Saturday, June 22, 2013

Father's Day

It was Father's Day last Sunday. My wife and daughter decided to take me to breakfast to my favorite restaurant. While we sat at the table, I saw a family sitting some distance away from us. They did not see us. At the table were a mom, her oldest son and her 2 daughters. There was no man at the table. I recognized them from clinic. The children had missed their well child visits, although I did not know why. Seeing them on Father's day was poignant. There is a story there.

A year or so ago, it was a Friday afternoon and I was going in to an examining room to see the last patients for the day. It was a well child for 3 siblings. We were runny behind and I was tired. I was scheduled to fly out of the country the next day to visit my family in Panama.

As the clinic visit unfolded, it became clear that their dad was physically abusing the children. He hated the oldest one, since he was a step-son. He had no patience with the younger ones. They were traumatized. After investigation, the father was removed from the home and mandated to go to anger management. When I saw the children in a follow up visit, the youngest one said to me:

"I miss my daddy! It's my fault he had to go away. I broke something and I made him angry. It was my fault!"

It broke my heart.

That was the family sitting at the table in the restaurant... without the dad. I did that.

Pediatricians are mandatory reporters of child abuse.

Tuesday, April 30, 2013

Aswani Salvador

I should start by saying that I have the parents' permission to write this entry, because I shall be divulging some identifying information.

I have a wonderful family in my practice. I see both the parents and kids (one of the fun things that comes from being a Med-Peds doc). Recently, the family was blessed by the addition of twin boys. I was excitededly looking forward to doing their newborn exams.

As it turned out, my schedule was packed, and their first exam in the Med-Peds department was to be done by my colleague, who had openings in her schedule. When they checked in, one of the girls at the appointment desk came up to me with a big smile on her face and asked me if I knew about this. I thought she was asking about whether I knew that one of my families had had twins. I smiled back and said, "Oh yes! I can't wait to meet them!"

She shook her head to indicate that that was not what she meant and smiled and showed me their appointment. They had named one of the baby boys Aswani Salvador! Aswani is my last name and we had chatted in the past about my mission trips to El Salvador. Dad had mentioned at one point in the pregnancy that he would like to name one of his children after me. I had thought he was kidding. Guess not.

It was a bit ironic that even Aswani could not get in to see Aswani -- the practice is that busy!

I did get to meet the twins eventually and was somewhat embarrassed to be holding Aswani.

I hope that Aswani doesn't get flak for his name growing up. :-)

Listening to her heart

My mom visited me here recently. While here,she developed a slight cough and congestion. In order to determine if she might be cooking a pneumonia, I decided to listen to her heart and lungs -- something I do for my patients.

I have listened to thousands (if not tens of thousands) of hearts and lungs by now. Just like other physicians who do this, I am listening for certain sounds, characterizing what I hear into abnormal and normal and building a differential diagnosis based on what I hear. Listening to a heart or to lung sounds is not the same as listening to a song in iTunes or on your phone or music player. One usually isn't appreciating some asthetic.

All this said, when I put my stethoscope on my mother's chest and heard her heart, I had a strange feeling. It occurred to me that when I was in her womb for 9 months (I was born full term), I heard that sound day and night. I was drawn by the experience to reflect on how my relationship to that sound has changed. As a fetus, I simply heard it. I wonder if fetuses derive comfort from hearing that heart sound as some have suggested. Here I was now listening with a physician's ear. I probably heard the sound of my mother's breathing both inside her womb and thereafter as she held me. Now I was listening for subtle changes in her breath sounds to determine if she had fluid in her lungs, an asthmatic's wheeze or something else.

It was a bit surreal.

Tuesday, March 19, 2013

El Salvador Mission Trip 2013

Before the trip….

I was praying for doctors and nurses. We had only 2 doctors – Yakub Elias and myself. We had only one RN I knew of, on the team. We had a few ER techs and nursing students, CNAs.

Day 1 in El Salvador – January 20, 2013

We arrived safely. On board the plane ride to El Salvador from Chicago, one of our team members passed out. She became cold and clammy. It was touch and go for a bit. However, she held on. It was probably a combination of being awake, on her feet and exhausted. She did okay.
Chatting with Richard Pickrell -- our worship pastor at the airport in Chicago on the way

We went through customs without a hitch. However, we were told the bad news: the customs officer would keep our medicine bags. Apparently, the processing of documents that would allow us to bring the medications into the country was not complete. The medications were therefore to be left there until the paperwork could be completed. Since we arrived on a Sunday, nothing could be done that day.

