Mexican Community Medicine 3: Frustration Potpourri

A wiry middle-aged man (who looked more like in his 60s but wasn’t) and his wife walked in. I honestly don’t know why they came in, he had so many minor conflicting complaints, but they mentioned that his sugar needed attention. He passed it to the attending who passed it to me. I took a look at the labwork from two weeks ago which showed a FBG of 270. I asked what’s it been since then, and he replied that he didn’t know but it was high.

I asked, “You don’t have a glucometer or urine sticks?” (glucometers are common but not always a “given” here) “What symptoms do you have? Are you peeing a lot? Thirsty?”
“No. Not really. I’m fine, except my sugar is high.”
“Then how do you know it’s high?”
“Because [grins, makes finger dip motion, then to mouth] it’s sweet.”
OK, physiologically, I know glucose spills into the urine, but the idea of tasting his own urine to find out was repulsive to my Western Judeo-Christian sensibilities. We aren’t in the 18th century anymore.

More painful history later, I find out that the reason he has no support for testing is because he never bothers to fill out paperwork to join the public insurance (which is FREE) and/or never bothers to keep his follow-up appts. He trusted this “doctor” who gave him some pills to take when his sugar was high, twice a day for 8 days. Right. No prevention, just after-the-fact diabetes management. Super.

I of course, asked about his diet, and he denied non-compliance and said he was puzzled why he didn’t have a normal glucose because “he stopped drinking Coke and eating sweets.” However, it was obvious he hadn’t let go of the bottle; in fact, he was hospitalized for acute liver failure earlier in the year. This man drinks at least 14 drinks/day, which is a guess-timate, because most of it is liquor from the bottle or pretty potent moonshine, not beers or individual cocktails.

So continuing the history, I asked about insulin management, and he said he got some in the hospital, and he and his wife started arguing if that time in the hospital his glucose was 490 or 450. I was sitting there slackjawed with the apparent disregard of the fact that 40-50–whatever already!–his glucose was consistently more than 3 times normal and it was being treated like “no big deal.” His wife is clearly part of the problem, because this wise guy would be cracking juvenile jokes left and right and his wife would be the only one laughing with him. I don’t know which was laughing least, his pancreas or his liver.

The attending did the “gotta get things together” spiel again, said, “Why do I want to bother starting all this paperwork to get you going when you’re not going to come back?” Dancing the dance, he said he would, that he was working (which meant traveling with people to do construction wherever) so he couldn’t come last time, etc. etc. So the paperwork started, the dance reached the conclusion. The doctor said, “So will I see you next week?” He replied, “Sure,” and after a two-second pause, “And if not, well I guess not. (laughs)” His enabler wife thought it was funny too. I wanted to reach over and slap him silly, but I’d probably faint from his breath (it was a ketone party for multiple reasons) before I got that close.

And this was one of MANY, such as the woman who allowed her 4-month-old’s tinea corporis to grow unchecked on her back for a month because she followed the advice of a family member using a mix of lard and chamomile leaves as an ointment or the mother who was trying to get her 3-month-old switched to solids and wondered why he wasn’t doing so well (she decided she was tired of breast-feeding). Patience, patience…

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Best of Medical Weblogs

The 2005 Medical Weblogs Award nominations have begun! If you have a favorite blog, now is the time to go put in the nomination. Look to this link to see if your favorite(s) is already there. There is a “nominate now” link or just go here to the comments section. Believe it or not, a lot of awesome sites that I read are not yet on the list. I will be adding a few more nominations for some that I really think are egregiously missing, but make haste for adding yours, since the nominations close as of Dec 30th.

I can’t compete with the big dogs for ANY of the categories, especially as a lowly 1st year with not much clinical experience, but I certainly wouldn’t pull a Sean Penn and refuse to accept a nomination if one were so inclined. Seriously, if you have any medical blogs you like to read and they are not on the list, show them some love already. Blogging is harder than it looks. ha!

Ass Clinic

In the spirit of the previous post, I have a “drive premeds away” story, too. Well, one of many. MUCH less in the patient embarrassment end as in the previous post than the MED student discomfort end , I had GI surgery for my ’subspeciality’ month for surgery. so that means you do ALL ends of the digestive systems. and guess what, HPV causes just as big warts down in the ass as on the other end. So, to tend to that, we had what all the surg residents referred to as:

“Ass Clinic”

check out butts all day, rating them on a 1-10 scale on surgery or not (oK, not on 1-10 scale, but in retrospect, well, we might as well have) I have seen way more butts than I care to see in my lifetime.

THEN

in the surgeries themselves, they are in trendelenburg –correction: JACKKNIFE — position. Remember how school cafeteria table folded in an upside down v? imagine being put on top of those with yer ass sticking up to the sky. that’s how I saw a GREAT number of my surgeries for 3-4 weeks, working on their ass. removing warts, hemorrhoids.

no wonder I didn’t go into surgery.

And you thought testicle shocks were only for torture…

No, this has nothing to do with our alleged covert torture centers throughout Europe (uh oh, now I’m probably being watched), but a new stocking stuffer just in time for the holidays!

