40 year old guy is brought into my tiny rural ER by ambulance. 1 hour ago he suddenly stopped talking, walking or responding to his family. He also started vomiting. When I look at him lying on the exam table, I see a left sided facial droop, legs extended, eyes unfocused, and lots of transient decerebrate posturing. (my first "Really?" moment: I've only seen this in textbooks before...) No, the family says, he didn't fall and hit his head. I search for a head wound but don't find one. I look at his pupils. They're reactive but unequal. He doesn't respond to questions or commands. His response to noxious stimuli is more decerebrate posturing.
For the lay folk out there, decerebrate posturing is extension of the elbows and internal rotation of the shoulders, along with leg extension. Can also go with neck extension and internal leg rotation, although this guy wasn't showing those signs. It's a sign of brainstem damage. No good. He gets a Glasgow Coma score of 4. All of us healthy awake people get a perfect score of 15. 4 is a pretty bad score.
Differential diagnosis: brainstem herniation (due to... what? hemorrage from an unwitnessed drunken fall? tumor? brain swelling from some other cause?), posterior stroke?
Previous state of health: heavy drinker on the weekends, last drink was last night. No other known medical problems. Has seemed very weak for the last 6 months, non-focal as far as I can get out of the family.
I still have no CT scanner here. Strangely enough, I also have no neurosurgeon. Also, it's Saturday, so I can't even get basic electrolytes. His blood glucose is 399. I place an NG tube, give some diazepam in case he's been drinking a lot less lately and there's a withdrawal component here (although I really don't think that explains the picture I'm seeing).
I spend about 1 hour convincing his family that he needs to be at a bigger hospital. Preferably one with a CT scanner. During this time his blood pressure, which was initially about 180/100 bounces up to 240/120, so I start in with the labetalol. I wind up giving quite a bit of labetalol while trying to simultaneously control his blood pressure and convince the family he doesn't belong in this hospital. It may be that the diazepam was counter productive. I think it calmed him a little, and he was less agitated and therefore doing less of the disturbing decerebrate posturing. The family therefore thought he was getting better, and wanted to take him home, or at least spend the night in my hospital. ("Really?" moment #2) I firmly stood my ground, and eventually convinced them he needed to be in a bigger hospital.
So we sent him 4 hours by ambulance with one of my nurses along for the ride. Unfortunately, the nurse's cell phone has no minutes on it, and we have no cell phones to give her, so she has no way to contact me for instructions en route if problems develop. ("Really?" moment #3) So I equip her with a lot of labetalol and a little more diazepam and extremely detailed "if-then" style instructions.
She can receive calls, so we call her periodically to check in. We learn that the patient is about the same, and has vomited some more. Also, her blood pressure cuff broke en route, destroying her ability to give labetalol according to my instructions. ("Really?" moment #4)
On our next call to her we then learn that the big hospital ER in the capital city is refusing to accept this patient. ("Really?" moment #5). I try to call and reach a doctor to talk to, but am unable to find my way through the Guatemalan phone system extension maze.
(Note, it's standard practice in the states to call an admitting doctor at the hospital where you're sending the patient before you send them. Makes sense, right? But I had been told that here, if you do that, they'll just tell you not to send them, so it's better for the patient to show up on their doorstep with a detailed note from me. Therefore I had not called ahead.)
We then called our nurse back again and learned that he had been accepted into the hospital after all.
Thank goodness.
You know, in the states we have a law that says any patient who shows up at an ER has the right to be seen. They have no such law here. When I'm working in the states and it's another somewhat drunk homeless guy who wants in out of the rain and wants a sandwich (and is extremely picky about exactly which kind of sandwich he wants, and why am I out of tuna currently?), this law annoys me. At the moment, it seems incredibly important.
Saturday, October 30, 2010
A Brief Life
DETAILS CHANGED OR OMITTED TO PROTECT THE PATIENT'S PRIVACY
Medical Presentation: (Note, if you want to skip this part, just know that this was a healthy young woman at term with her first baby in latent labor, without any problems or concerns. The details are given merely to emphasize that there were no warning signs for what happened.)
ID (identification): 20 year old woman, somewhere in her third trimester with her first pregnancy
CC (chief complaint): small amount of blood and white discharge per vagina, and contractions hourly
HPI (history of present illness):
She's been having mild irregular contractions for the last day or so. The blood is much less than a period. The discharge seems normal to her, she thinks she's going into labor. Baby is moving normally. No rupture of membranes.
ROS (review of systems): no fevers, vaginal pain or itching. No headaches, vision changes, RUQ (right upper quadrant, referring to the abdomen) pain, or ankle swelling. No nausea or vomiting or diarrhea. Denies any other symptoms.
Antepartum history:
By her report of last menses, she is 32 weeks along. She has been seen at another clinic in town three times for prenatal care, starting during the second trimester. At her first visit there, she says they did an ultrasound and gave her a due date that makes her currently 36 weeks along. She has no lab results (and my nurse says that clinic is too small, they don't do labs there). She has never been to here before. The paper she brings from the other clinic shows normal blood pressures on those three visits. She says she's had no problems with this pregnancy.
PMH (Past Medical History): Denies any medical problems.
PSH (Past Surgical History): Denies any prior surgeries.
Medications: reports she is taking prenatal vitamins only
Allergies: NKDA (no known drug allergies)
VS (vital signs): entirely normal
PE (physical exam):
General: normal, no distress, contractions appear extremely mild, does not look like active labor
Heart, lungs, reflexes and legs normal. No edema of the face or extremities.
Fundal height is 31 cm. (Note: in the States this corresponds to a gestational age of 31 weeks, but here women and their babies are often smaller at the same gestational age. I don't have a good adjustment scale.) Leopold's (where you feel the mom's belly): cephalic presentation, estimated size 6 pounds.
Cervical exam: 1.5 cm dilated, 25% effaced, -3 station, soft, posterior, cephalic presentation
Ultrasound (I did one first, then the OB confirmed):
Fundal anterior placenta with some mild calcifications (note, it gets more calcified with time, so this was reassuring that the baby was not very early), no previa.
Baby in cephalic presentation, heart beating, practicing breathing, actively moving around.
Estimated GA (gestational age) based on biparietal diameter, head circumference, femoral length, and abdominal circumference: 37 weeks and 2 days.
EFM (external fetal monitor): baseline 130s, moderate variability, accelerations present, no decelerations. Category 1 strip. (Note, this is perfect, strips don't get any better than that.)
Tocometer: contractions every 5-8 minutes. (most of them are so mild that the woman doesn't appear to notice them.)
Assessment:
20 year old G1P0 likely at term or slightly early
in latent labor
no concerning signs or symptoms, anticipate normal vaginal birth
Plan:
Okay to go home now, return here when labor is more active or if any concerning symptoms
___________________________________
What happened:
I explained to her that she was in very early labor, and that everything looked good on the ultrasound and the monitor. We drew the usual complement of prenatal lab tests. I told her that her body was preparing to have the baby, but it was still going to be many hours, possibly even days, so she should rest at home until the contractions were stronger and more frequent. I discussed other reasons she should come back sooner, including heavier bleeding, decreased fetal movement, etc. This was in the morning. She left with her family.
