Sunday, March 25, 2012

In Memory of Harry

Harry W. Kuse (1922 - 2012)
It's a Sunday evening. I have a new (to me) patient with cystic fibrosis on the floor. I was not supposed to work this evening, but whenever a cystic fibrosis comes in, plans change and I round on them daily. As I finished doing that (circa. 7:30 pm), I thought to go and see my patient and friend, Harry. Up until Friday, we had been trying to treat him and he was not responding. The plan was to transfer him to palliative care's service by Monday if he did not turn around. I looked up his name on the computer and found that he had already been transferred to their service. Things must have taken a turn for the worse, I thought. I walked down to the unit to see him and his family -- a doting daughter-in-law and son. The bed was wiped clean. Harry was dead. He died around 5:30 pm today.

I first met Harry way back when I was still doing residency training. I still remember entering the exam room to find this pleasant elderly gentleman reading a western novel without any reading glasses. Through the years I came to know Harry well. He probably read every western novel he could get his hands on. Towards the end, the only westerns he could find that he had not read were western romances so he began reading those too.

Harry had become quite deaf but absolutely refused to wear hearing aids. We communicated with him by writing things on a whiteboard and he would reply back verbally. In the beginning, his daughter-in-law had to 'translate' everything he said to me because I could not make out the words in his near mumbling, rumbling voice. Towards the end however, I was surprised to realize one day that I no longer needed her help. I understood him well enough.

Harry was a tough old guy. He would flirt with the nurses and aids at the nursing home and hospital and had a great sense of humor. In the last 3 weeks he took a turn for the worse and began a slow decline that failed to change despite antibiotics, breathing treatments or whatever we did. We began to see this coming.

I remember walking away from the hospital last Sunday reflecting that for the first time, perhaps, I was losing my clinical objectivity with respect to a patient. I did NOT want him to die! I was not ready for comfort measures and found myself suggesting to his hospital doctors that we try this or that treatment. They looked at me sympathetically, but puzzled and a little dissappointed. I was supposed to be on their side in telling the family that it was time to let Harry go and I wasn't helping. It gave me pause. When does a patient become a family member or a close friend so much so that clinical objectivity is lost? Can I truly do right by my patient if I become emotional towards the inevitable decline?

On Friday, I saw Harry for the last time. He would open his eyes when I called his name but close them seconds later. I confessed my struggle with objectivity to the family with a trembling voice. However, I did put my heart aside for the moment and told them that I thought Harry had fought long and hard and his body was giving up. It was time to stop the treatments that weren't helping and keep him comfortable. They agreed. His daughter-in-law had in fact already begun to assemble photos of Harry in a slideshow and shared some of them with me. We all shed tears as we smiled at Harry's mischievious smile and twinkle in his eye as he rode his little tractor in their garden, as he played with grandkids, and wore a valentine heart on his last valentine day. I was paged out of the room and had to rush away. That was the last time I saw Harry.

They say you're not supposed to get attached to your patients. How is that possible after taking care of them for years and going through thick and thin, near misses with death and some emotionally charged painful experiences together? Sometimes all even a doctor can do is shed tears and bid farewell to a patient who becomes a friend.

Goodbye Harry! I will miss you! I still got your kids to take care of. Know that they are in loving hands.

Saturday, March 03, 2012

Tension in the room

It was the last patient of the day. Why is it always the last patient of the day?

It was a well child exam of a beautiful toddler. She was in the room with both of her parents. She saw me enter and smiled. Mom gave her a photo to hand to me. It was a picture of her all dressed up looking so-oo big. I smiled and thanked her, giving her a hug.

In the room were mom and dad. When they looked at her or talked to her or to me about her, they beamed. Their eyes lit up as they proudly recited all the words she could say and the new things she was doing. They did not have any concerns. But...

When they looked at each other or exchanged a few words, the tension could be cut with a knife. I knew they were divorced. I knew they shared custody. They obviously loved their daughter. They showed their committment to her by both coming to the appointment -- or did they not trust each other to relay anything that may transpire at the doctor's to each other?

Divorce is such a sad part of our society. With more than half marriages ending in divorce, there are many children in shared custody. Most parents love their children even if they can no longer share a marriage with their child's parent. I hurt for the parents and the children in this situation. As a doctor who sees children, interacting with the adult parents is part of the equation. As a doctor to adults too, I feel the pain of both the parent and the child and want to help them both. But how?

I have seen this child since she was born. Her parents were married then and not now. I will continue to walk with her and with them doing what I can for all of them. One day, one visit, one situation at a time.