Mexican community medicine 2: The Pap Smear

Maria was a woman in her late 30s,simple and poor, like most of the people in the clinic. She didn’t have much to say about anything regarding the possible abnormalities found in her cervical cells 6 months prior, the moderate dysplasia (CIN II) that would probably cause most women to worry in the extreme until the next pap smear.

The doctor with whom we were rotating today motioned for her to go behind the screen and get undressed to prepare for today’s exam. He keeps talking to us, and we both unconsciously take positions on the other side of the screen so as not to see anything. We didn’t know if we could see or participate, since nothing was ever asked of the patient, but I assumed when the time was right the doctor would ask if we as students could join and at that time would motion us to foot of the table if she gave the OK.

There was nothing of the sort. As soon as she was ready, he heartily motioned us over as he prepared the kit, like, “Don’t just stand there, what are you waiting for?” After laying out the items, he was futzing with the light with gloved hands, so I said, “let me do that, you’re gloved,” to which he replied, “Oh don’t worry, it’s not sterile, it’s just for my protection, not hers.” That was only the beginning. From that point on, Maria wasn’t a patient: she was a practice dummy, a specimen from which to learn. As the doctor patiently explained the proper technique for inserting the speculum, I looked up to find Maria covering her face with her elbow and forearm, I assumed from shame but perhaps also from discomfort as I noticed rather obviously that no KY or lubricant was used on the speculum–<sarcasm>perhaps that’s too expensive given the free clinic.</sarcasm>.

For the rest of the exam, the doctor meticulously explained the proper technique for sampling the cervical cells, for avoiding the outer cervix while getting the inner cells, all the while quizzing on anatomy at the most basic level (I mean, come on…how much can you ask about the vagina and cervix?! It was ridiculous), everything about her under scrutiny, within earshot, pointing out various things. After fixing the samples and completing the pathetic attempt to quiz/educate us on anatomy, the speculum was removed, and the doctor said the first words to the patient since she went behind the screen, “All done. Get dressed and come back to the desk.”

Maria refused to look at us the whole time. I learned a lot in this experience, but I couldn’t help feeling like an accomplice in a violation, certainly not physical, but if nothing else a violation of decency. From the time she was sitting there waiting for her prescriptions (unrelated to Pap) to the time she left, I wanted to go over, look her in the eye and say, “I’m sorry for what happened. I didn’t know he was going to be that way.” I felt guilty about having been there, having seen her in an open-bare way that her husband probably hasn’t even seen, and also for having actually learned things paid for by her dehumanization.

I know teaching hospitals, VAs and county/community clinics in the US have to some degree a lot of the same environment, with different doctors being more or less empathetic towards their patients when rotating with students and/or residents. Stories of patients feeling dehumainzed during rounds with attendings are numerous and perhaps I am thinking about this way too much. The people here are seriously thankful for any help you give them, and as I’ve said before, they don’t see a big line in the sand between med student and doctor, so perhaps I’m over-reacting. I know what my standards are, what I would expect of myself as doctor and what I would demand (and have) as patient, and that was simply unacceptable.

To end on a positive note, I will say that this happened early in the week and was an isolated incident. I sat through a couple more Paps, a general pelvic exam and an IUD removal (they are still widely used here), and none of the other doctors–all male–ever ignored the patient in the way described above. They would explain something to me or to us, but they would also keep talking to the patient, warning them of something moving or a possible point of discomfort, etc., never making them feel like a specimen. One can learn from a patient, one can teach using a patient, and still remember the patient is a person.

I hope Maria’s dysplasia does not progress. She had no significant risk factors (HPV, early age of sexual activity, etc) so I hope that it’s just a matter of aberrant histology rather than the ticking time bomb of cancer. I hope also that she forgets about what happened; perhaps it wasn’t the first time if that guy’s been her doctor for a while. I know I’ll never forget her.

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Cursed (reg)

I am so sick it’s not funny. I have been running a 101-deg fever, and coughing lung cookies thanks to the little petri dishes at the kindergarten we had to visit this week as part of our community medicine rotation. What sucks is that I am sick yet again, losing a weekend yet again, impacting my studies yet again, and raising my stress levels as always — something that I’m sure all these sicknesses are thriving on with my lowered immunity.

It’s like I take one step forward and two steps back. Last weekend when I had my GI infection really bad, I was wondering about PMC between the wound in my leg and my running to the bathroom every 15 minutes how I was going to complete the week, get the credit, and not postpone my move by another week having to make it up. Of course, Monday was also the anatomy final, so I was compromised there too. But by Tuesday/Wednesday, I thought, “Wow, I think I’ll finish this and everything will be better.” Then *bam* in bed 18hrs/day with cold/flu. Now I worry about schedules and timing, but this time it’s biochem.

I have never EVER been this sick in my life, and I am not any less healthy or fit or whatever now than I have been in the recent past. I think it’s the stress combined with the new environment, and the catch-22 is that the more stress I have with life/school, the more susceptible I am to get sick, which make it much easier to get sick, etc. etc.

I just want this semester to end already.