The Castillo del Rey bus that took us around El Salvador

Happy to be back in El Salvador -- loading up luggage from the airport

a 'tower' of medicines ready for clinic the next morning

at the airport at San Salvador, waiting for our ride
In the evening, we sat and counted out tablets and poured liquid medications (we had sent an order of medications that was delivered from Europe to King’s Castle and this was what we had to work with). We wondered if it would be enough. I discovered that 2 nurses that had come with a team before us had stayed behind to work with us. One of them – Mary flushed ears all day and the deaf could hear after she was done!

Day 2 – January 21, 2013 – First day of work

After a 2.5 hour drive to Miraflores, El Salvador (picture), we set up clinic in the church. We saw 158 people there. A mother brought in a toddler with a fever of 104. We were able to treat this child with an antibiotic and brought her temperature down to normal.

She was playful when she left. We saw 10 dental patients and gave out 45 pairs of eyeglasses.

Day 3 – January 22, 2013 – Second day of work

We worked out of the gym in Lago Coatepeque that day. I was nervous because we were already low on medicines (not having what we had brought down from the States yet). We saw 182 patients this day. I gave a walker to an 103 year old male (picture) who took off.

103 year old man with his new walker
We saw a 44 year old female with a piece of sewing needle stuck in her hand for 7 months. Dr. Elias removed it. My last patient of the day was a 12 year old female that had been sexually abused for 4 months. Mom wanted a pregnancy test. She was not pregnant but did have symptoms consistent with a sexually transmitted disease. We treated her and she received counseling. Yakub’s last patient was a 4 year old boy with seizure-like spells. He too had been abused when he was younger. He was on 3 different classes of medications for seizures but his EEG was negative. We prayed for him. We saw 15 dental patients and gave out 76 pairs of eye glasses.

Planning the day with Tammy, one of the local missionary nurses from Castillo del Rey

Our dentist, Andrea McNeely, assisted by Richard Pickrell
Our meds arrived! Our whole team worked hard to count them up and have them ready for the next day. It was great team work!

Day 4 – January 23, 2013 – Third day of work

We worked out of the gym again. We saw 191 people that day. One of them was an 11 month old boy that was severely dehydrated with a high fever, diarrhea and a rash. We were able to get an IV started and treated him with fluids. We saw 14 dental patients and gave out 78 pairs of eye glasses.

I LOVE working in medical missions!

Guadalupe is a small town we passed on the way

Day 5 – January 24, 2013 – Fourth day of work

We got in the bus and drove about 2 hours to San Juan Miraflores Abajo, in the same municipality as Miraflores. We saw 143 patients. Patients here asked about diabetes, cholesterol and weight. One patient wanted to know if the vitamins I was giving her would make her fat. Several patients had blood sugars in the 500s. Dr. Yakub sort of yelled at one woman to be more careful with her diet and she recommitted her life to the Lord in counseling after that. Another complained that her son would not eat regular food, but would eat pizza and burgers just fine. We saw 12 dental patients here and gave out 59 pairs of eye glasses.

Examining the eyes of a young man

Hands - a little girl's hand in mine

A cheloid on the ear of a teenager, came from wearing an earring on her pinna
a skin rash on a middle-aged man -- I suspect ichthyosis

the rash was on both the upper and lower extremities

A close up of the rash on the lower extremity

Day 6 – January 25, 2013 – Last day of work

the portable dental suction unit our dentist uses

Our dentist had all her instruments set out daily for the work ahead

Hands - our dentist holding some of the infected teeth she extracted.
We drove to Nueva Esperanza (about an hour away). We saw 266 patients here. There were a lot of young mothers – 13 through 18. Dangerous place: girls are lifted out of the classrooms by gangs and no one does anything. We treated one 4 month old baby with a severe staphylococcus infection. We saw 19 dental patients and gave out 88 pairs of eye glasses.