That evening, she came back saying she'd been having contractions every 5 minutes for the last 6 hours. She still didn't look like she was in active labor. I repeated the cervical exam, and other than a slight increase in effacement (50% now), her cervix was unchanged. We got another 20 minute strip on the monitors, and the baby still looked great. Her contractions on the monitor where now every 2-3 minutes, but she was still not feeling most of them. I told her everything still looked good, and her body was continuing to progress towards labor but it was still going to be away, and she could rest more comfortably at home. She insisted that she wanted to stay in the hospital overnight. She was the only patient there, and they pay for this themselves, so I said fine.
The next morning I checked her cervix again, and it was now 75% effaced, but no more dilated than it had been 24 hrs prior. The woman still appeared to be in only mild discomfort. Again I told her she could go home if she wanted, and return when the contractions were stronger. Again I reviewed the reasons to return. She left with her family.
I went off duty, but encouraged the person on duty to call me for the birth (I enjoy delivering babies more than many doctors do).
I checked in that evening, but we hadn't heard from her again.
I checked in the next day, and was told the following story:
She went into active labor at home. They went to a pharmacy. She pushed there for 4 hours. The baby was born alive, and nursed a few sucks, then died. Then they brought it here, to the hospital. Resuscitation was attempted, but the baby had already been dead too long. The mouth and nose were filled with thick meconium, according to the doctor who was on call. Oh, and yes, it looked like a full term infant, no signs of prematurity. Weight 3.2 kg. 7 lbs. Bigger than I had thought.
___________________________________
Discussion:
WTF?
A pharmacy? Why? Was she put off by my telling her it was okay to go home so many times? Did she think I wasn't taking the birth seriously? Why oh why didn't she come back here? We would have suctioned that meconium out! This is just sad.
I deal with primips (women having their first baby) in latent labor all the time. I send them home all the time. They come back. They don't go to a pharmacy to push.
Did my cultural incompetence kill this baby?
No, I know that's not my blame to take on, but really... what role did my behavior play in her decision to not return here for the birth? Can I learn something? What, exactly?
Furthermore...
There are things that we see here that we just don't see in the states, because the massive healthcare delivery system that I work within has hugely reduced their frequency. Yes, I've seen meconium aspiration, but the vast majority of babies born through meconium are perfectly fine. The worst case I saw had to be hospitalized for a few weeks. Why don't we see bad mec asp in the States more often? Because it's standard protocol to suction any meconium out before stimulating the baby to breathe. And if the baby has problems, we have oxygen and other equipment there to help, right away. Plenty of babies get a little PPV (positive pressure ventilation) after birth, or a little meconium suctioning. I guess my point is that these interventions happen so routinely where I usually work that I don't always fully appreciate the dangers of going without them.
This was the second birth here since I've been here, and the first vaginal birth. And the baby died.
Along the same lines, they see pregnant ladies with eclampsia (no, not pre-eclampsia) here about once a month. Why? Because they weren't getting prenatal care, so no body took their blood pressures. Until they came in seizing. Some of these ladies die.
I think the benefit of seeing these things is appreciating those aspects of our healthcare system that really do prevent serious disease. Some of what we routinely do is bureaucratic. But some of it very definitely prevents morbidity and mortality, and it's sobering to see the reality of that so directly.
What are the barriers to good care here?
1) Money/Resources of the hospital: this one is obvious. No blood bank, no CT scanner, only 3 labs on the weekend (urine dip, urine pregancy, and blood glucose), no general anesthesia. Not enough money to pay all the doctors, so many of them are volunteers, like me. This feeds into problem #3 (see below).
2) Impoverished population + fee for service model. They have to pay for every pair of sterile gloves I open, every minute that their toddler is on oxygen, every medicine, every packet of gauze I open. I often have to prescribe only half a course of antibiotics because they don't have enough money with them to buy the entire course. (I tell them to come back for the rest.) Many patients simply can't afford the health care that they need, even at the dirt bottom prices charged here. So people come in late, leave early, and refuse needed interventions.
3) Cultural beliefs and communication: this is the stickiest one. Partially because it's so hard to understand what's really going on, and partially because it's the one an individual like me feels ought to be most addressable. I don't need to be a millionaire or solicit donations. All I have to do is relate well to my patients, hear their concerns, educate them on their condition, and make sure they understand what I recommend and why. Right? I'm a family practice doc, I should be able to relate to my patients and make them feel heard and cared for. We do that really well in Family Practice Land, right? But it's not that easy. We kinda share a language. (Their first language is the local Mayan dialect, and mine is English, but the nurses all speak both the Mayan tongue and Spanish, so I can communicate with my patients via nurse translator.) But we have deep seated differences in our beliefs about health.
For example, I think the toddler with increased work of breathing, breath sounds consistent with pneumonia, oxygen saturation in the 80s and a fever of 38.2 should have oxygen by nasal canula, acetaminophen, a chest x-ray, and maybe some antibiotics. The parents refused the x-ray, so I offered empiric antibiotics, which they accepted. They accepted a few hours of oxygen supplementation, but then insisted on going home, no matter how many times I showed them her O2 saturation was still in the 80s, and why that was important. Oh, and they dressed her like she was going skiing on their way out the door, including a ski mask that covered her mouth. (Temperature here is in the 70s, I'm comfy in a t-shirt.) Their reasoning was that too much air was dangerous when you have a fever. I showed them on the O2 monitor that her saturation went up if her mouth was not covered by the ski mask, which I think convinced them to leave it off.
But I still don't really understand the structure of the belief system that says too much air is dangerous when you have a fever.
It's differences like these that are so hard to overcome. We are just not working from the same set of beliefs, so nothing I say makes sense to them. And I don't know or understand all of their beliefs, so I don't really know what I'm trying to work with.
Solution
We teach "cultural competence" in medical school, but all that can do is enable us to recognize this problem for what it is. To actually fix the problem, I have to become deeply familiar with each and every population that I work with. (And of course most people are the product of a complicated blend of populations, so really knowing the individual is optimal, go continuity of care!)
Hey... you know what would be a really useful series of books? Medical Cultural Competence for Population X. I'm thinking pocket book sized and not too thick. It was explain the underlying beliefs about health and disease that lay people in that population often hold, with examples. There's an opportunity here to publish hundreds if not thousands of books in this line. Each medical practitioner would want several, based on the specific populations they serve.
Alright, who's feeling entrepreneurial?
Medical Presentation: (Note, if you want to skip this part, just know that this was a healthy young woman at term with her first baby in latent labor, without any problems or concerns. The details are given merely to emphasize that there were no warning signs for what happened.)
ID (identification): 20 year old woman, somewhere in her third trimester with her first pregnancy
CC (chief complaint): small amount of blood and white discharge per vagina, and contractions hourly
HPI (history of present illness):
She's been having mild irregular contractions for the last day or so. The blood is much less than a period. The discharge seems normal to her, she thinks she's going into labor. Baby is moving normally. No rupture of membranes.
ROS (review of systems): no fevers, vaginal pain or itching. No headaches, vision changes, RUQ (right upper quadrant, referring to the abdomen) pain, or ankle swelling. No nausea or vomiting or diarrhea. Denies any other symptoms.
