Rhett’s Blog

Death

Today was a pretty slow day in the hospital. This whole week has been super slow, beside that exciting ER case we had a couple days ago. Little did I know September is the slowest month of the year here, so if you want to do a rotation here, don’t come in September. They said their busiest months are December, January. What I wanted to blog about was the news I got today. Word came back from the PICU in Belize City that the 4-month-old we transferred there on Wednesday had died. How sad I was to hear that news. We had done so much to keep that kid live and it was literally a miracle he had pulled through and was stable and breathing on his own when he left here. What’s even worse is when I found out how he died. I’m not sure what other underlying issues he had, besides the hypovolemic shock, but likely there was something else going on. Sometime that evening they had to put him on the ventilator. Dr. Sierra told me that sometime that evening the ventilator he was on had malfunctioned and quit working so he died. I couldn’t believe my ears, but that is the story we are hearing here. I’m not sure what could have happened. Was somebody not there with him? Did they not have alarms or monitors on him? Was there no back-up ventilator? Who knows. It’s a sad deal that shows some of the weaknesses of the health care system here. It’s never easy to hear news like this, especially after all that we had done to keep this baby alive, but it’s part of being a doctor. As a physician, you can reach some of the highest highs when you save a life, but also some of the lowest lows when a patient dies. Somebody has to bear that cross. I’m proud to be able to do it.

Code in ER

This week has been mainly uneventful, but today we had a crazy ER experience. The hospital here doesn’t usually see the life or death situations in their ER and the administrator here told me to have such an experience I had to be lucky enough to be in the right place at the right time as most students don’t see it that rotate here. The life or death situation occurred today though.

                Dr. Lazo and I rushed to the ER about 10 am this morning. There was a 4-month-old male who had a 1 day history of diarrhea and vomiting. Over the last few hours the baby had become lethargic and limp. He was very pale, capillary refill time was prolonged, and his blood pressure was low. This was obviously a serious situation, but I didn’t realize how serious it was at the time. Up to this point in my career I haven’t had much ER experience so I was new to such a life or death situation.

                What’s the big deal though, right? Treatment is simple. He’s obviously severely dehydrated so you just start an IV and let the fluids run. The problem was this kid was in hypovolemic shock by the time we saw him and nobody was able to get any type of line into his vasculature! He was stuck over 10 times, but he was a chubby infant and his vasculature was severely retracted and nobody was able to get an IV in. They tried in the neck to, but no success. Dr. Sierra tried using a 16 gauge needle for an intraosseous placement, but that wasn’t working either. Things were getting pretty scary and the only fluids we could give were oral rehydration through an NG tube, which wasn’t doing anything. Dr. Lazo had the surgery experience so he was going to try to put in a central line through the neck. The nurses created a sterile field and Dr. Lazo began the procedure. When he reached the vein I couldn’t believe how tiny it was. It’s like putting a small line through a tube the size of a pencil lead. It was a pretty difficult task and it didn’t help that there was a lot of chaos going around in the ER because of the whole situation.

                The baby was completely covered by the drape at this point, but there was someone from the lab that was at the baby’s head rubbing his hand and speaking to him. Dr. Sierra was peaking under the drape periodically. The baby had been stable up to this point, but I think people were forgetting to watch the patient and more interested in watching Dr. Lazo. This baby’s life depended on his ability to get a line in.

At one point, no one had checked the baby for a bit, and I’m sure the lab tech at his head didn’t have experience for such a situation. I peeked under the drape and was shocked to see no chest movements! I grabbed my stethoscope and could hear no breath sounds. I could make out a faint heart beat, but it was very bradycardic. I told Dr. Sierra and he grabbed the ambu back as I began chest compressions. He was trying to give good breaths, but it was difficult as the procedure was still going on and he was having a hard time getting a good seal. We got a rhythm going and the baby was given epinephrine. Regardless of all the CPR we did though; if Dr. Lazo couldn’t get that line in we were in big trouble. It was hot, humid, muggy, and chaos was going on behind us with the nurses running for this and that and the child’s parents were nearby sobbing. I was checking the pulse periodically, but wasn’t feeling one. I had made up my mind that this baby was dead. What a disappointment too; if we could just get a line in we could probably save him! I checked the heartbeat with my stethoscope again and was surprised to hear some improvement. The rate was <60, but was definitely stronger. I looked at the IV bottle and could see it was running! I looked at the incision and could see Dr. Lazo had managed to get in a vein and was securing the line in place! We continued CPR and I continued to recheck the heart rate; 80 bpm, 100 bpm, then 120 bpm! This baby was turning around fast since we finally were able to get some fluids into him and just in the nick of time. I stopped chest compressions and Dr. Sierra continued to bag the infant. After a bit of time the infant was breathing by himself and crying. That was music to my ears!