El Salvador Mission Trip 2012 - Part 1

From January 20 to 29, 2012, a group of 56 people, including 4 doctors, 1 dentist, 7 nurses and others travelled from Marshfield, WI to El Salvador to work, pray, love, repair and build. In 4 days, we visited 4 different underserved sites in the country and delivered medical care to 800 people. Here are some pictures from that trip.

On medical missions, if you'll need it, take it with you!

Every morning, we'd have breakfast at 6:30 am. About an hour later, we would load our two buses with people and equipment. Pretty tight fit! Most of our trips involved 2 to 4 hours of bus travel each way to the places we worked at.

To get to some destinations, it was necessary to transfer everything to smaller pickup trucks.

Sometimes, the roads were too narrow for a bus, so we'd transfer everything to small pickup trucks and go the rest of the way

Let's make bubbles!

We had a lot of fun and I think, got back more than we gave. Here is one of our high school volunteers (Olivia Heegeman) teaching a little girl how to blow bubbles.

Blowing bubbles is fun!

It worked! Laughter is free.

removing an infected ingrown toenail
One of doctors -- Princy Ghera-- was a Med-Peds resident from our (Marshfield Clinic's) combined residency program in internal medicine and pediatrics. She finishes her residency this June and is going on to become a pediatric pulmonologist. Here she is removing an infected ingrown toenail while I looked on.

Here's the patient (mom) holding onto her daughte for comfort.

Interestingly, while she worked on the patient's toe, the patient, a mom, held tightly onto her daughter, while the second one looked curiously at me trying to comfort her. Usually mothers comfort their children during medical procedures. But who says the roles cannot be reversed?
Our team purposely went to the poorer parts of the country. Our goal was to provide free medical care and services to those without access.

Some of the houses nearby where we worked

El Salvador Mission Trip 2012 - Part 2

Counting pills
 A regular ritual before we can hit the road to visit the places we go to provide medical care is counting pills. We pre-package 30-days supply of pills in little plastic bags that have symbols of a rising sun, mid-day sun and setting sun. We pour out volumes of syrups and liquid medication into one-person size bottles. This takes quite a while and by the end of night, not many of us are left smiling as we are here at the start of the activity.
In the background you can see our evangelism team learning street skits and dances they used to reach people on the streets while we saw patients.

Are they any more left?
 Basically, the evening before our 'work week' begins is used to set up and package all our meds and plan what we'll take.

on the road
 Once we're all packed, we hit the road. Our daily bus ride took 2-4 hours each way. The roads weren't the best. Because of constant use, these vehicles often lose their shocks and their suspension gets shot. One of the teams that came down with us were a dedicated group of auto mechanics that stayed behind at the center and overhauled, repaired and maintained all the vehicles and equipment.

Onto a smaller pickup where our bus could not go

For me personally, it was fun to load the bus, then unload the bus and load the pickup truck, then unload the pickup truck and set up everything in the places we provided care. We all worked hard to do this. It was good exercise.

Setting up
 Here we are outside a church in Las Delicias. We set up our clinic inside that church and saw approximately 200 patients that day.

Dr. Boris Magana 'checking in'  a patient.
  Once we were set up, there was a system. People in the area were told beforehand that a medical team would be coming and they could come and get free care and medication. They were given coupons (free) ahead of time. Once they showed up, they filed into Dr. Boris' station. He took down a chief complaint, filling it out onto a medical form on which the next station could write down vital signs, blood sugars.

Checking blood sugars
  This year, thanks for donations from the makers of OneTouch, we were able to check blood sugars. We diagnosed several new cases of diabetes and some known cases with uncontrolled diabetes. One patient with a blood sugar of 600 (normal: 70 to 100) told us that he knew he had diabetes. He said the local hospital was out of insulin. We are trying to build a clinic where patients can come and receive continued medical care. For now, Dr Boris sees them rotating visits through the various places we were about once a month.

Checking vitals
Once patients had checked in, the stepped to the vitals station where nurses checked vitals.

Nurses wrote the vitals onto the patient's 'char' (a single sheet given out at the triage station above).

Getting busy
 To keep people amused and occupied during the several hours wait it took to process and see everyone, we had a couple of volunteers entertain. Zip (Fran Davis) sews her own clown costumes and is a great hit with the children every year.