Antepartum history:
By her report of last menses, she is 32 weeks along. She has been seen at another clinic in town three times for prenatal care, starting during the second trimester. At her first visit there, she says they did an ultrasound and gave her a due date that makes her currently 36 weeks along. She has no lab results (and my nurse says that clinic is too small, they don't do labs there). She has never been to here before. The paper she brings from the other clinic shows normal blood pressures on those three visits. She says she's had no problems with this pregnancy.
PMH (Past Medical History): Denies any medical problems.
PSH (Past Surgical History): Denies any prior surgeries.
Medications: reports she is taking prenatal vitamins only
Allergies: NKDA (no known drug allergies)
VS (vital signs): entirely normal
PE (physical exam):
General: normal, no distress, contractions appear extremely mild, does not look like active labor
Heart, lungs, reflexes and legs normal. No edema of the face or extremities.
Fundal height is 31 cm. (Note: in the States this corresponds to a gestational age of 31 weeks, but here women and their babies are often smaller at the same gestational age. I don't have a good adjustment scale.) Leopold's (where you feel the mom's belly): cephalic presentation, estimated size 6 pounds.
Cervical exam: 1.5 cm dilated, 25% effaced, -3 station, soft, posterior, cephalic presentation
Ultrasound (I did one first, then the OB confirmed):
Fundal anterior placenta with some mild calcifications (note, it gets more calcified with time, so this was reassuring that the baby was not very early), no previa.
Baby in cephalic presentation, heart beating, practicing breathing, actively moving around.
Estimated GA (gestational age) based on biparietal diameter, head circumference, femoral length, and abdominal circumference: 37 weeks and 2 days.
EFM (external fetal monitor): baseline 130s, moderate variability, accelerations present, no decelerations. Category 1 strip. (Note, this is perfect, strips don't get any better than that.)
Tocometer: contractions every 5-8 minutes. (most of them are so mild that the woman doesn't appear to notice them.)
Assessment:
20 year old G1P0 likely at term or slightly early
in latent labor
no concerning signs or symptoms, anticipate normal vaginal birth
Plan:
Okay to go home now, return here when labor is more active or if any concerning symptoms
___________________________________
What happened:
I explained to her that she was in very early labor, and that everything looked good on the ultrasound and the monitor. We drew the usual complement of prenatal lab tests. I told her that her body was preparing to have the baby, but it was still going to be many hours, possibly even days, so she should rest at home until the contractions were stronger and more frequent. I discussed other reasons she should come back sooner, including heavier bleeding, decreased fetal movement, etc. This was in the morning. She left with her family.
That evening, she came back saying she'd been having contractions every 5 minutes for the last 6 hours. She still didn't look like she was in active labor. I repeated the cervical exam, and other than a slight increase in effacement (50% now), her cervix was unchanged. We got another 20 minute strip on the monitors, and the baby still looked great. Her contractions on the monitor where now every 2-3 minutes, but she was still not feeling most of them. I told her everything still looked good, and her body was continuing to progress towards labor but it was still going to be away, and she could rest more comfortably at home. She insisted that she wanted to stay in the hospital overnight. She was the only patient there, and they pay for this themselves, so I said fine.
The next morning I checked her cervix again, and it was now 75% effaced, but no more dilated than it had been 24 hrs prior. The woman still appeared to be in only mild discomfort. Again I told her she could go home if she wanted, and return when the contractions were stronger. Again I reviewed the reasons to return. She left with her family.
I went off duty, but encouraged the person on duty to call me for the birth (I enjoy delivering babies more than many doctors do).
I checked in that evening, but we hadn't heard from her again.
I checked in the next day, and was told the following story:
She went into active labor at home. They went to a pharmacy. She pushed there for 4 hours. The baby was born alive, and nursed a few sucks, then died. Then they brought it here, to the hospital. Resuscitation was attempted, but the baby had already been dead too long. The mouth and nose were filled with thick meconium, according to the doctor who was on call. Oh, and yes, it looked like a full term infant, no signs of prematurity. Weight 3.2 kg. 7 lbs. Bigger than I had thought.
___________________________________
Discussion:
WTF?
A pharmacy? Why? Was she put off by my telling her it was okay to go home so many times? Did she think I wasn't taking the birth seriously? Why oh why didn't she come back here? We would have suctioned that meconium out! This is just sad.
I deal with primips (women having their first baby) in latent labor all the time. I send them home all the time. They come back. They don't go to a pharmacy to push.
Did my cultural incompetence kill this baby?
No, I know that's not my blame to take on, but really... what role did my behavior play in her decision to not return here for the birth? Can I learn something? What, exactly?
Furthermore...
There are things that we see here that we just don't see in the states, because the massive healthcare delivery system that I work within has hugely reduced their frequency. Yes, I've seen meconium aspiration, but the vast majority of babies born through meconium are perfectly fine. The worst case I saw had to be hospitalized for a few weeks. Why don't we see bad mec asp in the States more often? Because it's standard protocol to suction any meconium out before stimulating the baby to breathe. And if the baby has problems, we have oxygen and other equipment there to help, right away. Plenty of babies get a little PPV (positive pressure ventilation) after birth, or a little meconium suctioning. I guess my point is that these interventions happen so routinely where I usually work that I don't always fully appreciate the dangers of going without them.
This was the second birth here since I've been here, and the first vaginal birth. And the baby died.
Along the same lines, they see pregnant ladies with eclampsia (no, not pre-eclampsia) here about once a month. Why? Because they weren't getting prenatal care, so no body took their blood pressures. Until they came in seizing. Some of these ladies die.
I think the benefit of seeing these things is appreciating those aspects of our healthcare system that really do prevent serious disease. Some of what we routinely do is bureaucratic. But some of it very definitely prevents morbidity and mortality, and it's sobering to see the reality of that so directly.
What are the barriers to good care here?
1) Money/Resources of the hospital: this one is obvious. No blood bank, no CT scanner, only 3 labs on the weekend (urine dip, urine pregancy, and blood glucose), no general anesthesia. Not enough money to pay all the doctors, so many of them are volunteers, like me. This feeds into problem #3 (see below).
2) Impoverished population + fee for service model. They have to pay for every pair of sterile gloves I open, every minute that their toddler is on oxygen, every medicine, every packet of gauze I open. I often have to prescribe only half a course of antibiotics because they don't have enough money with them to buy the entire course. (I tell them to come back for the rest.) Many patients simply can't afford the health care that they need, even at the dirt bottom prices charged here. So people come in late, leave early, and refuse needed interventions.
3) Cultural beliefs and communication: this is the stickiest one. Partially because it's so hard to understand what's really going on, and partially because it's the one an individual like me feels ought to be most addressable. I don't need to be a millionaire or solicit donations. All I have to do is relate well to my patients, hear their concerns, educate them on their condition, and make sure they understand what I recommend and why. Right? I'm a family practice doc, I should be able to relate to my patients and make them feel heard and cared for. We do that really well in Family Practice Land, right? But it's not that easy. We kinda share a language. (Their first language is the local Mayan dialect, and mine is English, but the nurses all speak both the Mayan tongue and Spanish, so I can communicate with my patients via nurse translator.) But we have deep seated differences in our beliefs about health.