That wasn’t totally the end of the action though. The incision that Dr. Lazo had made was bleeding quite a bit and they were having difficulty controlling it. Luckily, they had called a local surgeon from San Ignacio in and he had just shown up. He was able to adjust a few things and stop the bleeding. The child had lost a pretty good amount of blood for his size, but was stable and doing well considering the situation. After stabilization we transferred the infant to Belize City where they have a pediatric intensive care unit. I can only hope that everything works out for this little guy and that there is no permanent damage.

This was a great learning experience for me and one I will never forget. Things didn’t go very smoothly and there are a lot of areas were things could improve, but at least the outcome was good and I can learn from the experience. I’m grateful to have been here as things like this don’t regularly happen at La Loma Luz, but my overall experience here has been fairly wild at times. I’m having lots of fun, learning a lot, and grateful for much of the independence I have been able to experience. It’s a great preparation for internship to be making some of the decisions and seeing what I can handle. I’m glad I came to Belize!

A Great Week

This week has been pretty good. There have been some interesting cases and I’ve been able to have some independence. Thursday was a bit interesting because there was no doctor here! Dr. Sierra was here in the morning and was leaving at noon. Then Dr. Gamero was supposed to show up at noon to finish the day off. The morning had a number of clinic patients and since Dr. Sierra was the only physician he was really busy. He’s great because he lets me see the patients start to finish and make the decisions, while giving me advice. He gave me a stack of charts and I went and saw them in the other office. The afternoon was full of even more responsibility when Dr. Gamero didn’t show up! He had gotten held up in Belize City and patients were lining up. I did the only thing I could and just started seeing everybody myself. It was actually fairly slow so I didn’t have to see many. Dr. Gamero finally showed up in the evening when I was giving fluids to an ER patient. That night Dr. Lazo and his wife returned so I’m wondering if my days of fun with all the responsibility are over. He’s a great guy, but seems really hesitant to let me do anything. We’ll see what happens.

                One interesting case that came in this week was a young Mennonite girl. She had a history of aplastic anemia and had been to Guatemala for diagnosis and treatment. She wasn’t my patient so I’m not really sure what type of treatment she was getting. She was as white as a ghost and had been feeling weak. I’m thinking she hadn’t had any treatment or anything since Guatemala and they were finally seeing a physician because she was feeling pretty weak. Dr. Sierra ran a CBC and her cell counts were pretty bad! Her WBC was 1.0, her Hgb was around 5 I think, and her platelets were 5! All obviously very concerning, but the platelet really jumped out at me. Dr. Sierra ordered a transfusion with pRBCs, but didn’t order any platelets. I mentioned that she really needed some platelets, but apparently they don’t have any! I asked about transferring her and he said they don’t have any platelets anywhere in Belize! As I think about it, I wonder if I misunderstood because how could they not have platelets anywhere? The nurse confirmed though that platelets just weren’t available so I was pretty shocked. The only option for platelets would be to send her out of the country. Dr. Sierra wanted to try steroids first though to see if he could raise the plt count that way. I’m not sure what has happened to her because I left town, but that was just another interesting example of the poverty present here within Belize really affects healthcare.

                I took some vacation time since I have been working straight since arrival and I want to see the tourist side of Belize too. I went to the Mayan ruins of Caracol one day and took a trip out to the tropical islands called the cayes today. Caracol was absolutely breathtaking and I would highly recommend it to anyone coming here. I suppose Tikal in Guatemala is the more popular touristy spot, but that was part of what was great. There was not one tourist there so we had the whole site to ourselves. I took a boat out to Caye Caulker this morning and I’m staying in a hotel here for a couple nights, since there is a holiday on Monday (Independence Day). This place is amazing. It is an absolute tropical paradise and I’m having a really good time here. I took a snorkeling tour this afternoon and saw so many kinds of fish and I swam among sting rays. I can’t wait for some more activities and I think I’m going to take a sea kayak out tomorrow and explore around a bit. Belize also has some great tourist sites, so in addition to all the good work I’ve been able to do here I’m happy to be able to see some of the things that make Belize so great. I’m half-way done and this experience has been great so far.

