Brgy. Magay, Compostela
November 9, 2016
My team of three nurses and one medical student (me) went up to this uphill village several kilometers from the town center. That area was scheduled for immunizations that day. One nurse reviewed each record, another prepared the shots, the third one posted outside the makeshift clinic to control the crowd. The remaining role of administering the vaccines fell onto me. Although we had warned the people that we were not catering consults, dispensing prescriptions, or providing prenatal care, I was uniquely poised to give a brief verbal advice—from pediatric to obstetric to gynecology to medical—here and there.
As we gathered to leave, a young woman stood by the door. She wanted advice for a problem. We kindly turned her down. If we were going to accommodate her, word would swiftly fly; and in no time, the clinic would be flooded with consults, wave after wave like a storm. It was almost evening and we could not risk driving on narrow, winding paths in absolute darkness. So my team apologetically referred her to the rural health unit at the town center at a more convenient time. But she did not stir.
Her eyes imploring, she held my gaze. Mobility was a major deterrent in the accessibility of health services. Motorcycles were considered a luxury. Most people travel on foot, on beasts or by pedaled vehicles. These geographically and economically challenged communities subsequently took advantage whenever health care workers dropped by. Quietly, I motioned to my team to carefully look outside. Everybody had left. My hunger for knowledge and experience had not. We would be quick, I promised. The young woman pulled up a chair and I sat across her, our knees touching.
Here was a 31-year old healthy looking but anxious woman who had been recently plagued by insomnia. She spent most of her time at home, if not taking various menial jobs like laundry to augment the household income. She had been married for eight years but remained childless. She had not experienced insomnia this bothersome even during the times she had felt depressed in the past. She denied any domestic abuse. The couple had been trying to conceive but she could not carry a pregnancy through the first trimester. So that visit was particularly important: time was running out for her and she could not afford to lose her new baby. She was five weeks pregnant when episodes of extreme nervousness began to interrupt her sleep. She would wake up at night in a tremendous sweat, her heart racing and pounding painfully. Those symptoms would last for a few minutes, and they would resolve spontaneously. For that week, she had been experiencing the attacks with much more frequency. She sought the advice of her family, some of whom had shared her history of multiple spontaneous abortions. But they believed her to be a little paranoid because of the possibility of another miscarriage. She had tried some herbs and activities but they did little to improve her symptoms or cure her.
Psychiatry and Rheumatology had been some of my weakest points. So I wanted to cheat, open Medscape on my phone, and validate my top differential diagnoses. But somehow I could not get my eyes off the little swell on her neck. Wait a minute. I asked to feel her wrist while I auscultated her heart. Wait a minute. Aside from that tiny bump under her apple (that wasn’t really obvious but seemed to me unusual for such a slender young woman), she appeared otherwise normal from head to foot. No way. Her angry pulse was bounding erratically beneath my finger pads. My stethoscope was picking up a dangerous march of a drunken man. This man could have been walking very briskly, if he wasn’t constantly stumbling upon himself. I had met this man many times before. When he started running, he could be fatal.
“You’ve never had a regular menstrual cycle, have you?” I asked.
“Since I first bled, no.”
“In your past pregnancies, have you experienced similar anxiety attacks?”
“Yes, but very mild and few, never at night.”
“Any in the family–mom, aunts, cousins–having goiter? Lump in the neck, you know?”
“Oh yes, my mom and sister. But it never bothered them.” She paused, reflecting. “Do you think I might have goiter?”
“Listen,” I said, leaning closer, “it could be worse.”
The man was an impending thyroid storm.
At the moment, her vital signs were within her normal range, save for the mild tachycardia and irregularly irregular rhythm. The rest of a succeeding focused exam supported my impression: slightly enlarged, non-tender, non-lumpy, soft and squishy left thyroid lobe; no bruits. She had none of the eye signs which usually appear in chronicity.
It is a sentiment shared among medical students that medicine is a difficult process. The learning curve is steep; and not everyone can reach the peak intact, in time, if at all. But those who have transitioned from armchair medicine to clinical practice would probably agree that translating bulky concepts to digestible boluses for the layman can be a daunting task. The gift of conversation is select, as is the gift of charm. Persuasion is a skill acquired by even fewer of the human race.
Somebody needed to run. Faster than the drunken man. Right now. It was getting dark outside, my team warned.
I explained to her my thoughts, the urgency of her situation and the limitations of our local health center. Moreover, the only doctor in the entire municipality was out of town for a seminar. Our group of medical students basically had been overseeing the facility on his behalf. On a scratch paper, I wrote “TSH” and “FT4” on one side, the date, her vitals and pertinent neck findings on the other. Then with much trepidation, I stamped with my name and school and signed it. Without an M.D. and license number though, I would not know how much authority the paper possessed. But somehow, a message had to be carried through. Anything was better than nothing.
