Sex, Drugs, and Public Health

November 4, 2017

Case # 2 – Too Cute

Filed under: Uncategorized — cbmosher @ 4:05 am

Look closely at her picture.  At her hands.



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.



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.



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.”




“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.



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.



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.



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.



“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.



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.




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



Everyone involved hopes for a success with Jhon.




“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.



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.



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.




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.





Wrapping up Ecuador, part 1

Filed under: Uncategorized — cbmosher @ 3:11 am


We finished up work in Post-Anesthesia Unit (“Recuperación” is their official word for it) with patients both hard to awaken – – –



And patients radiating The Cool – – –




Our magnificent Logistics experts (Sandy and Yovi) ferreted out and purchased walking boots, a wheelchair, crutches, and a walker with money donated by generous U.S. friends. We taught people to use these devices (with varying success – the walker failed our 80 year-old with a fractured patella, thus the wheelchair). After a final rounding on the patients and arranging for follow-up, we did our own “recuperación” by exploring the city before descending again to Guayaquil.


To arrive at the Regional Hospital in Cuenca, we had taken a bus from Guayaquil (the country’s name warns you about such sea-level cities: Hot. Muggy). The bus had climbed us east, into the mountains and over an Andean pass at 13,500 from which vantage you can look down on the clouds.



Then you drop into a valley where the city of Cuenca sprawls at 8,200 feet.



The city has been conquered and colonized several times, morphing into the hybrid where we spent the week. Ten thousand years ago, it was the center of a hunting culture. Then agriculture developed, evolving a stable population center, peopled by a now extinct race.


The Quechua took it over and re-made it into an urban center with their stone work. It became “Tomebamba,” the northern hub and second largest city of their Inca Empire. Then the Spanish arrived and built their colonial churches and administrative buildings on the decaying bones of the Incas.


It subsequently grew into an Ecuadorian spa town with steaming baths fed by volcanic heat and with regional resources (like the hospital) for the farmers of the surrounding mountains.


Most recently, the city’s been invaded and colonized by 20,000 white-skinned English speakers grown too old and wealthy to work.


These are the parts of town where I felt most at home – – –






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