More interesting cases in Belize

Last night an interesting and complicated case came in. They called me in at about 7 pm for a 17 year old female who had vomiting and fever. I wasn’t expecting anything too complicated from that description, maybe a simple gastroenteritis, but things turned out to be different. It was a bit difficult to get to the history and find the main reason she was there. Turned out the vomiting wasn’t the most concerning thing, but the fact she had been having difficulty breathing for 4 days and cough. Dr. Sierra happened to be in the hospital at the time so he came in to help out. She sounded consolidated on the left side we decided to get a chest x-ray and CBC. In the meantime, we wanted to get more history because there were definitely some medical issues with this girl. She was 17 years old and only weighed 50 pounds! She was tiny. She had fallen on her knees three years ago and had fractured both femurs! Since that time she hadn’t been able to walk. On physical exam she had some obvious skeletal deformities. She was obviously very small in stature. She had severe scoliosis and a flail chest. The distal end of her forearms where deformed and twisted into hyperpronation. She was a bit knock kneed too. Before she broke her femurs the parents said she was normal and walking fine. In only 3 years she had become deformed and unable to walk. In addition, she had a history of nephritic syndrome about a year and a half ago. Obviously, she had had a huge lack of proper health care, most likely because of the family’s poverty. Her deformities had never been addressed by a physician and I’m pretty sure the kidney problem hadn’t been cared for properly. We did a creatinine also because of the history of renal problems. The family was poor so we were severely limited on the tests we could perform. Well, her chest x-ray was positive for left lower lobar pneumonia. To add to that her Hgb was 6.6 and hematocrit  20.5. And to make things even worse, her creatinine was 3.6. This girl was pretty sick.

                We had to get permission from the administrator to admit her as her family may not be able to pay. She was transfused and started on ceftriaxone. At this point she needs to see a specialist in nephrology, but I’m not sure what is available here in the country. I’m thinking whatever nephritic syndrome she had was not treated properly and this had progressed to chronic kidney failure. As far as the bone problems, this may be due to vitamin D deficiency or a genetic syndrome. She needs to see specialist for that too. We are treating the immediate threat of pneumonia and are otherwise very limited in what else we can do. We can’t really investigate into her problems because of the cost and this being a private hospital without a charity fund makes things quite difficult. She probably needs to go to a government sponsored institution for her other issues to get addressed where cost isn’t an issue. It’s such a sad case. I’m sure many of her problems could have been prevented with proper medical care, and now she may never walk again. Until next time. . .

Interesting Case

What an interesting case that came in today. A 17-year-old boy came to the ER with severe burns on the soles of both feet. He was a paraplegic from 2 months ago when he fell out of tree. He has had no sensation or motor function below his chest since then. The family is from a local village and fairly poor. They took him to a type of “witch doctor” last week on Wednesday to see how he could help. His idea was to “shock” the feet in a way that they would be shocked into functioning again. In order to do this, he placed the boy’s feet into scalding water. They where bandaged and sent home. That had been nearly a week ago and there had been no medical care or changing of bandages since then. When they brought him in his feet were covered, but I quickly saw the extent of the injury when I removed the bandages. Luckily, he only had second degree burns, but both feet were infected and in some serious need of attention. I have had little experience with caring for burns so I consulted with Dr. Gamero and he explained what needed to be done. The nurses helped me get things ready for cleansing and debriding the feet. With anyone else we would have had to do the procedure under general anesthesia, but with him being devoid of sensation in his feet that wasn’t a worry. I cleaned the feet as best I could with iodine solution, and scraped and cut away layer after layer of dead skin. I was having a lot of fun doing the procedure even though it was pretty gross. His feet looked a lot better when all was said and done. We bandaged him up and admitted him to the hospital. They don’t have a burn unit in Belize unfortunately so there was no where to transfer him. I wrote the admit note and orders and I put him on some heavy duty antibiotics and did some labs. He also had a raging UTI from having the same catheter in for 21 days so we changed that too. For a country in Central America, Belize has a fairly good health care system, but the case showed me the cost of poverty in a developing nation. This family was poor and had no money to get proper medical care. They went to who they could for care, but this ended up making things much worse. Luckily, the father worked for a local Mennonite community and his employers where kind enough to pay for his current medical care. They don’t have the funds for him to stay very long in the hospital, but we will have to train the parents on how to properly care for the wounds and that will have to do. In such a poor country, a lot of times we don’t have a lot of choices with what type of medical care we can give. If you think Medicare in the U.S. is bad, we are much more limited in what testing we can and cannot do. It’s probably the most frustrating thing about working in the hospital here.