Zip (Fran Davis) with a couple of fans

A family waiting to be seen

El Salvador Mission Trip 2012 - Part 3 -- Seeing the doctor and dentist

Once processed, patients take their seats in a waiting area and are seen by a doctor and/or dentist. If referred, they are sent to a station to get their ears flushed, get an injection, get sunglasses or get their teeth varnished (for the kids).
towards the end of the day, there were few patients left to see

Seeing a patient in El Salvador in a medical missions environment is different than seeing them in the office in the States. It is noisy, busy and there is little or no privacy. There is no exam table. Most patients give their history using terms that would mystify most internists. If you ask them "How can I help you?" they look at you confused and say "I don't need any help!" In El Salvador, doctors ask "Que tiene?" -- What d'you have? That magic phrase gets them talking and interestingly, they all begin with "Fijarse doctor, es que tengo..." (Focus on this doctor, it's that I have...). They used expressions like "tengo nervios" (literally, I have nerves or nervousness), "Mis ojos arden" (my eyes burn) or "me duele mis canas". Through the years, we have figured out that there is a lot of dehydration, dry eyes, fatigue, and perhaps parasite-related complaints.
Getting a history -- the key to a diagnosis

Dr. Dave Heegeman seeing a patient
 More scary though was that they would use medical terms in their description of symptoms like "cuando tengo cholera..." (when I have cholera...) or "tengo mucho parasitos (I have a lot of parasites...) or "siento mucho malaria" (feel malaria). This can be quite bewildering in the beginning.

Dr. Thao Trinh, a pediatrician seeing a patient

Dr. Princy Ghera checks a thyroid
One learns to adapt and ask different questions until one is satisfied that one has a story that makes sense.

Thinking it through -- the internist's job

What are we going to do next?
 Dr. Boris and myself are talking to Oscar and his mother about what to do for him after I debrided necrotic stage 3 pressure ulcers.

Rick Mueller (our dentist) and Amy Neumann assisting
 Our dentist Rick Mueller has come with us every year. He brings along a portable dentists chair and a pump compressor unit for suction and a whole slew of instruments. Assisting him here is Amy Neumann who is actually a violinist and information technology specialist, but she learned on the job quickly enough.

El Salvador Mission Trip 2012 - Part 4 -- Eye problems

Eye damage from a chemical spill
Something that has struck me on previous trips to El Salvador (this was trip 3) is the number of eye problems we see. Sometimes we arrive too late to make a difference. This gentleman worked in construction and was applying a chemical to a ceiling (without safety glasses). A drop of the solution fell into his left eye. Miraculously, he can still see from some parts of that eye

Nevus in eye
  I saw a lot of congenital nevi in the eye (see the one in the right eye lateral to the iris in this little boy. Interestingly, I have seen more eye nevi in the eyes of my hispanic patients even here in Wisconsin.

Another Nevus in the eye
  Here is a close up of another patient's eye showing a nevus there. In all these cases, the nevus was present since birth and did not cause any visual changes.

bilateral pterygia
  Every year we go to El Salvador on these trips, we see a lot of patients with pinguecula and pterygia. Here is a middle-aged lady with bilateral pterygia (see the white stuck-on appearing growth spreading from the medial canthi towards the iris). If this continues, it will cut off her vision -- and we have seen examples of that too. Since surgery was not possible (we did not have an ophthalmologist with an operating microscope and operating room), we did the next best thing. A simple was to prevent spread of these is to protect the eyes from the sun. We took as many sunglasses as we could and gave them away, prioritizing patients with pingueculas and pterygia.

pterygium in left eye
  Here is another example of a middle-aged man with the pterygium in the left eye.

spreading pterygium
 In this example, the pterygium had already spread to the pupil and vision was being obstructed.
pterygium in left eye
Yet another example of a pterygium in the left eye.

cataract in right eye in a 90-something year old
Okay, to end on a slightly cheerful note, I had this spry 90-something year old female come in with complaints of decreasing vision in her right eye. She had a cataract, but hey, she had no other complaints. She was feeling just fine! Just because you live in a third world country in poverty does not necessarily mean you can't make it to 90.

El Salvador Mission Trip 2012 - Part 5 -- Assorted medical problems

Fingernail clubbing
Just some pictorial representations of common findings from some of the 800 patients we saw. Keep in mind that most of the patients we saw did not have medical problems that could be photographed. The most common complaints and diagnoses were headaches, fatigue, eyes burning (all secondary to dehydration and dust from an acidic volcanic iron-rich soil). The picture shows fingernail clubbing (note the curvature of the nails) in a young paraplegic. He is wheelchair-bound and hunched over so does not take deep breaths. I suspect his clubbing is related to some lower lung atelectasis from his poor posture.

