Two weeks in a Peruvian medicine ward

Working, not being a patient, thank goodness. Antonio Lorena Hospital is the poorest hospital in Cusco. In fact, the best insurance any patient has is the Seguro Integral de Salud or SIS for short, which is pretty much analogous to Medicaid in the US, except worse. Peru has a two-tier system: those who have good jobs or can afford to have private insurance, and those who can’t have SIS. I still don’t fully understand all the details of the system, but the gist of it is that it does not cover much. A brief list of things that are not covered include: chronic illness (heart failure, diabetes, and all their complications, pretty much >50% of all hospitalizations in the US), most imaging studies (X-rays and CT scans in lots of cases), routine laboratory tests (I’m talking about blood count and chemistries here), and of course many kinds of medications. To complicate things, Lorena hospital does not have a CT scanner or ability to run blood or urine cultures (or at least not well, since no one ever orders them). I believe it has one portable XR machine that is utilized in the ICU, but hardly ever on the medicine wards. Whether or not a patient has insurance, the responsibility for procuring medications or paying for diagnostic tests still rests on the family of the patient. That means the family is given a “prescription” every time a new medication or diagnostic test is ordered and told to pay for it that day, or else things won’t get done. As one ICU physician later told me the medicine ward is an example of “natural selection.” The care in the ICU would be slightly better, as I will discuss later.

I spend my first 2 weeks in Lorena in the women’s medicine ward. The departments are segregated into wards for men and women, which is a good idea since there is very little semblance of privacy. The ward consisted of about 20 beds in a giant room, mostly occupied. There was an “isolation section” for those with confirmed or suspected tuberculosis (TBC) that was little more than a concrete wall that reached halfway to the ceiling, with a door that was open all the time. Awesome. The diagnoses varied from diseases rare to the US, such as neurocystercicosis, leishmaniasis, and TBC to more common things such as complications of diabetes and CHF.

The ward is staffed by 3 interns a resident, and a rotating group of attendings and specialists. The interns are fresh out of medical school (in Peru the medical school is 6 years of classes and 1 year of interning out of high school), albeit with less clinical experience than the 1^st year residents in the US. They are in charge of doing a lot of paper work. They write daily notes, copy down orders as given by the resident and attendings, and also take a detailed patient history during admissions (They fill out a poorly structured form that leaves a paragraph to take down the history of present illness and half a page to fill out info on what type of house they live in, how much tea they drink, and a full OBGYN history. If they don’t fill out the form as complete as possible, they get in trouble). What they don’t do is write a “plan” section to their daily notes, which I find somewhat concerning, especially when some of them don’t seem to have the slightest idea what the plan should be. By the way, most of them are a month or two away from finishing, and would be able to work independently the next year. Sure, some interns are brighter and harder working than others. I can also sympathize with their schedule a little. They literally work 7 days a week for a whole year without breaks and with call every 4^th night or so. The resident is in his 3^rd and last year and is very knowledgeable and helpful. The attendings are fairly knowledgeable as well. Rounding goes on for about 3 hours, with specialists coming in and out. It is as much of a bore as it would be in the US. As far as pimping goes, most attendings do not bother to ask questions. However, there is one cardiologist who loves to pimp. He asks a series of basic science questions as well as simple clinical practice questions that most 3^rd year US medical student should know. However, one of the interns was actually thrown out of rounds, not once but two days in a row, not reading up about atrial fibrillation!

 I spent my weekdays until early afternoon in the wards. After a few days of learning the system, I picked a few patients to see in the morning and presented them to the attendings. I found it a rewarding experience to get the initial history from these patients when they first arrived. I also presented my plan daily, which was often unfeasible due to resources. Sure, this lady is acting totally confused, but we can’t get a CT scan because the family can’t pay or it, or sure this person is could be septic, but there are no blood cultures to order. Even getting routine labs or chest XR is a struggle. Most patients with infections get a blood count about once every 5 days. There were 4 deaths in the ward during my 2 weeks there. A couple of them were really sick, but a couple deaths were surprising. I don’t know if this is an abnormal number or not. It’s true that the patients that come to Lorena generally are sicker. There were a few very frustrating cases. There was the otherwise healthy 20 y/o girl with back pain who waited in the hospital for almost 2 weeks for an MRI. There was the old patient with a subdural hemorrhage who waited 2 days to be transferred to hospital with a neurosurgical unit. One of the patients I helped to take care of, a 90 y/o with a variety of medical problem was one of the deaths. Finally, there was the 35 y/o woman with severe valvular disease from rheumatic fever who would need heart surgery. She didn’t even have money to pay for an echocardiogram. The cardiologist did it for free. I don’t see her living another 5 years. It was a sad case. 

Overall, I learned a great deal about how medicine is practiced in a 3^rd world country. Yes, Lorena has limited resources, Peru’s medical insurance system isn’t perfect, the interns have a lot to learn, and the doctors don’t have the best bed-side manner (oh boy, I’m going to have to write a separate post about that), but I genuinely believe that the doctors care and try, and maybe aren’t so burnt out as doctors in the US (another topic I should explore). I met some very knowledgeable physicians and a different set of patients than I would ever see in the US. There is more to say that I can possibly include, or possibly expect anyone to read in a single post.  