Learning Case

Yesterday, a young man came into the ER with fever, sweating, confusion, nausea, and a bit of loose stool. He was acting very lethargic and was soaked with sweat. Physical exam was normal except for some abdominal tenderness throughout the abdomen. I was trying to think about what could be the cause rather than what needed to be done right then, but I did start some fluids and gave him something for fever and went to think. After I wrote the note it seemed obvious that he needed to be admitted and observed overnight, but it just didn’t click in my mind immediately; blame it on being so green in medicine I guess. Well, we got him admitted and started pumping fluids in him. The big problem was that the nurses were trying to call someone to come into the lab, but nobody would answer their phone. I had never admitted a patient at the hospital either and wasn’t sure of the process so I had the nurses call the attending physician, but he wouldn’t answer either. Later on I found out they called the wrong number, but I thought it was crazy people weren’t answering the phone. Well anyway, I just admitted him like I would any other patient in the US. As I checked on him again when I was done writing my notes he was like a totally new person; no more confusion or lethargy. I was a bit shocked, but glad to see him turning around. I guess I just hadn’t had the experience of seeing someone who is dehydrated with confusion then having them totally change just from giving them a bit of fluids. This morning, after the lab technician showed up, I found out that he had amebic dysentery. I ran a CBC, BMP, Stool O&P, and a UA. I also threw on a malaria test and dengue because I wasn’t sure what he had although those were unlikely possibilities, but he had only had a bit of loose stools and he was complaining of muscle and bone aches (His urine was also pink in the morning, but I later found out that was due to a medication (B complex) that they mix in the IV fluid. He had cysts in his stool that I was able to look at with the lab tech. This was the first case of entaomeba histolytica I had had so I was grateful for the experience. I sent him home this morning with Metronidazole and some other medication to kill the cysts (All their medications are in Spanish and couldn’t find a translation, but the Dr. confirmed it was the right one to use). The attending had showed up that morning and he seemed okay with all that I had done. He mentioned not to order so many tests with locals because they can’t afford it. I’m not used to ordering only the bare meager amount of tests, so that’s going to be a challenge. Plus, not being used to the exact symptoms of some of these tropical diseases makes it harder to narrow down the tests. I guess I better study up a bit, because I’ve already seen a few dengue fevers and now amebic dysentery, so hopefully I’ll have many more things that are rarer in the U.S. Until next time. . .

In the ER and more

It is Friday and my first week in Belize is almost over. This has been a pretty exciting week. The first few days were pretty slow going in the hospital. I mainly just observed and followed a few different physicians around. I observed a few surgeries too. Well, there was a little chaos with staffing the doctors for Thursday through the weekend. Dr. Lazo was going out of town on vacation leaving Thursday and all next week with his wife, who is the other OB/Gyn. Dr. Gamero was planning on covering, but he got called away on a family emergency. There is only one other physician here that works nearly full time – Dr. Sierra the pediatrician, although he normally doesn’t take call. On Wednesday I had had a talk with Dr. Lazo that I would like more responsibility and to be more involved in procedures. He seemed really resistant to having me do anything, which was very frustrating. When I found out all the difficulty with staffing I mentioned to him that I would be willing to help in any way I could. In the end, Dr. Lazo decided to let me be the primary on-call physician for the ER with Dr. Sierra as my supervisor for Thursday afternoon until next Tuesday. It has been a pretty crazy experience so far. Last night I had a couple cases of influenza and a dengue fever. Later in the evening a little boy came in with a trampoline injury. I think he dislocated his elbow, but the x-ray was pretty bad so it was difficult to tell. We splinted him and sent him to follow up with an orthopedist.

