ask.

“I’m an amputee,” she reveals. “She can see how it hasn’t kept me from a productive and fun life. Let me know.”

As she walks away, I watch her gait closely. Can’t see a limp, a stiffness or anything abnormal.

Jordy’s mother, however, isn’t ready to hear it. She beams optimism and faith. “What can I do for my son to help him?” she asks.

I go over post-op care at home. I feel a responsibility to temper things a little. I remind her that we don’t know how well the tibia will heal, in spite of good alignment. Then I say something I seldom say. It seems appropriate in this case:

Señora, you can pray.”

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Insights:

  • Pentacostal “christianity” has penetrated deeply into traditionally Catholic Latin America.

* Congenital Psuedoarthrosis – if Jordy indeed has it – is pretty rare. About one in every 250,000.

 

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Case # 2 – Too Cute

Filed under: Uncategorized — cbmosher @ 4:05 am

Look closely at her picture.  At her hands.

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She came to us with congenitally misplaced digits on both hands and with mild club foot deformities.

 

The hand surgeon had me translate for the mother.  He said he might not have time to do both hands and feet. With which hand or foot did she want him to begin?

 

She said she’d noticed the girl drawing and playing with preference for her left hand. So the left hand was most important. As long as she wore shoes, she could walk without crying.

 

The surgeon did a “tendon and pulley reconstruction” in her hand using a plastic tube, giving her improved finger function.

 

 

Case # 3 – The Jesus Family Drama

Filed under: Uncategorized — cbmosher @ 3:59 am

This kid wasn’t on the schedule.

 

On the morning of the last surgery day, we found the mother standing outside our little office, clutching X-rays. By her dress, it was clear she was Quechua and very likely lived beyond the city. When she spoke, her Spanish was so heavily inflected with the language of the Incas that we had to repeat and re-phrase things.

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Her five year-old had a fractured femur, treated with a cast a week prior in her remote town (a four hour ride away). She was concerned that it wouldn’t heal correctly.

 

The X-ray thru the cast revealed that she was correct. The two halves of the femur overlapped by several inches. If it healed, the leg would be shorter.

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I called over the head orthopedist. “We’re full,” he shook his head. “We leave tomorrow.” I handed him the X-rays.

 

He shook his head again. “This needs to be fixed.”

 

She wheeled in her five year-old. A strikingly beautiful girl with long black hair. The two of them were taken down to E.R. to be admitted while our surgeon found room on the schedule.

 

I was assigned to follow up in the E.R. : make sure the kid didn’t eat; check lab work (would transfusions be needed?). Looking at the paperwork in E.R., I found a mistake. Pointed it out to the nurse.

 

“This says the patient is a boy.”

 

“Sí.”

 

“But – ”

 

“He has long hair,” the nurse rolled her eyes. “They’re Indians.” Controlled distain dripped from the last word.

 

His mother approached me with small, deferential steps. “I don’t know what to do,” tears began to well in her lower lids. “My husband says that the cast is good enough. He says if Jesus is not well after surgery, he’ll divorce me!” she trembled.

 

Pretty ballsy decision you made, Señora. But a good one.

 

I reassured her that, without surgery, it was likely her son would have difficulty walking. Without promises, I said it was probable that things would turn out better with the bone held in place while healing.

 

After surgery, up on the ward, Mom remained anxious. The poor kid was in pain. I gave her liquid analgesics and instructions how to give them.

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Then the kid’s father walked in.

 

The man had the short stature of the Quechua but looked strong – most likely a farmer. He greeted me and Steve, then thanked us for what we’d done. It seemed overdone, compelled by social pressure (an Indigenous, treated in his own country as a second-class citizen, speaking with a couple of North Americans). We made a point of saying – enunciating carefully – that he had made the right decision to seek out surgery. That, because of his decision, it was likely that his son would have a better outcome than with the cast only, making sure not to promise an outcome.

 

Mom looked more relaxed after that.

 

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Steve demonstrated the importance of keeping the cast dry with correct placement of a urinal. I gave Mom some money to buy more Tylenol and Ibuprofen (she had no cash). We set up an appointment with an Ecuadorian physician. Hoping for the best.