For example, I think the toddler with increased work of breathing, breath sounds consistent with pneumonia, oxygen saturation in the 80s and a fever of 38.2 should have oxygen by nasal canula, acetaminophen, a chest x-ray, and maybe some antibiotics. The parents refused the x-ray, so I offered empiric antibiotics, which they accepted. They accepted a few hours of oxygen supplementation, but then insisted on going home, no matter how many times I showed them her O2 saturation was still in the 80s, and why that was important. Oh, and they dressed her like she was going skiing on their way out the door, including a ski mask that covered her mouth. (Temperature here is in the 70s, I'm comfy in a t-shirt.) Their reasoning was that too much air was dangerous when you have a fever. I showed them on the O2 monitor that her saturation went up if her mouth was not covered by the ski mask, which I think convinced them to leave it off.
But I still don't really understand the structure of the belief system that says too much air is dangerous when you have a fever.
It's differences like these that are so hard to overcome. We are just not working from the same set of beliefs, so nothing I say makes sense to them. And I don't know or understand all of their beliefs, so I don't really know what I'm trying to work with.
Solution
We teach "cultural competence" in medical school, but all that can do is enable us to recognize this problem for what it is. To actually fix the problem, I have to become deeply familiar with each and every population that I work with. (And of course most people are the product of a complicated blend of populations, so really knowing the individual is optimal, go continuity of care!)
Hey... you know what would be a really useful series of books? Medical Cultural Competence for Population X. I'm thinking pocket book sized and not too thick. It was explain the underlying beliefs about health and disease that lay people in that population often hold, with examples. There's an opportunity here to publish hundreds if not thousands of books in this line. Each medical practitioner would want several, based on the specific populations they serve.
Alright, who's feeling entrepreneurial?
Sunday, October 24, 2010
Nose Job
One of the more interesting patients from my last call night came in with a pretty good sized cut in his nose.
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The white thing is a Q-tip, holding the flap of nose back so you can appreciate it better.
Said it happened about 4 hours ago, "on the street", but he didn't remember how. He was still drunk.
I'm kinda thinking he was attacked with a serrated knife, or a broken bottle. No blunt trauma -- whatever it was was sharp, but it had a few little side cuts to it also.
I've never stitched up something this big on the face before, but I figured it couldn't be more difficult than perineal repairs, so I had the nurse clean it, then I got out some 4-0 vicryl and placed a few deep sutures, then did a running subcuticular stitch with 4-0 prolene. Some steristrips to hold the ends of the prolene down and to cover the wound, some ibuprofen and Keflex (I don't know the statistics, but nose wounds have GOT to be high risk for infection, right?), and sent him on his way.
.jpg)
He didn't bring much money with him, so he could only buy 3 days worth of Keflex. So he'll come back and see me on Tuesday, and I'll make sure it looks okay and probably give him a little more Keflex. Stitches out in a week, then I'll take a last photo.
Update, 4 days later:
Well, he was supposed to come back on day 3, but I suppose day 4 isn't all that bad.
I took out the prolene subcutaneous stitch today. (Was gonna wait until day 7 but it was a twisty enough route that I was worried about whether I'd be able to pull it after all that time.)
I think it looks alright. I cleaned it again, replaced the steristrips, and gave him more Keflex. He still says he has no idea how this happened, but he doesn't really like to meet my gaze. Definitely embarrassed. Is here with his dad, as he was the first time. He's supposed to come back again in 3-5 days.
The white thing is a Q-tip, holding the flap of nose back so you can appreciate it better.
Said it happened about 4 hours ago, "on the street", but he didn't remember how. He was still drunk.
I'm kinda thinking he was attacked with a serrated knife, or a broken bottle. No blunt trauma -- whatever it was was sharp, but it had a few little side cuts to it also.
I've never stitched up something this big on the face before, but I figured it couldn't be more difficult than perineal repairs, so I had the nurse clean it, then I got out some 4-0 vicryl and placed a few deep sutures, then did a running subcuticular stitch with 4-0 prolene. Some steristrips to hold the ends of the prolene down and to cover the wound, some ibuprofen and Keflex (I don't know the statistics, but nose wounds have GOT to be high risk for infection, right?), and sent him on his way.
He didn't bring much money with him, so he could only buy 3 days worth of Keflex. So he'll come back and see me on Tuesday, and I'll make sure it looks okay and probably give him a little more Keflex. Stitches out in a week, then I'll take a last photo.
Update, 4 days later:
Well, he was supposed to come back on day 3, but I suppose day 4 isn't all that bad.
I took out the prolene subcutaneous stitch today. (Was gonna wait until day 7 but it was a twisty enough route that I was worried about whether I'd be able to pull it after all that time.)
I think it looks alright. I cleaned it again, replaced the steristrips, and gave him more Keflex. He still says he has no idea how this happened, but he doesn't really like to meet my gaze. Definitely embarrassed. Is here with his dad, as he was the first time. He's supposed to come back again in 3-5 days.
Friday, October 22, 2010
My first Hospitalito call night
On Wednesday, for the first time in my life, I was responsible for patients without an attending doctor on site with me.
I was responsible for the 2 bed ER, and the hospitalized patients (we have 4 inpatient beds here).
My resources:
People: one well trained nurse (aka "life saver") who speaks both Spanish and the local Mayan tongue, 2 staff with less education (maybe the equivilent of MAs?), a "guardian" (like, of the grounds), who knows which button to press on the xray so I can get poor quality xrays overnight.
Labs: urine dip, a blood glucose and a urine pregnancy. Period.
Other diagnostics: EKGs, XRay, external fetal monitor and tocometer. (The EKG machine works with metallic suction devices that leave bruises!)
Reference materials: A shelf of reference books, plus my own that I brought. A computer.
Basic supplies: stethoscope, otoscope, ophthalmoscope, trauma shears, sutures, intubation equipment, gauze, iodoform, lidocaine, needles and syringes,
IV fluids: LR and NS and D 2.5 1/2NS
Backup: The phone numbers of 4 other family docs who I can call in a pinch, and an OB.
My patients (details changed to protect their privacy)
1) A woman in early labor with a history of 2 cesarean sections who wanted a vaginal birth.
Her first C-section was done after she labored at home for 30 hrs, came in with a dead fetus in her, finished dilating with the help of pitocin, suffered eclampsia (yes, she seized) and failed to birth her baby vaginally despite the aid of pitocin, forceps, and vacuum. After this nightmare the dead baby was finally birthed by C-section, after which she had complications including endometritis and wound dehiscence.
Her second C-section was done preemptively, to avoid all of the above. From that birth, she has a healthy child.
Now, she's here with her third pregnancy, wanting a vaginal birth. She wants this because she's been told she can only have 3 C-sections in her life, and she wants 4 (living) children. So she figures if she accepts a C-section this time, she's done bearing children.
She is only 1 cm dilated, and her contractions are still very mild, but the baby is having frequent decels (of it's heart beat) on the monitor. Most of them are variable, to ~100 bpm. There is one, however, that drops to the 50s for 3 minutes. This makes me unhappy.
This, my first call shift as the only MD inhouse, happens to be a holiday, so the normal hospital staff are not here. If I thought this baby or mother were dying and I recommended a crash C-section to them, and if they accepted it, I would have to call in the OB, the family doc who does the spinal anesthesia, and the surgical tech. This would take at least 10 minutes, not to mention the time to administer the anesthesia. This makes me unhappy.