This morning was when things got a bit crazy. I was called in the morning to come in for an abdominal pain case, which ended up being a typical case of cholecystitis, but only mild. In the middle of taking the history a nurse rushes in and tells me I needed to come right away. I asked what going on. She says a patient had just come in labor and she was delivering right now. They had been trying to call Dr. Sierra, but he wasn’t answering his phone. Medical school hasn’t been too scary so far because regardless of what I was doing I always knew there was an attending nearby to help me out. In this situation, as I was running down the hallway of the hospital, I was scared to death because I knew I was the only one that could respond. What if there was some major complication? Was I ready to make the right decisions in such an intense situation? I wasn’t sure about that, but at that point I had no choice. When I entered the patients room there wasn’t much time to do anything, I didn’t have time to ask her any pregnancy history nor even how far along she was (We had actually seen the patient earlier this week so I knew she was around 37 weeks, and I knew some of her history). They didn’t even have time to get her to the delivery room so she was in a regular bed. Once I got my gloves on the baby’s head was right there. It took only one push and she came right out. As I suctioned and clamped I was praying that everything would be okay. Luckily, the little thing let out a few squeeks and then a good cry. I gave her to the nurses to take care of while I turned my attention back to mom. Things seemed to be in control; not too much bleeding, uterus was contracting well, and mom looked good; there was no IV running or any monitors going. I sent the nurse to get something in case she wouldn’t stop bleeding and something for pain. The placenta delivered without problem and was complete. I was worried about tearing due to the rapidity of the delivery. She had a 2^nd degree tear of the perineum, but the cervix looked okay. I had never really sewed up a tear like those, only had seen a few, but since I was the only one there I had to do it. When all was said and done, it looked pretty good and the nurse was impressed. Halfway through the suturing Dr. Sierra showed up and basically took over. Overall, it was a pretty nerve racking experience, but looking back, I’m not sure why. Everything was routine and besides happening real fast the delivery went really well like a text book.

I’m sure this weekend is going to be a great learning experience managing the ER. I was planning to head out and see some Myan ruins, but this works too. I came to Belize for some great medical experiences and so far I’m getting those. The first few days I didn’t think I would get to do much, but I think the staff is finally getting used to me and hopefully, starting to have some trust in me. Until next time. . .

In Belize

I have been in Belize for about 2 days now and things are going well. The hospital here is small, but they provide good health care for the people around here. I’ve been working with Dr. Lazo so far this week, who is the OB/Gyn. We’ve mainly just seen patients in the clinic with typical Gyn problems and of course a number of OB visits. No deliveries yet that I’m aware of.

They share ER call between the 3 full-time physicians here. There was a couple interesting cases that came through the ER today. The first one was a young man who had classic symptoms of ruptured appendix. He had been having symptoms for two weeks, but had been treated with only antibiotics up to this point. We got him back for surgery as soon as possible and the surgery went fairly well. The appendix was ruptured and the surgeon pulled out a huge seed of some sort that was blocking things. The surgery went great and right now he’s doing very well. The other case was a MVA. This guy in the local Mennonite community here got hit by a car while riding his motorcycle. He was really lucky. He had no neurological damage or head trauma. In the end, he had only suffered a colles fracture of the right arm. One final interesting thing is the number of dengue fever cases going around. I never thought I would see dengue fever in my career, but I’ve already seen about 4 cases here. Most cases are fairly mild with no hemorrhagic component; however, one little girl from this morning had a platelet count of 22,000. We sent her to Belize City for care.

Belize is such a beautiful country. It is obviously a very small country, but has a pretty diverse geography. On the east end are beautiful beaches and blue waters with the 2^nd largest barrier reef in the world. On the west side the elevation is higher with mountains (mountains in their standards, but more like hills according to someone from Utah) and tropical pine trees. Add on top of that a vast array of Mayan ruins and you have a pretty amazing place. I’m excited that I’ll be able to find some time on the weekends to see a few things and try to get a complete experience while here in Belize. Until next time, this is Rhett signing off.

First Post - 3 days before take off.

I’m officially beginning my INMED blog! My flight for Belize leaves in about 3 days. I am so excited to start this adventure! I must admit I am a little nervous, but having traveled outside the US a few times calms me a bit. What a great experience this will be to serve the people of Belize at La Loma de Luz Adventist Hospital. I’m excited for all the experiences I’ll have and people I’ll meet. I hope to be able to have many experiences in OB and in procedures. It seems that there is a broad diversity of experiences available at the hospital so I’m excited for that. I’ll post again after I have touched down in Belize!

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