There was a storm last night here on Pohnpei (my mistake, pronounced pawn-a-pey) and it freaked me out a little bit. I woke up at 245 am (local time) to change positions in my waterbed. I tried really hard not to kick my feet too far out because I had the bug net around me. I had ear plugs in but could still hear the strong winds. I felt the cool mist from the rain and instantly felt 10 degrees cooler. As I laid my head back down I saw the lightning crack though I did not hear thunder.
In the morning, I bear witness the storm laid in it's wake. As I walked over the tree branches that were on the ground and hopped over puddles of water toward the hotel's restaurant, I overheard the owner's son talking to another patron. They were discussing how that storm was one of the strongest systems that has passed through in a long time. Funny how the best sleep I've acquired while on this island was through during that beast. Later I find out there was a typhoon affecting the Philippine area and moving it's way toward Southeast Asia. Is it the same system? I am not certain but prayers to the ones who have endured or will endure nature's fury.
I understand the nature of my business is to help the indigenous population and everything I have blogged about has been pleasure. Please don't let this blog set a precedence to our working habits.
Today is only Tuesday (day 2 on Pohnpei) and we have already evaluated, screened, and consulted on 43 patients. We are expecting 2.5 more full clinics before we move islands. There are many interesting cases here in the FSM. One of the more interesting ones was presented by a female native.
I remember this patient encounter so vividly. Since we started work here in FSM, I find myself frequently behind a desk as Mike does his physical exams. For some reason, I was up and about as this specific patient came in with her mother and younger sister. At first, I thought nothing of it as I see mom shaking hands with our good doctor and the younger sister full of energy and smiles. I walked passed the family to shut the door for privacy. The patient was young (an older teenager) but seemed tired from her walk (from outside in the waiting room onto the examination bed). The patient was playful with her kid sister and you can see the bond they share. As I prepare the patients medical record, one of the first items that is reviewed is vital signs. I looked at her chart as I was walking back toward my desk and saw her oxygen saturation level: 74%. For those of you who are not in the medical field, an acceptable and normal oxygen saturation level is anything above 95%.
As Mike was interviewing the patient to obtain her history of present illness, I was looking through her chart. Then I heard our translator say "inoperable." I stopped what I was doing and looked up to listen more intently. Apparently, this congenital heart condition that our patient has been suffering from was seen when she was two years old. She was referred and actually transferred off the island for surgical intervention. It was then when mother was told her condition was "inoperable." Though this may have been the best and logical choice at the time it was made, it certainly was not an everlasting decision. As our patient became older, she was evaluated and even admitted numerous times (for a variety of problems) as reflected in her medical records. Not once did anyone address her chronic cardiac issues (one major one being pulmonary hypertension secondary to a hole between the two ventricles of the heart) though it was listed as one of her diagnoses.
Medicine has seen advances by leaps and bounds in the last several years. Albeit the tools doctors use or the medicines they prescribed, medicine has been improving however you look at it. One treatment of pulmonary hypertension is the administration of pulmonary vasodilators. Of course, the patient was not on it, why would they? When inquired about the medication, the attending physician had informed us that it has been ordered on several occasions (there is one other documented case of pulmonary hypertension on the island), and when the medication arrives, the get 1/10 of what is required (here is where I am not sure if it was due to financial issues or other problems). The other patient has only been getting, at most, half of what he is supposed to receive. This patient unfortunately has been receiving nothing.
When Mike was doing his exam, I could literally see her heart beating. It wasn't just in her chest where the heart is located, I saw the pulsation near her neck and through her back. I saw severe clubbing, a condition that makes your fingers and toes bulky and blue (a condition you only get when you are hypoxic, or have oxygen saturation <95 for a long long time). She appeared tired in nature and rightfully so, she doesn't have enough "red" blood in her body. Her heart murmur sounded like a sloshing liquid that even my untrained ears could tell sounded wrong.
What makes this case stand out to me is how tragic it is. Yes, when she was two years old, it may have been too early to operate on her (not big enough anatomy to operate on). It may be due to not having the right medicine developed yet. Whatever the case may be, she has been seen numerous times in the interim and inevitably nothing was done. Now it's too late. Her condition may and probably is permanent.
She left our clinic today with a diagnosis of Eisenmenger syndrome, a condition where one would have more "blue blood" in the body than "red blood." This could lead to organ damage and even organ failure. Prognosis: 15? 20? 25? or so years. She may not have the ability to become pregnant and have kids of her own. Was she a candidate for surgery? Not right now. Can she start the pulmonary vasodilator medications? She could but how much will will it help now? It just makes me sad because all of this could have been prevented. Unfortunately, this happens frequently here in FSM, some states more often than others.
Oh and here's a fun fact: FSM has cut all costs for dialysis. If you have a kidney problems, either plan to move or plan a funeral. The donated blood is only partially screened. Little is known of the donor other than type, rH, and HIV status. If you're lucky, they will screen for hepatitis and other blood borne illnesses. So don't be anemic. I know our healthcare system has it's faults, but be happy you have something to complain about. I'm not trying to say the FSM healthcare system is careless and inhumane. I am simply stating the fact that they are stuck with what they have and must make the most of what they got.
Tomorrow brings a new day. Hopefully our team can catch other cases and intervene before they start down the wrong path.
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