Ear pits
  Look at the little 'dot' in front of the ear near the place where the auricle attaches to the head. This young lady came in complaining of chronic drainage from this ear pit, which was located in front of both ears. The drainage was clear to white. I suspect it is a brachial cleft tract -- a tract left behind during embyrological development. Unfortunately, we did not have a solution for her. If she lived the States, we might have had an ENT specialist inject something into the tract and image it to delineate the anatomy and come up with a solution to the problem of constant drainage.

Flat wart
  This little boy had a flat wart. We offered reassurance to the family, explaining that these resolve without treatment.

Gum abscess
  This young girl was brought in by her mother for the two red bodies near the attachment of the inner lip to the gum line. I confess: I did not know what this was. Fortunately, our dentist did. He taught me that there were abscesses running from the roots of the maxillary incisors (the two front teeth) because of infection. Because of her age, he pointed out that when the teeth fell out this should resolve. We did give her some antibiotics. We saw a lot of dental caries and brought kits to varnish teeth with fluoride for the children. We varnished as many teeth as we could.

Lichen planus
  This older lady had adequate circulation in her upper extremities. When I got back to the States, I asked my dermatology colleagues what they thought this was. They suggested lichen planus. I could not think of anything I could do for this lady while I was in El Salvador. In any case, they did not hurt, had not progressed and did not bother her.

psoriatic patch on elbow
 This gentleman came in with a scaly rash on his elbows, lower legs, scalp. It was a textbook case of psoriasis.

psoriatic patch on dorsum of foot

Venous stasis dermatitis
 We gave him steroid creams to use for flare-ups. Treatment of psoriasis is expensive and sometimes technology-dependent. Could not offer any of the fancy immunumodulating drugs we have here in the U.S.

This picture of a leg from another patient showed some dermatitis due to decreased venous circulation in a diabetic.

Infected dermatitis
  This young man broke out in circular lesions on his arms bilaterally. We were suspecting a sexually transmitted disease related rash, or a viral infection. The skin lesions were itchy and had begun oozing pus. We treated him with antibiotics to cover him for the first and last condition we thought likely. (In the States, I might have done a punch biopsy and got the pathologist to weigh in, or sent him to a dermatologist)

This elderly woman came in with a non-healing, persisting ulcerative lesion slightly above her left eyebrow. From the appearance of it, we suspected squamous cell carcinoma, one of the skin cancers. We excised it. Here she is after the excision.
Skin closed after a squamous cell carcinoma excision

 I guess bathing is not a high priority when other problems are more pressing. This young man's ears were so packed with cerumen (ear wax) that it hurt him. We tried to remove it with a currette but it was painful and would not budge. Rather than damage his eardrum, we flushed his ears out.

getting ears flushed for cerumen impaction
 We did this for a lot of children and adults, getting out quite a bit of cerumen. Patients were surprised and in some cases, horrified, that all that came out of their ears. We followed it up with some basic hygiene education.

El Salvador Mission Trip 2012 - part 6 - Goofing off and having fun

Mission trips have their bloopers and bleepers. We did a lot of goofy and funny stuff and laughed a lot. We cried a lot too. Medical missions are emotional. One can feel overwhelmed, overjoyed, overcome with sorrow and frustation and discover things about oneself and one's companions on the trip. It bonds the group together as most shared adventures will.
You have to know Scott to know that he would pull a stunt like this for the camera. Okay, he did not really eat the bug and it was dead (we hope).

now this tastes a LOT better!
 The children of El Salvador would win your heart, break your heart and make you want to love them all at the same time.

Okay, I'm ready. First patient....!

 This little girl grabbed the stethoscope and wanted to examine everyone.

Listening to heart of a childrens' pastor. Imagine that!

She told everyone the same thing: "You have hiccups!" When we asked her what we should do to be cured, she uttered real words of wisdom. She said "Don't eat too much!"
Will I live, doctor?

Does your ear hurt?
 When I was finished examing this little one, she wanted to examine me. Who am I to turn down a free physical?

It's MY turn to listen to YOUR heart!

US versus El Salvador impromptu soccer match in the street
Here's Dr. Thao's daughter trying to get the ball away from an El Salvadoran player. Soccer in the street.

Hey! Put me down!
  We had quite a few high school and college kids with us on the trip. It was wonderful to see them do what kids do -- play. Even with the barrier of language and culture, children magically know how to play and laugh together.

Yup! She loves me!
  While we saw patients, our evangelism team would play soccer, skip rope, laugh or just love on the many children we saw in the street.

Outside the church at Nueva Esperanza
 Soccer is a fun game. There is no equipment involved, except the ball. Well, not really. It is a very popular sport in El Salvador.