They have not yet decided that they would accept a crash c-section if mother or baby seemed to be dying. This makes me unhappy.
If her uterus ruptures (it is not in great shape, after 2 c-sections and the endometritis) and she is bleeding out internally, I cannot give her any blood, because we do not have any here. This makes me unhappy.
The first baby, who was dead before she came in, was not especially large, yet she couldn't pass it vaginally with the help of pitocin, forceps, and vacuum. Therefore, I have no reason to think that she can birth the current baby vaginally. This makes me unhappy.
So, I find myself in the unusual (for me) position of trying to frighten a woman who wants a vaginal birth into accepting a cesarean section.
I am not sucessful. Neither is the family doc who's going off shift. Neither is the OB who we call in.
The patient leaves to go to another hospital a few hours away with the goal of having a vaginal birth. The next day I learn that they did a C-section there.
2) A baby girl with either pneumonia or bronchiolitis. I admitted her to one of my 4 hospital beds so I could keep her oxygen level up. Easy peasy.
3) A 12 year old girl here for a check back on her neck abscess, which was I&D'd a few days ago. Looks like it's healing, I repack it and send her out. Easy peasy.
4) A man walks in carrying his 11 year old son, who is seizing. He has been seizing for 2 hrs. (Suddenly I am treating status epilepticus, despite the fact that none of my patients have ever actually seized in front of me before.) In the past 4 days, this boy has seized ~30 times, according to his mother's careful records. He has not recovered from his post-ictal state between seizures at all in those 4 days. He therefore has not eaten, drunk anything, or taken any of his meds in that time. He usually takes 3 meds to prevent seizures. Oh, and he has gastrointestinal tuberculosis, and is off of those meds too. Before this all started 4 days ago he was in his normal state (disabled, developmentally delayed, treated for TB for the last 5 months) other than a little cough for 1 week.
The benzos I give stop his seizure for a few minutes. Then I have to give more. Then I have to give more. By the third round, I have figured out which of the longer acting anticonvulsants we actually have here. And which ones I can give IV, since oral meds are out of the question for this boy who typically (according to his mother) stays in a drowsy, post-ictal state for 3-4 days after a seizure. And I have managed to calculate a pediatric dose for him after cross referencing several sources, all of which give slightly different numbers. They do all agree that one should adjust the dosing based on serum drug levels. Very funny. We proceed to hydrate him with IV fluids and wait for him to wake up enough to take his oral meds so his parents can take him home. 2 days later, we are still waiting, but at least he hasn't seized again.
5) An utterly hysterical man with gastritis. He went to a clinic this morning, and says they did an ultrasound and saw a gallstone. They told him to come back if his symptoms got worse. His gastritis symptoms got worse and he is now terrified of "the stone growing in me". He is very melodramatic and all the staff are laughing at him behind the curtain. He wants another ultrasound. I treat his gastritis instead. Eventually he is calm enough to understand my explanation of why the gallstone has nothing to do with his gastritis. He goes home. Easy peasy.
6) A young woman with vaginal hemorrhage. Last period 3 months ago, but it was always irregular. She has no idea if she's pregnant. For some reason we don't have any pregnancy tests at the moment (I thought that was one of the 3 labs I could do!) Yes she feels lightheaded and dizzy. Conjunctiva are quite pale. No, I still don't have any blood here. Methergin and IV fluid bolus have been ordered. Vital signs are not too scary at the moment. Speculum exam: I go through a lot of gauze trying to clear the blood enough to see the cervix. I remove several large clots, and then the blood just keeps flowing. I am unhappy. I switch to manual exam, since I can't see a damn thing. Her cervix is 2 cm dilated, and something is sticking out of it. It's soft, squishy, and vaguely tubular. Is that another clot or is it the "products of conception"? I am afraid to try pulling on it, because sometimes that can make the bleeding worse, and then what the hell would I do? I think she's lost about 500 mLs of blood since I met her 10 minutes ago. I end my exam and call the OB. He comes in, repeats the speculum exam, and uses the ring forceps to pull what turned out to be the products of conception from the cervix. Maybe after my Planned Parenthood rotation I'll feel confident enough to do that. She stops bleeding and we relax. She stays overnight for observation and some labs and an ultrasound in the morning.
7) I am awoken in the middle of the night for another seizing patient. This is a middle aged man. Family says he seized at home. Nurse says he seized again here, but it stopped on it's own before I got downstairs. Post-ictal for a few minutes, then coherent and obnoxious. Demands meds, refuses to stay for observation. Didn't bring in the meds he's already on, and has no idea what they are. Belly looks like a drinker, but denies any alcohol for the last 2 years. 30 year history of seizures, and a long history of coming into our ER with seizures and then leaving AMA. He's been told to see a neurologist many times, but never does. He leaves AMA again. We go back to sleep.
I sign out the three hospitalized patients in the morning, and go home relieved that both I and all my patients survived the night.
I'm on again tomorrow.
I was responsible for the 2 bed ER, and the hospitalized patients (we have 4 inpatient beds here).
My resources:
People: one well trained nurse (aka "life saver") who speaks both Spanish and the local Mayan tongue, 2 staff with less education (maybe the equivilent of MAs?), a "guardian" (like, of the grounds), who knows which button to press on the xray so I can get poor quality xrays overnight.
Labs: urine dip, a blood glucose and a urine pregnancy. Period.
Other diagnostics: EKGs, XRay, external fetal monitor and tocometer. (The EKG machine works with metallic suction devices that leave bruises!)
Reference materials: A shelf of reference books, plus my own that I brought. A computer.
Basic supplies: stethoscope, otoscope, ophthalmoscope, trauma shears, sutures, intubation equipment, gauze, iodoform, lidocaine, needles and syringes,
IV fluids: LR and NS and D 2.5 1/2NS
Backup: The phone numbers of 4 other family docs who I can call in a pinch, and an OB.
My patients (details changed to protect their privacy)
1) A woman in early labor with a history of 2 cesarean sections who wanted a vaginal birth.
Her first C-section was done after she labored at home for 30 hrs, came in with a dead fetus in her, finished dilating with the help of pitocin, suffered eclampsia (yes, she seized) and failed to birth her baby vaginally despite the aid of pitocin, forceps, and vacuum. After this nightmare the dead baby was finally birthed by C-section, after which she had complications including endometritis and wound dehiscence.
Her second C-section was done preemptively, to avoid all of the above. From that birth, she has a healthy child.
Now, she's here with her third pregnancy, wanting a vaginal birth. She wants this because she's been told she can only have 3 C-sections in her life, and she wants 4 (living) children. So she figures if she accepts a C-section this time, she's done bearing children.
She is only 1 cm dilated, and her contractions are still very mild, but the baby is having frequent decels (of it's heart beat) on the monitor. Most of them are variable, to ~100 bpm. There is one, however, that drops to the 50s for 3 minutes. This makes me unhappy.
This, my first call shift as the only MD inhouse, happens to be a holiday, so the normal hospital staff are not here. If I thought this baby or mother were dying and I recommended a crash C-section to them, and if they accepted it, I would have to call in the OB, the family doc who does the spinal anesthesia, and the surgical tech. This would take at least 10 minutes, not to mention the time to administer the anesthesia. This makes me unhappy.
They have not yet decided that they would accept a crash c-section if mother or baby seemed to be dying. This makes me unhappy.