 

Insights:

1. Prejudice and social marginalization of Indigenous people in South America

is no less than in the U.S. What’s notable in Andean countries (Ecuador,

Peru, Bolivia) is that this racial discrimination continues even though

Indigenous constitute a much higher percentage of the population (25% /

45% / 55%) than we see here.

 

  1. Rural health care is grossly inferior to that available in the cities.

 

 

Case # 4 – A Zebra

Filed under: Uncategorized — cbmosher @ 3:42 am

 

Five year-old Jhon was carried into our exam room for clearance by anesthesia. The nurse reached for him, and the anesthesiologist jumped up.

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“Be careful with him! Don’t even take a blood pressure – you could break his arm.”

 

The boy has a severe case of Osteogenesis Imperfecta – a genetic defect in bone metabolism that results in a delicate, easily fractured and deformed skeleton.

 

In his X-ray you can see that the “long” bones of the legs are neither long nor straight. Moreover, if you compare the density of his bones with those of Jordy (case # 1), you’ll see how fragile they appear.

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The surgeons believed they could help him by straightening his femurs and tibias. The anesthesiologists cleared him in spite of a distortion of his chest cage which made it impossible for his lungs to work fully.

 

You can see how they achieved this on his right femur and tibia.

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In spite of his severe deformity and a childhood of pain from fractured bones, this is a pretty easy kid to like.

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Everyone involved hopes for a success with Jhon.

 

Insights:

 

“Zebra” in medical jargon, refers to a rare disease. “When you hear hoofbeats” – the saying refers to symptoms – “think of horses, not zebras.” Med Students are, like the general public, fascinated by rare conditions. But the Physician’s responsibility is to diagnose accurately. So the admonition is to think of and rule out the most common diseases first.

 

O I occurs in only one of every 20,000 births. There are eight different types of its manifestation, so some kids are only mildly affected. The mother of another kid in Cuenca told me that she knew of six other kids in the city with the disease.

Case # 5 – Big Red’s Kid

Filed under: Uncategorized — cbmosher @ 3:29 am

 

During the screening Sunday, we were sensitized to look for “syndromes” – kids who looked different enuf that we had to be aware of possible congenital defects, some of which could present dangers in anesthesia or surgery. We had, after all, seen a few kids with Cerebral Palsy, two with Osteogenesis Imperfecta, and a suspected case of Congenital Psuedoarthrosis.

 

Ximena caught our attention immediately. Pale skin, large head, big for age (she weighed more at 7 months than another girl with the same problem at one year, 4 months).

 

Then Dad walked in.

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It felt a little weird to converse with him in Spanish, but that was his native language. A gentle giant from another land.

 

Like many other small children we saw, this girl had congenital hip dislocations. The pediatric orthopedist planned to reduce both dislocations. He would do it “closed” i.e. without surgery. Just put the hip where needed, then place a cast.

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Once the child had recovered from anesthesia and the family was on the floor (ward), the surgeon asked me to translate for him. He explained that the hips’ acetabulum was much flatter than he’d thought (should be shaped like a cup to hold the ball-like head of the femur). He was concerned that the femur might easily dislocate again before the bones grew adequately to hold the femur within the pelvis’ acetabulum. Because of this, he did only one hip. The other could be done in the future once this hip was secure.

 

The parents had concern and anxiety all over their faces. “Will you be back to do the second surgery?’ they had me ask the North American surgeon.

 

“No,” he reassured them. “The Ecuadorian surgeons can do this just fine.”

 

Their faces, tho polite, told us they weren’t buying. “When will you be back?”

 

“We don’t know for sure. Maybe in a year.”

 

“Can the second hip wait for a year?’

 

“No. Not that long. Really, the Ecuadorian surgeons can do this. It’s not that difficult.”

 

It took a lot more talking before the family was as reassured as we could make them. They were appreciative and gave gifts to all the members of our team when we left.

 

Insight:

 

A major trap in these medical missions is the unspoken message that North American doctors are better than the locals. It undermines confidence in the medical care available to the people 51 weeks a year. I like the way the Pediatric Orthopedist handled this.

 

 

 

 

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