Why do we give out glasses? (Picture 1 of eye) – because sun damage causes pinguecula that progresses to (picture 2 of eye) pterygium, that causes blindness. Only surgery can remove this growth once it forms.

pinguecola -- spreading from the medial canthus towards the pupil

Pterygium -- the growth now covers the pupil in this older woman
All told, we saw 940 medical patients, gave out 346 pairs of eye glasses and treated 70 dental patients. With only 2 doctors and not having our US meds for 2 of the 5 days, we still saw more patients than we have in each of the past 3 years. The LORD knew how to space us out with our meds and he gave us grace to serve. In the end, we had enough doctors, 4 awesome nurses who did excellent work and many, many helpers in the medical work. Everyone pitched in to count meds and load the buses each day.

from left to right: Drs Yakub Elias, Vijay Aswani and Boris Magana

Nail disorder in an older woman

assymmetric enlargement of right lobe of thyroid

Vitiligo patch on knee of a teenage boy

vitiligo patch on the back of neck of the same teenage boy

I suspect Buerger disease in this unfortunate lady, who has had bilateral above the knee amputations due to poor circulation and now has decreased circulation in her fingers.

Listening to the lungs of a man complaining of cough

Dr. Elias checking ocular movement and cranial nerves in a young lady

100 people who came to the medical work accepted Christ.

On the last day, I was discussing why so many people in the sites where we saw patients get intestinal parasites. We were discussing how we might improve sanitation and drinking water. One of the missionaries that was there this year holds a Masters in Environmental Engineering from Johns Hopkins and was with Engineers without Borders. He is going to work on setting up an appropriate technology solution.

We plan to work on educational materiel to teach basic hygiene, sanitation.


Last year, at Nueva Esperanza, I got to see a paraplegic who had the worst pressure sores I had ever seen (picture of buttock sore). Working under less than sterile and optimal conditions, with Terry Martin as a nurse to assist, I debrided his wounds. He told me they healed and closed us on their own (picture of healed sores).

Sacral and buttock ulcers before debridement last year

This year, most of the ulcers have healed up well!
We gave him a wheelchair cushion and a mattress.

This is a picture of the mattress we got Oscar. His little nephew stands nearby

Oscar with his mom, a nephew and a niece in his house.
This time, I was able to go to his house and see where he lived. Here are the pictures. For someone in a wheelchair, he lives in a dirt floor house with boulders in the driveway.

the floor of Oscar's house

Oscar lives in poverty, the only breadwinner in his home being his sister. She works in a Fruit of the Loom factory in El Salvador making mens underwear (check the labels on yours, if you wear FotL).

The dirt flooor of Oscar's home is readily visible in this picture

and in this one

This is Oscar's driveway that turns to mud in the rains.
During rains, it turns to mud. He is unable to leave his room to go to his sister’s room next door because of a step-down into her room. We would like to put a floor in his house, level his driveway and put cement over it. This will cost $ 1200. We have someone reliable who is presently there and can help.

Update on the Clinic

The clinic is coming along nicely and God willing, should become operational before the year is out. We need money or airconditioning, electricity and supplies within the building. Here are some pictures.

Outside the clinic... I swear the wind was blowing through my shirt... I am not that fat!

The inside of the clinic near the receiving entrance. The floor has been laid down and there are now windows and doors in place

Our dentist with Dr. Boris in a proposed work area.

Birthday cake

I was working Urgent Care one weekend. It was almost the end of the shift, and being a Sunday, most of us were looking forward to going home to enjoy the rest of the day. Suddenly, we were informed that a family of 5 were checking in! It appeared that they were all at a birthday party and had eaten cake. When Mom was washing the knife they had used, she noticed a piece of it was missing. Of course, everyone's concern was that perhaps someone had ended up eating a piece of cake with a piece of knife in it. There were also several people checked in on the adult's side of urgent care (I was working on the Peds side).

Usually, we would get x-rays to look for the 'foreign body'. Fortunately, an astute x-ray technician (who also probably wanted to go home) asked if we could x-ray the cake instead. As it tunred out, the family had brought the knife (what was left of it) and the cake. Here is what we saw:
tray of cake -- can you see the knife piece?
How about now?
The piece missed what was missing from the knife. Not only was everyone relieved, but this x-ray technician saved several people including children from having to be exposed to the radiation of x-rays.

There was only one problem: how do you record the images in the radiology software system? To whom should the bill go to?