If her uterus ruptures (it is not in great shape, after 2 c-sections and the endometritis) and she is bleeding out internally, I cannot give her any blood, because we do not have any here. This makes me unhappy.
The first baby, who was dead before she came in, was not especially large, yet she couldn't pass it vaginally with the help of pitocin, forceps, and vacuum. Therefore, I have no reason to think that she can birth the current baby vaginally. This makes me unhappy.
So, I find myself in the unusual (for me) position of trying to frighten a woman who wants a vaginal birth into accepting a cesarean section.
I am not sucessful. Neither is the family doc who's going off shift. Neither is the OB who we call in.
The patient leaves to go to another hospital a few hours away with the goal of having a vaginal birth. The next day I learn that they did a C-section there.
2) A baby girl with either pneumonia or bronchiolitis. I admitted her to one of my 4 hospital beds so I could keep her oxygen level up. Easy peasy.
3) A 12 year old girl here for a check back on her neck abscess, which was I&D'd a few days ago. Looks like it's healing, I repack it and send her out. Easy peasy.
4) A man walks in carrying his 11 year old son, who is seizing. He has been seizing for 2 hrs. (Suddenly I am treating status epilepticus, despite the fact that none of my patients have ever actually seized in front of me before.) In the past 4 days, this boy has seized ~30 times, according to his mother's careful records. He has not recovered from his post-ictal state between seizures at all in those 4 days. He therefore has not eaten, drunk anything, or taken any of his meds in that time. He usually takes 3 meds to prevent seizures. Oh, and he has gastrointestinal tuberculosis, and is off of those meds too. Before this all started 4 days ago he was in his normal state (disabled, developmentally delayed, treated for TB for the last 5 months) other than a little cough for 1 week.
The benzos I give stop his seizure for a few minutes. Then I have to give more. Then I have to give more. By the third round, I have figured out which of the longer acting anticonvulsants we actually have here. And which ones I can give IV, since oral meds are out of the question for this boy who typically (according to his mother) stays in a drowsy, post-ictal state for 3-4 days after a seizure. And I have managed to calculate a pediatric dose for him after cross referencing several sources, all of which give slightly different numbers. They do all agree that one should adjust the dosing based on serum drug levels. Very funny. We proceed to hydrate him with IV fluids and wait for him to wake up enough to take his oral meds so his parents can take him home. 2 days later, we are still waiting, but at least he hasn't seized again.
5) An utterly hysterical man with gastritis. He went to a clinic this morning, and says they did an ultrasound and saw a gallstone. They told him to come back if his symptoms got worse. His gastritis symptoms got worse and he is now terrified of "the stone growing in me". He is very melodramatic and all the staff are laughing at him behind the curtain. He wants another ultrasound. I treat his gastritis instead. Eventually he is calm enough to understand my explanation of why the gallstone has nothing to do with his gastritis. He goes home. Easy peasy.
6) A young woman with vaginal hemorrhage. Last period 3 months ago, but it was always irregular. She has no idea if she's pregnant. For some reason we don't have any pregnancy tests at the moment (I thought that was one of the 3 labs I could do!) Yes she feels lightheaded and dizzy. Conjunctiva are quite pale. No, I still don't have any blood here. Methergin and IV fluid bolus have been ordered. Vital signs are not too scary at the moment. Speculum exam: I go through a lot of gauze trying to clear the blood enough to see the cervix. I remove several large clots, and then the blood just keeps flowing. I am unhappy. I switch to manual exam, since I can't see a damn thing. Her cervix is 2 cm dilated, and something is sticking out of it. It's soft, squishy, and vaguely tubular. Is that another clot or is it the "products of conception"? I am afraid to try pulling on it, because sometimes that can make the bleeding worse, and then what the hell would I do? I think she's lost about 500 mLs of blood since I met her 10 minutes ago. I end my exam and call the OB. He comes in, repeats the speculum exam, and uses the ring forceps to pull what turned out to be the products of conception from the cervix. Maybe after my Planned Parenthood rotation I'll feel confident enough to do that. She stops bleeding and we relax. She stays overnight for observation and some labs and an ultrasound in the morning.
7) I am awoken in the middle of the night for another seizing patient. This is a middle aged man. Family says he seized at home. Nurse says he seized again here, but it stopped on it's own before I got downstairs. Post-ictal for a few minutes, then coherent and obnoxious. Demands meds, refuses to stay for observation. Didn't bring in the meds he's already on, and has no idea what they are. Belly looks like a drinker, but denies any alcohol for the last 2 years. 30 year history of seizures, and a long history of coming into our ER with seizures and then leaving AMA. He's been told to see a neurologist many times, but never does. He leaves AMA again. We go back to sleep.
I sign out the three hospitalized patients in the morning, and go home relieved that both I and all my patients survived the night.
I'm on again tomorrow.
Monday, October 18, 2010
First Day at Hospitalito
I show up, as directed, for morning report at 7:30 am. The "morning report room" is actually an open air patio overlooking Lake Atitlan, with plastic chairs around a beat-up wooden table and a roof made of plant matter.
We are operating in "tiempo latino", so no one else shows up until 7:45. Eventually 6 of us are gathered around the table, and I get my first experience of trying to follow sign-out in Spanish. There are 4 hospitalized patients, and I follow along just fine (probably because the person giving report is speaking with an American accent). I am feeling quite proud of myself for following along until the obstetrician from Spain starts speaking. Now, please understand, most Guatemalans speak Spanish as a second language (like me!) and therefore speak relatively slowly, carefully, and without a lot of slang. So I had been following most conversations pretty well. Our Spanish obstetrician, on the other hand, speaks a very fast lispy native tongue, and I catch about 25% of his words and comprehend only the rare complete sentence. I had been hoping to learn a lot from this guy, so this does not bode well.
Now for an hour of orientation, which is good, aside from the schedule (I get 24 hr in-house calls on Wednesday and Saturdays, and most other non-post-call days in clinic), and the confirmation that I will indeed be the only MD in house when I'm on call overnight and on weekends. I'm used to having an attending physician in house with me at all times, and to being encouraged to run questions by them if I have even the slightest doubt about the best thing to do for a patient. This will be a whole new kinda fun, I can tell.
Then I thought it was time to get to work, but instead I'm encouraged to go eat breakfast. (Um, I did that before I came to work, but thanks.) Oh, and change my clothes. Apparently my clinic clothes are not appropriate attire, I'm supposed to wear scrubs, including in clinic. OK, can do.
Eventually I start actually seeing patients, and realize that very few of them speak Spanish. They all seem to speak the local native Mayan language. So I need a translator to get to Spanish. Of course, I'm still thinking in English, so my head is kinda spinning with the three languages between us. I keep having to cross out English words in my clinic notes. All my abbreviations (SOB, CP, PERRL, AFOS, CTAB, RRR no m, no c/c/e, no N/V/D) are based on English and presumably therefore no good. I have no idea what the equivalent abbreviations in Spanish are. So I'm writing everything out, and using my dictionary to do so. I have decent experience talking to patients in Spanish (LA county hospital, thank you), but documenting in Spanish is new. How do you say wheeze? crackles? My dictionary doesn't know. C.O.P.D.? E.P.O.C., apparently.
