February 25, 2008
HAPPY BIRTHDAY ALLISON (I’m such a terrible father)
Sweet Sixteen-WOW! (Everyone please call her and wish her a happy birthday!)
Rise and shine
I was getting a good night’s sleep, one that I hadn’t gotten in a long time. Beep! Beep! Beep! Andy turn’s over to shut the alarm off. “Time to get up already? What time is it?” “5:30” Andy yawns. “Wanna go walking?” “Well, I’m not doing anything, let’s hit the road.” The manager of the hotel sleeps on the ground or couch at night and wakes up to let us out the front.
I didn’t mind walking in pitch black. A lot of the members of the team have had this routine. Bill would jog, the Lowe’s walk, Andy and Dr. Obregon walked etc. Since Andy has his black-belt it was like taking my own body guard with me.
We were walking in dark alleys and streets. All of a sudden a group of monks start crossing the street like ducks in a row. The monks are bald, wear orange gowns, and are barefoot. The carry collection bags to receive money from merchants in the street after they say a prayer or blessing. They walk by quietly and then start chanting at the person’s house and the kneeling occupants and they give them money. I was trying to remember how to say, “I gave at the office” in Lao. The monks quietly walk in a straight line with bare feet arranged either from oldest to youngest or could be tallest to shortest. I look at Andy he could pass as a monk if he had a orange robe. Maybe he’s too tall. I want to pause and tell them about Commandment 1 (Do not worship any other gods) but I think it might be futile. My high tech $$$Z- coil shoes stand out next to their bare feet. I am getting used the bounce and recoil of the shoes and my back feels wonderful but feel like I’m bouncing like a kangaroo. Maybe I need Stride-Rite shoes. Many of the merchants are already getting set up shop. They sleep in their kiosk overnight and there is a man asleep in a chair guarding the bikes or scooters that he will rent the next day. People are walking on the streets already going to work. Weight challenged individuals are rare due to the exercise inherent in walking great distances. We see another set of monks lined up walking coming from a nearby temple.
Andy has a strategy to find our way back to the hotel. He says as we walk, just turn one way and you’ll always turn toward your start point. I said “Sounds great.” (He didn’t know that I took a business card from the hotel just in case we had to ask for directions.) So we head out. It’s great walking. I forgot how to walk. So Lena, we are going to walk more when I get back. Hold me to it, okay because I am one of those weight challenged individuals. He has an uncanny sense of directions. I wasn’t worried but I did eye those taxis or tuk-tuks. We saw a lot of French influence still in the names of buildings and architecture. There is even an Arche de Triomphe in the city. Andy has an uncanny sense of direction and brought us back home as promised. How silly I was to have doubted Andy.
I SEE THE LIGHT
After a meal with the members of the Blue team we headed to a church. Bill had to do political shuffling with the members of the Lao Evangelical Church regarding, well, support for the interpreters. It was an unexpected expense that he had to deal with but he handled it well. We have about a dozen or so helpers including several pastors from the LEC that will accompany us to the various locations to help with translation. Some of us met Pastor Saykham from one of the churches here. They are all under the umbrella organization LEC. We went to the Nashay Evangelical Church.
The dentists were working the in the dark literally. They looked like miners in a coal mine with their headlights shining for illumination. The room was hot and humid. The optometrists worked in there as well. We do well do adapt to the circumstances and facilities that are available to us. We have make shift exam rooms for privacy. For the most part, patients accept not being private. Dr. Tajiri recruited Dave for helping work on the lenses. It is a two man minimum requirement. Gi helped when we were in Thailand and was great at it. Dave helped fill in the gap and is a fast learner. I think he was being groomed in Thailand for this position. That leaves Ben to work the pharmacy but has Gerry to help with pill counting sorting and writing the labels. There seems to be some jobs that are monotonous. I am grateful for the variety of patients that I see and the dentists have their fill with garden variety and complex cases.
NEXT!…
Those nurses triage (direct patients) for 6-7 working hours in the hot sun with crowds vying for position in line. “I was here first.” “How much longer to see the doctor?” “Is the doctor on time?” The apparent disorganization is really organized. The patients have to be themselves (patient). They are the gatekeepers. Now, Andy has been working for Children’s hospital for 22 years (mainly ER) and Cindy has 25 years as a clinical nurse, teacher, and FNP (Family Nurse Practioner). By the time we docs get the patient there is a lot of screening done and history taken and sometimes we just need to sign a prescription. So they are excellent in what they do and they make a great team. We see a lot of children so it’s nice to have Andy’s experience in acute care and Cindy who can be thorough as a nurse practioner. They fill out a form and assign them a number and the patients wait to be called and escorted. It can be monotonous.
The pharmacists have tens of thousands of pills to first find and then sort, count, package, and label for all of the dental and medical patients. I think they end up cross-eyed and will have to see the optometrists. The worse of it is trying to read the doctors’ handwriting! They must really like what they do-pushing drugs-by sorting by hand. But it can be monotonous.
The optometrists and Dave along with Arlene and Gail are a sight for sore eyes. They planned their department with foresight and you can see clearly why they can process so many patients through the production line. Every day, all day long. How many eyes can you examine? Don’t they all look alike? How many visual chart exams can you do before the chart looks like a Rorschach pattern? Does Dr. Tajiri ever break? How many lenses can he whittle away to fit the lenses? Is he enjoying himself? I hope that he doesn’t have an axe to grind. Dr. Chinn must be a sharp shooter by now with his PAR gun. Now that seems monotonous.