Soccer at 11,000 feet

Here is a little life skill that I never picked up and do I ever regret it now. It wouldn’t even be so bad if I could at least keep up with everyone else. It might be the altitude or the fact that I’m grossly out of shape and haven’t been able to run much because of my bum knee, but I suck. At least I have people to play with. I started playing a weekly game with Spanish teachers from a few schools. The first week I played 3 v 3 on a court about the size of an NBA court. I was out of breath in about 15 minutes and about 30 minutes, I was pretty much squatting down every couple of minutes. I had about 5 opportunities to score and blew them all.

I just came back from my second today. I played ok for the first 20 minutes on a smaller court. The turning point, though, was when jostling for a ball, I accidentally launched it about 30 feet out of bounds. This is the best part, turns out it landed inside a police station. Furthermore, it landed in a  kennel! I had the unfortunate duty to ask the policeman to help me find the soccer ball. Kennels are scary. Good thing the doggies were behind bars, but remind me never to piss off a police dog. Apparently the police thought it was so funny that a gringo lost the soccer ball. Apparently the dogs like the flavor of foreigners. Thanks. Asshole. I blew a couple of good opportunities to score and pretty much was relegated to goalie by the end. Suck suck suck. Oh well, I’ll keep at it, and hopefully I’ll hold my own. At least I am having fun sucking.    

My first patient interview in Spanish

After 3 weeks of Spanish classes, I finally got my first opportunity to do my first patient interview in Spanish. It was part was our clinic project, which is visit houses around the neighborhood and provide medical advice as needed. We encountered a gentleman who had had a devastating hemorrhagic stroke a few months back. I was with Kate and nurse at the clinic and we sat and talked with him, his wife and his two sons. I was able to get most of the relevant history and perform a pretty thorough neuro exam on him (Dr. J would be proud). Kate and I then advised him the best that we could. It was obviously frustrating not getting all the facts and not being able to write prescriptions, but overall it was an encouraging experience. I hoped that we were able to answer some of the family’s questions that other doctors might not have had the patience to answer.

Llama vs Nansen

I’ve always heard that llamas were mean animals. But how can that be? They are so cute with their shaggy fur and dumb looking eyes. One Friday morning, instead of sitting in class, my Spanish teacher Ricardo, took Kate, Cara (another student), and I on a field trip to the university. The first stop was the university zoo. Now this is no ordinary zoo. In fact, this might have been the most animated zoo I’ve ever been to. It shelters wild animals while they recover from various ailments, then return them to the wild. It’s the only zoo where I’ve been handed a toucan, turtles come in wheelbarrows, and the monkeys show you their…manhood.  

Anyways, there were llamas roaming the premises as well. One in particular was having an especially active morning. It picked on Ricardo first, attempting to bite him. Cusquenos, apparently, have experience with fending off llamas. He even put the llama in a headlock. After a bit of a struggle the llama went away. It came back a minute later, though, this time to try to eat Cara’s hair. Again Ricardo fended him away. I was next on the target list. The llama stopped a few feet in front of me and stared at me with those silly eyes. Like a dumb gringo, I put on a fighting stance with a dumb smile. The llama was not amused. It had had it with dumb gringos. It struck. It went on its hind foot, which made it seem about 7 ft tall, and proceeded to chase me down. When I decided I couldn’t outrun the llama, I turned to fend it off. Luckily for me, the llama’s charge was more fierce than its attack. All it tried to do was to extend its silly neck and try to bite me with its flat molars. It was easy for me to fend it off with my one semester of college Jeet Kun Do (intercepting fists!). I walked away but the llama followed me. After a few more rounds of this exchange, Ricardo came to the rescue. He grabbed its lease and tied it to a garbage can. Llama maiming averted!       

In summary: Ricardo tames llama, and llama tames Nansen. 

Oh yea, and when I got home, Kate thought it would be funny to surprise me with a stuffed llama. I was safe though, it was tied to a Pringles can. Hooray!

 

Death Street

Each day we put our lives at risk walking to Spanish class. Imagine the streets of Venice, except with Incan stones and car traffic. Each day is a test agility and flexibility as we avoid incoming pedestrians on the one side of the street with a sidewalk too narrow for two people to walk side by side, while stepping off the curb to play a game of chicken with the oncoming cars. This is not the only street like this. In fact, we have identified death street 1-4. It is quite amazing that these streets haven’t changed in the last 400 years. But now instead of human and horse traffic, there are cars as well.   

One day, walking back home with our backs to oncoming cars, both Kate and I, while entirely on the sidewalk, managed to get sideswiped by the side view mirror of a passing car. It didn’t even slow down. We were fine. It was just a little incredulous. Another time, a lady stepped off the curb just as a car passed by. She was lucky to just get side swiped by the mirror. Everything is an adventure here.