Reassuringly, I knew what to do for almost all my patients today. (And the one I didn't know how to help stymied the other docs too.) My knowledge of the system infrastructure here is quite lacking, and my Spanish could be better, but at least my medical knowledge seems adequate. This is good.
Next, we have a C-section. Yay! I get to assist! Breech primagravida, healthy mom and baby.
Apparently, one of the family docs here from the states does the spinal anesthesia, because there is no anesthesiologist. So he gives me a rundown on the how-to basics, which is cool. Not much different than an LP, but of course one has to watch the blood pressure and the respirations carefully. He preps his meds from a cheat sheet.
The OR has an out-of-use fireplace in the corner. That chimney is the only ventilation system, as the windows and doors are (happily) closed during the case. The bovie doesn't work. The tools are a little more basic than we have at home, but overall I find the set-up fairly familiar.
Now, I'm operating with our Spanish Obstetrician. Problem is, I don't understand a damn thing he's saying the whole time. So I'm across the table from him, with an open belly between us, and I'm cutting, retracting, exposing, sewing, etc, and he's jabbering away with what is presumably useful information. Thank heavens I've assisted on this particular surgery many times in the past, and therefore have some clue what to do. When the tone of his voice suggests displeasure, I try randomly changing my technique a little to see if his tone becomes happier. Mostly, he sounds fairly happy during the case. When I feel I really must understand what he wants from me, I ask and keep asking until I understand his reply. He is kind about our language barrier, but doesn't seem capable of slowing down his lispy speech.
Eventually we have a baby. It's too blue and floppy for my tastes, but comes around eventually with a little positive pressure ventilation (from the family doc who had done the spinal earlier). Apgars of 1 and 8. Phew.
Lunchtime. Surprise! Happy birthday to one person today and another tomorrow! Someone made soup for everyone, and now it's a party! Soup is kinda tasty, although I don't recognize all the ingredients. At 2:15, I realize I am late to be upstairs in clinic, which I had been told starts at 2 pm. So I excuse myself from the table, and head up stairs, only to find it completely dark and deserted. I must wait for the receptionist and nurse, who apparently are still downstairs eating soup. Around 3:30 I finally have patients to see. I proceed to find a bit of a stride, and I do not feel the need to ask any medical questions of the other doctors for the 4 people I see this afternoon, only "do we have x here" questions directed at the pharmacist. I find this encouraging. It helps that the obstetrician is elsewhere.
We wrap up the day at 4:45, and I walk the 10 minutes home to my aunt and children. They've had a good first day as well, having procured milk, a brighter light-bulb for the kitchen, and a clothes-line. Of course, these were bought in town, which one has to get to via harrowing tuk-tuk transport, but that's another story.
We are operating in "tiempo latino", so no one else shows up until 7:45. Eventually 6 of us are gathered around the table, and I get my first experience of trying to follow sign-out in Spanish. There are 4 hospitalized patients, and I follow along just fine (probably because the person giving report is speaking with an American accent). I am feeling quite proud of myself for following along until the obstetrician from Spain starts speaking. Now, please understand, most Guatemalans speak Spanish as a second language (like me!) and therefore speak relatively slowly, carefully, and without a lot of slang. So I had been following most conversations pretty well. Our Spanish obstetrician, on the other hand, speaks a very fast lispy native tongue, and I catch about 25% of his words and comprehend only the rare complete sentence. I had been hoping to learn a lot from this guy, so this does not bode well.
Now for an hour of orientation, which is good, aside from the schedule (I get 24 hr in-house calls on Wednesday and Saturdays, and most other non-post-call days in clinic), and the confirmation that I will indeed be the only MD in house when I'm on call overnight and on weekends. I'm used to having an attending physician in house with me at all times, and to being encouraged to run questions by them if I have even the slightest doubt about the best thing to do for a patient. This will be a whole new kinda fun, I can tell.
Then I thought it was time to get to work, but instead I'm encouraged to go eat breakfast. (Um, I did that before I came to work, but thanks.) Oh, and change my clothes. Apparently my clinic clothes are not appropriate attire, I'm supposed to wear scrubs, including in clinic. OK, can do.
Eventually I start actually seeing patients, and realize that very few of them speak Spanish. They all seem to speak the local native Mayan language. So I need a translator to get to Spanish. Of course, I'm still thinking in English, so my head is kinda spinning with the three languages between us. I keep having to cross out English words in my clinic notes. All my abbreviations (SOB, CP, PERRL, AFOS, CTAB, RRR no m, no c/c/e, no N/V/D) are based on English and presumably therefore no good. I have no idea what the equivalent abbreviations in Spanish are. So I'm writing everything out, and using my dictionary to do so. I have decent experience talking to patients in Spanish (LA county hospital, thank you), but documenting in Spanish is new. How do you say wheeze? crackles? My dictionary doesn't know. C.O.P.D.? E.P.O.C., apparently.
Reassuringly, I knew what to do for almost all my patients today. (And the one I didn't know how to help stymied the other docs too.) My knowledge of the system infrastructure here is quite lacking, and my Spanish could be better, but at least my medical knowledge seems adequate. This is good.
Next, we have a C-section. Yay! I get to assist! Breech primagravida, healthy mom and baby.
Apparently, one of the family docs here from the states does the spinal anesthesia, because there is no anesthesiologist. So he gives me a rundown on the how-to basics, which is cool. Not much different than an LP, but of course one has to watch the blood pressure and the respirations carefully. He preps his meds from a cheat sheet.
The OR has an out-of-use fireplace in the corner. That chimney is the only ventilation system, as the windows and doors are (happily) closed during the case. The bovie doesn't work. The tools are a little more basic than we have at home, but overall I find the set-up fairly familiar.
Now, I'm operating with our Spanish Obstetrician. Problem is, I don't understand a damn thing he's saying the whole time. So I'm across the table from him, with an open belly between us, and I'm cutting, retracting, exposing, sewing, etc, and he's jabbering away with what is presumably useful information. Thank heavens I've assisted on this particular surgery many times in the past, and therefore have some clue what to do. When the tone of his voice suggests displeasure, I try randomly changing my technique a little to see if his tone becomes happier. Mostly, he sounds fairly happy during the case. When I feel I really must understand what he wants from me, I ask and keep asking until I understand his reply. He is kind about our language barrier, but doesn't seem capable of slowing down his lispy speech.
Eventually we have a baby. It's too blue and floppy for my tastes, but comes around eventually with a little positive pressure ventilation (from the family doc who had done the spinal earlier). Apgars of 1 and 8. Phew.
Lunchtime. Surprise! Happy birthday to one person today and another tomorrow! Someone made soup for everyone, and now it's a party! Soup is kinda tasty, although I don't recognize all the ingredients. At 2:15, I realize I am late to be upstairs in clinic, which I had been told starts at 2 pm. So I excuse myself from the table, and head up stairs, only to find it completely dark and deserted. I must wait for the receptionist and nurse, who apparently are still downstairs eating soup. Around 3:30 I finally have patients to see. I proceed to find a bit of a stride, and I do not feel the need to ask any medical questions of the other doctors for the 4 people I see this afternoon, only "do we have x here" questions directed at the pharmacist. I find this encouraging. It helps that the obstetrician is elsewhere.