GO WITH THE FLOW
Variety is the spice of life, right? Not! I first get hit with this lady with a mass the size of a softball on the side of her cheek. How long has it been there, you may ask. 19 years. It feels like a fatty tumor or it could be a salivary gland tumor. I think this disfiguring mass should be taken out. So where can we do it. It is hard to get cooperation from local hospitals. Sometimes it is difficult for us to express our thoughts and desires through interpreters. The hospital would need to charge $300-500 US to “support” this patient so they ask who would “support” this patient. Certainly not the hospital or government. We brought most surgical supplies anyway and we just needed a place to do it. The logistics to set it up, get a preop workup, and no follow-up was weighed and we decided not to pursue it. It may have taken 2 docs away from clinic and put the added burden from our absence on the remaining docs in clinic so no go. “Hey, since I am here can I get this tooth extracted and get some glasses?” she asks. Why not!? That has been the burden because some patients want multiple clinic evaluations and at first we went with the flow.
CLUELESS
The next patient I see breaks my heart. She’s skinny, weighs about 65 lb. Her neck looks like a tree trunk with two large firm masses along side her face and neck. What the neck! It has been getting bigger over the past two years. It is starting to affect her swallowing and certainly her speech. She saw a doctor who said go to Thailand. Apparently Thailand has more sophisticated technology, doctors, and treatment. There is only one CT scan for four “major” hospitals in the capital city, Vientiane. In Fresno there is one on every major block. She cannot afford to go to Thailand, much less afford the treatment. I look at her and think she is going to die. This must be cancer. Some lymphoma. I reach way back into my medical school training. Hodgkin’s lymphoma. Burkitt’s lymphoma. Non-Hodgkins lymphoma. Don’t-matter-what-kinda-lymphoma. Infectious lymphadenopathy. The mass is stiff and hard about 5 inches by 3 inches on ONE side and 4 inches by 2 inches on the other. It is hard for her to speak. How am I suppose to tell this patient with her angel eyes, who is only 20 years old, that she is going to die? She traveled from afar to meet the sophisticated doctors from America and what are we going to offer her, vitamins?” This case belongs on “House.” This is a ROYAL pain in the neck! I’m frustrated. We have grand rounds with the other docs. She at least needs a biopsy of the tissue. No clue. No help. Is this some exotic cancer indigenous to the region from a source or influence that we know nothing about? Maybe I can make her comfortable. I learned this hospice thinking when Lenas’ mother was dying from lung cancer and was medicated for several months just to ease the pain especially when her mom developed shingles on top of the cancer.
I send her to the pharmacy to give her pain medication to make her comfortable and advise her to go to Thailand. I imagine she is thinking, “Great advice, doc. Go to Thailand to be buried? I can do that here. Thanks but no thanks.” Even if she were to go and get a biopsy and the diagnosis could be made, the tumor could be so advanced that she may die anyway. She walks away no better than she came. I feel useless. “You’re too empathetic”, I tell myself. “Be detached, I’ll live longer.” She’s about my daughter’s age. Parents aren’t supposed to outlive their children. I have to clear my mind to address others that I MIGHT be able to help. What great medical advice can I tell the next patient? I am feeling useless. I need to cut something out to cure the patient. I’m a surgeon, not a medicine doctor. Perhaps a witch doctor could help. A few patients go by and I am feeling my confidence back. I see a familiar outline of a person’s face, which I cannot see, with the bright background. Another “Tree trunk Syndrome”? WHAAAT!
A young boy in his twenties at this same clinic who lives far away from the other girl has a similar condition, except the masses are smaller. I can make out several large lymph nodes the size of marbles adjacent to the solid firm masses above. They parallel his neck line and obliterate the jaw line. He only had these masses for two months. Why so fast growing? Cancers are fast growing. Some infectious process may be as well. The docs discuss this and we don’t know what it is. If someone reading this has a clue, LET ME KNOW! Please! I go to my iphone and search the internet. I can’t find anything useful. Even if I knew what it might be how could they can afford treatment. I get the girl back and talk to them together to see if their was some epidemiologic connection. I find none. If by chance this was a benign process or an infectious one by some odd ball organism, it might respond to antibiotics. So I prescribed some antibiotics with pain relief which hopes hat something might help. The consolation is she accepted the Lord earlier in the day. I pray for her comfort and healing. She may be terminal but she is saved.
As the day grew longer, we got more exhausted mentally and physically. We had a lot of patients and could not see everyone. Some patients sneaked through and said I lost my paper. Naively I would get them another one so they ended up cutting to the front of the line. Some would go to one clinic and then complain about a dental or visual problem and then they would go to the front of the line at that clinic. One Hmong family apparently travelled far. She said they had a number. I said, “What number.” She pulled out a 2” by 2” piece of paper with the number “117” written in neat red magic marker. Her friends pull our “183” and “185” This paper looked unfamiliar to me or anyone else. I want to be fair so I go to registration and triage. We were not using numbers so they were fake papers. Were those patients duped by someone else or were they trying to dupe use. What nerve! They go to the end of the line. She was pregnant with two kids and she may have traveled a great distance, but we had to turn her away.
We are ready to go back to the hotel. We pack up and I don’t have a total for today but we helped a lot. Others, weren’t helped at all. I am ready to go back and rest. I decide not to join the group for dinner with the LEC helpers. I need to chill, and jounal (that’s why you got two yesterday). The team went to a restaurant and we took the helpers. They are trying to budget (especially with this new expense) and ate for about $6.00. Good thing it was a 13 course meal. The team was gracious enough to bring me dessert and left-overs. I did eat the food which was fairly good. Well I’m beat and need to go to internet café then I’ll catch some zzzz’s.
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