Prolapse, pessaries and HPV

Hey everyone!

Week 2 at Loma de Luz has wrapped up. This past week we had an OB/GYN from Colorado Springs join the team, so we had a lot of GYN action. I think I fitted more women with pessaries this last week than I had my entire life. I worked closely with Dr. Lockey and she taught me really good exam tricks. Unfortunately, cervical cancer ,although preventable, is a major  cause of mortality here. Some women don't have access to health care and find out too late. There is also the case of not having reliable test results, here at Loma De Luz all the cytology samples get sent to the US. So, needless to say we saw a lot of really sad cases involving cervical cancer this week.

This upcoming week there will be a team of ENT residents joining. Im looking forward to working with them.

And to end this week of OB/GYN with a Bang! Mrs Rosalia (not her real name) is a 39yo G13P9 who presented to the hospital after 2days of laboring at home. She walked [in labor] 3hrs to get to the hospital. She was 6cm dilated on arrival. We AROM'ed her and prepared to have a quick delivery. PPH kit was in the room. Baby looked great on the monitor, but after 1hr went by and she was unchanged and then 2hrs went by we knew something was wrong. She had 1 prenatal visit and nothing more, she had all of her babies at home previously- 2 breech deliveries that ended as fetal demise. Bedside US showed an EFW 4800g, no wonder baby never came out. We decided to go to c-section. After delivery of the placenta uterus was still pretty boggy and there was brisk bleeding. As we started closing the hysterotomy we noticed what appeared to be an inferior extension of the hysterotomy into the cervix. We continued to close quickly and steadily. BP was 74/36, but the anesthesiologist believed it to be related to the spinal anesthesia. By the time the uterus was closed the bleeding seemed well controlled. Tone had improved after a pit bolus and methergine. We did a BTL and put the uterus back in the abdominal cavity. BP remained low. There was more than normal amount of bleeding but at this point it didnt seem overly concerning. As we finished closing and we started to clean up we started noticing the towels around the surgical field were soaked in blood, so was underneath the surgical drape (we dont have fancy drapes that catch the blood..). Then I noticed there was a huge puddle on the floor and more blood kept falling from the bed. Initially we thought it was just from moving the towels, but vaginal exam revealed brisk bleeding. We gave cytotec. We tried a bakri balloon. We gave 3L of NS and 1 UPRBC. We were unable to bring the blood pressure back up and by this point patient was tachycardic.  There is no blood bank in the middle of Honduras, we were going to need more blood. We put out an emergency alert to have everyone who was O+ run to the hospital to donate blood, 8 of us donated. In the middle of all of this the general surgeon arrived and she was taken for a hysterectomy. And 9 units of blood later, she is currently stable. Baby likely has some meconium aspiration and is requiring a bit of oxygen, but is also stable. Today was stressful to say the least. However, I am humbled by the response of the staff at the hospital. I am not at all surprised to have nurses and doctors donate blood for a patient, but electricians and kitchen staff also stepped in and that is incredible.

And so one more day goes by at Loma de Luz.
Until next time.
-g

Greetings from Balfate, Honduras, everyone!

I apologize for the delayed posting, it has been a CRAZY few days combined with some technical difficulties. So, to make up I will try to recap my first week at Hospital Loma de Luz to the best of my abilities.

My entire time here has been an adventure. Starting with getting off a regular Boeing 737 in Roatan and then having to board a tiny propeller plane to fly to La Ceiba on the Honduran mainland. I am terrified of flying so I prayed the entire 20minute duration of that flight. But survived, and unbeknownst to be, the taxi ride from La Ceiba to Balfate (1.5hrs) would be even more terrifying. I should be used to horrible Latin American driving standards (I learned to drive in Mexico for crying out loud!), but I guess you forget and get used to seat belts and air bags and side mirrors which aren't always necessarily available....anyways I survived and made it to Loma de Luz. The first day started being woken up at 5am by a howling monkey outside my window and running across a hanging bridge to get to the hospital. And so, it began...

My first day at Loma de Luz I shadowed Alisa, a nurse practitioner who showed me the ropes. She taught me how the EMR works. How patient flow is managed. Where to find things. Introduced me to the staff. I got a copy of the current med formulary and saw a few patients. I work in the clinic 5 days a week and am on 24hr call twice/wk, one of those days is usually a weekend. 

This week has been GI bleed week and motorcycle accident week. We had Mr. M who presented with a complaint of convulsions. After trying to piece together the story we realized he was recently started on warfarin for A fib. His INR was too high to read. His gums and conjunctiva were white. Surprisingly we had vitamin K and he received 2 doses overnight. Several of us donated blood as he required 4U PRBCs and there is no blood bank available. He recovered and got discharged yesterday!

Mrs M presented with hematemesis and melena. She is neutropenic (still unsure why). Has a history of recurrent GI bleed and we're currently treating her with PPI, H2 blockers and NPO. I just heard today we're running low on PPIs until Friday when the new shipment arrives. She is stable from a GI bleed stand point. It is definitely weird not being able to get an EGD on site and knowing this is all we can do for her, and replace blood if needed knowing if she lived somewhere else (developed nation) she could get a life saving EGD...

I was on call Saturday with Dr. Bryan Jennings (recent NCFM graduate) and we had the craziest/busiest shift they've had in a while. In 24hours I saw 19 legitimately sick patients. Admitted 4 patients. Managed an induction and delivered a baby. I had to repair a pretty gnarly head laceration after a motorcycle accident. I learned to do a infraorbital and mental nerve blocks to repair lip lacerations after yet another motorcycle accident. And a 16yr old walked in very calmly to the ED and said he had a cut on his hand, when I asked him to take the bandage off the entire tip of his 3rd finger was missing (how was he so calm?!). For some reason he stuck his finger and it got cut on the motorcycle chain...the tip was no where to be found. We have no hand surgeons available, but we have a general surgeon who does a lot of ortho surgeries who recommended closing as best we could and follow up in a couple of days with him. 

Most of the crazy cases are obviously seen in the ED. But, I like clinic (partially because there isn't a burden of heavy documentation and time constraints, unlike in the US). I get to sit and talk to the patients. Learn their stories. It is also nice because most of the time the patients do not know what medications they're on. What happened during a hospitalization. What the diagnoses were, etc so trying to piece the story together takes longer. The patient's at LDL are so grateful for the medical help. I've had patients that drove 8 or 12 hrs to be seen at the clinic. Some leave their villages 2 days in advance and make the pilgrimage to LDL in hopes of being seen. The worse clinic cases I've seen have been botched orthopedic cases. It truly is sad. I saw an 8yo F with Blount's disease. Usually bracing will do the trick and correct a bowing tibia, but if needed a relatively simple growth plate arrest surgery would've corrected her problem. However, she is 18months out from surgery she has infected hardware, non healing ulcers and the xray revealed an eroded fibula from the chronic infection. The likelihood of her needed an amputation is high. I cant help but think that this would never happen in the US.

I could go on and on about other cases over the last week, but I've written enough. To sum up my first week at LDL

1. I am in awe of how much the full-time missionaries can do with so little

2. My sense of compassion and love for medicine has been re-ignited by the gratitude and stories from the patients I've met at LDL

3. I cannot help but feel sad by some of these patients knowing that by no fault of their own they were meant to live in a developing country were some life saving resources are just not available- but that they exist somewhere else. 

P.S I've also become very good friends with the LDL dog: Paisley. I may or may not steal her in the afternoons to soothe my puppy withdrawals....

Till next time,

g