We wrap up the day at 4:45, and I walk the 10 minutes home to my aunt and children. They've had a good first day as well, having procured milk, a brighter light-bulb for the kitchen, and a clothes-line. Of course, these were bought in town, which one has to get to via harrowing tuk-tuk transport, but that's another story.
The Plane Trip
My 3 year old twins had never been on a plane before.
They've never been to a country other than the US, and certainly not a third-world country with malaria and giant spiders.
So I thought I'd take them with me for my month working at a tiny hospital and clinic in rural Guatemala. Luckily, my amazing, creative, relaxed, dependable angel of an aunt volunteered save my ass by coming with me and caring for them while I'm at work. However, she was going to meet us in Guatemala City, so I got to do their first plane flight solo.
This scared me, and I self-treated my anxiety with retail therapy well ahead of time: children's benadryl, children's tylenol, new coloring books, new magnet toys, new (educational, of course) games downloaded to iPhone, extra iPhone brought so they could each have one at all times if needed, laptop and Planet Earth DVDs, child-sized headphones x 2, etch-a-sketch (travel size), and magnetic drawing pad x 2.
Oh, and extra battery for laptop.
Then I felt a little better.
Seattle to Guatemala City, with a layover in Dallas. 9:17 am to 6:50 pm (=5:50 pm Seattle time), so about 9 hrs + ~ 3 hrs for check-in, security (Mommy, I don't want to take my shoes off!), immigration, and customs (yes sir, I would like to bring 3 jars of peanut butter into the country, please).
Most controversial decision of the flight: car-seats to be checked, or carried on? I was gonna bring them for sure, because we had a 4 hr drive each way in the country and Guatemalans are not known for good roads or safe driving practices. But, do I want them with me on the plane?
Main Upside: these children are well conditioned to sit for hours at a time in their car-seats.
Secondary Upside: in the exceedingly unlikely event of a pretty bad but not catastrophic landing they might survive with fewer injuries than toddlers in just the plain plane lap-belts.
Downside: these are not your little infant-sized made-outta-plastic car-seats, these are venti-sized, important-parts-made-outta-metal car-seats, and really frickin' heavy. I was scared enough of the flight that I opted to bring them on, so I got to literally drag them through security, around the terminals at 3 airports, and through customs and immigration.
Lessons learned:
1) When a large burly man offers to carry your two venti-sized metal car-seats for you, accept the offer.
2) A wheelchair is a useful thing, even if your legs work just fine.
(Why the hell can't you take the luggage carts with you through security?)
3) Those moving walkways at the airports will transport your venti-metal car-seats for you, but slowly.
4) You can stack the car-seats on top of each other and drag them both by a strap, and still hold two toddlers' hands, if you're talented that way.
5) Do not let them tell you to board with Zone 1. Everyone is happier if you preboard.
6) No, you are not limited to one car-seat per row. (Really, lady? Now that I've dragged these things all the way to your gate which is inconveniently located in BFE you want me to check one and then bring two toddlers onto your plane who are screaming at each other about why one gets to have their car-seat on the plane and the other doesn't? Really? No, I didn't think so either. So glad you see it my way now.)
Worst moment of the flight:
"Mommy, I have to go potty".
nuf said?
No, I don't think so.
Imagine yourself in a teeny tiny airplane bathroom.
Now add two slightly cranky over-stimulated toddlers.
Now put one of them on the potty, doing #2. (The other one is squeezed into the corner behind you.)
Now you are wiping the bottom of the one on the potty. (The other one is pushing your legs from behind because, well, she is pretty short on breathing room.)
Now your glasses that you had tucked into the top of your shirt fall forward into the poop.
Now the toddler on the potty reaches for the pretty blue button marked "flush".
Now that's enough said.
In the end, we all arrived safe and sound in Guatemala City, and I even managed to retain (and thoroughly clean) my glasses. All's well that end's well.
They've never been to a country other than the US, and certainly not a third-world country with malaria and giant spiders.
So I thought I'd take them with me for my month working at a tiny hospital and clinic in rural Guatemala. Luckily, my amazing, creative, relaxed, dependable angel of an aunt volunteered save my ass by coming with me and caring for them while I'm at work. However, she was going to meet us in Guatemala City, so I got to do their first plane flight solo.
This scared me, and I self-treated my anxiety with retail therapy well ahead of time: children's benadryl, children's tylenol, new coloring books, new magnet toys, new (educational, of course) games downloaded to iPhone, extra iPhone brought so they could each have one at all times if needed, laptop and Planet Earth DVDs, child-sized headphones x 2, etch-a-sketch (travel size), and magnetic drawing pad x 2.
Oh, and extra battery for laptop.
Then I felt a little better.
Seattle to Guatemala City, with a layover in Dallas. 9:17 am to 6:50 pm (=5:50 pm Seattle time), so about 9 hrs + ~ 3 hrs for check-in, security (Mommy, I don't want to take my shoes off!), immigration, and customs (yes sir, I would like to bring 3 jars of peanut butter into the country, please).
Most controversial decision of the flight: car-seats to be checked, or carried on? I was gonna bring them for sure, because we had a 4 hr drive each way in the country and Guatemalans are not known for good roads or safe driving practices. But, do I want them with me on the plane?
Main Upside: these children are well conditioned to sit for hours at a time in their car-seats.
Secondary Upside: in the exceedingly unlikely event of a pretty bad but not catastrophic landing they might survive with fewer injuries than toddlers in just the plain plane lap-belts.
Downside: these are not your little infant-sized made-outta-plastic car-seats, these are venti-sized, important-parts-made-outta-metal car-seats, and really frickin' heavy. I was scared enough of the flight that I opted to bring them on, so I got to literally drag them through security, around the terminals at 3 airports, and through customs and immigration.
Lessons learned:
1) When a large burly man offers to carry your two venti-sized metal car-seats for you, accept the offer.
2) A wheelchair is a useful thing, even if your legs work just fine.
(Why the hell can't you take the luggage carts with you through security?)
3) Those moving walkways at the airports will transport your venti-metal car-seats for you, but slowly.
4) You can stack the car-seats on top of each other and drag them both by a strap, and still hold two toddlers' hands, if you're talented that way.
5) Do not let them tell you to board with Zone 1. Everyone is happier if you preboard.
6) No, you are not limited to one car-seat per row. (Really, lady? Now that I've dragged these things all the way to your gate which is inconveniently located in BFE you want me to check one and then bring two toddlers onto your plane who are screaming at each other about why one gets to have their car-seat on the plane and the other doesn't? Really? No, I didn't think so either. So glad you see it my way now.)
Worst moment of the flight:
"Mommy, I have to go potty".
nuf said?
No, I don't think so.
Imagine yourself in a teeny tiny airplane bathroom.
Now add two slightly cranky over-stimulated toddlers.
Now put one of them on the potty, doing #2. (The other one is squeezed into the corner behind you.)
Now you are wiping the bottom of the one on the potty. (The other one is pushing your legs from behind because, well, she is pretty short on breathing room.)
Now your glasses that you had tucked into the top of your shirt fall forward into the poop.
Now the toddler on the potty reaches for the pretty blue button marked "flush".
Now that's enough said.
In the end, we all arrived safe and sound in Guatemala City, and I even managed to retain (and thoroughly clean) my glasses. All's well that end's well.
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