“Listen carefully, ma’am,” I said. “It’s late now but you need to be seen at a bigger facility as soon as possible. There’s a government hospital in Danao City. These two tests can be expensive. So if you have to pick either one, get the TSH first. (I placed a star beside TSH.) Bring the result to the doctor along with this paper. He’ll take care of you.”
My team came down from the hills just before night fell upon a brewing storm. I carried her storm with me as I returned to camp. The feeling that I had made a terrible mistake persisted for a while, but I could not identify what it was or where it could have gone awry.
November 16, 2016
One week after the brief encounter with the running man, I had an elderly man pass out in front of me right after I removed the last sutures on his right foot under local anesthesia. He recovered shortly but turned very pale, diaphoretic and confused. His blood pressure dropped to 80/50, heart rate to 60. The doctor was out and I had no time to rummage his stock for a vial of D50W and a syringe. So I asked the crowd of witnesses and they provided me with candy and water.
We placed him on a bed, in Trendelenberg position (we had to improvise with the mattress). Then I instructed him to put the candy under his tongue, keep some water in his mouth to help dissolve the sugar, and swallow in sips from time to time. Sublingual and oral, it should go down fast. But his vitals did not go up after five minutes: 80/60 on both arms; 40 regular beats per minute. Don’t you go down on me. We had no saline, no IV sets, no cannulas in this primary care facility.
He laid down comfortably with his feet elevated and his head below the level of his heart and began chatting animatedly with his niece. In between sips of water, he assured me it wasn’t my fault (referring to the suture removal earlier). Some color had already returned to his lips and nailbeds, and he started to feel warm. I stayed by his side, staring stupidly at my beeping pulse oximeter. Bradycardia, narrow pulse pressure, delayed capillary refill. Don’t you go down on me.
Fifteen minutes since his collapse, I let him sit up slowly and repeated his blood pressure: 186/120. Twice on each arm. Heart rate shoot up to 110. Are you weird or what? That was actually good enough for the moment, but I was not going to let him off easily. I instructed him to consume another liter of water and eat bread while I attended to my other patients, two of whom were also under close monitoring at the facility for hypertensive urgency. And then there was the new guy who had a severe allergic reaction after eating peanuts. And we didn’t have epinephrine. Few pharmacies sold diphenhydramine with prescription. In thirty minutes I would reassess him.
One arm read 110/60, but his heart rate went back and further down to 37 regular beats per minute. I listened and palpated for a full two minutes hopping I could catch some dropped beats–which is crazy (but we had no ECG machines). Thirty-seven. Is this really just vasovagal? He insisted he was feeling so much better. No headaches, lightheadedness, nausea, visual disturbances. No abdominal or chest discomfort, however vague. His lungs were clear. He denied paresthesia, weakness. Cranial nerves were basically intact. He was a chronic hypertensive on amlodipine and ‘something else’, but had been non-adherent to his regimen, monitoring and follow up. He could not recall either his usual or highest recorded blood pressure. He was never worked up beyond blood pressure taking.
I called up Danao City hospital. I introduced myself to the receiving physician who sounded glad of this distraction. They sounded like they had much time and space–extra beds. But he wouldn’t accept my patient for just syncope, who was already stabilized and had no neurologic deficits. Was there something wrong with my endorsement? Too many in fact. I had not performed a full neurologic assessment to concretely say it’s a TIA-related syncope, or a cardiac one. Where is the lesion? That’s just one thing. My ultimate concern had been the bradycardia, but I had not thought of opening a reference book in a busy facility to explain why it is worrisome in a guy who just had a fainting spell. The patient had been poorly compliant with amlodipine or that ‘something else’ enough to rule out drug toxicity. Syncope in itself is generally benign, unless there’s something else masquerading behind it. Am I just being paranoid? What was I scared of specifically? My gut might have feelings but it could not explain itself at all.
We ended up sending the man home with a written request for a 12-L ECG (which he probably couldn’t afford even with his insurance) and to return after a week for evaluation of his antihypertensive regimen. He never came back. He should be running for life. Once he stops, the storm devours him.
Unlike the drunken man who is the storm.
Many days passed. I realized that our group of students had gained enough confidence and authority to send our patients to nearby hospitals on behalf of the lone medical officer who had to singlehandedly carry out all administrative and clinical responsibilities without us. After all, we were running a primary care that had been ill-equipped to handle urgent and emergency care. Then I remembered the young mother-to-be and how bad I had managed her case. We could have brought her down the hill with us where an ambulance could have picked her up (they didn’t go beyond the reach of roads). I sent her home with a piece of paper instead.