Wednesday, April 6, 2011

Blood, Pus, & Speculums

As we spend time in clinics and in our global health class, I find myself more and more interested and focused on children's and women's health. The biggest rates and statistics of death and disease in developing countries are from children under the age of 5 and from maternal complications during pregnancy and delivery. In Africa I received a lot of experience in delivering babies and some complications that arise from that. Here in Nicaragua there has been less of that and more a presence of STIs, pelvic inflammatory disease, and cervical cancer - which has a very high prevalence rate in this area.

Dr. Caldera really pushes women's health and has been trying to make it more of a norm. Despite that, many women are still very shy about mentioning any symptoms or letting us do an exam on them. It is a lot different from the hospital in Africa where there was no personal space or privacy. Whole wards of people together while we did all kinds of dressing changes and most of the nurses being male. Here, even with a personal enclosed area, a blanket covering most everything and only girls assisting Dr. Caldera, it can still be hard to convince the women to let us examine them.

Dr. Caldera is one of the kindest, most understanding doctors I've ever worked with. He takes so much extra time to teach us and to let us do procedures ourselves. Because of the wariness of the women, the few of us girls have gotten a lot of experience in gynecology this semester. Vaginal exams, pregnancy check-ups, speculums galore, and even an entire clinic of just Pap smears in one village. I know that this subject is not an interest for many, but the more I see how much the women suffer from these problems and diseases, the more I want to know more on how to help them.

Our group is set up to have 2 students on call with Dr. Caldera at all times for any medical emergencies that come up, or house calls. These trips vary a lot between actual emergencies, just visiting an old woman with a cough, and transporting maybe a kid with a broken arm to the hospital in Waspam. My most recent call, I call our gynecological emergency day. David and I are partners and were called late Sunday morning to go with Dr. Caldera to see a woman that had been bleeding excessively. We walked down to the clinic first to grab a pregnancy test, a speculum, and some other meds and vitamins that might prove useful. Then we walked our way through the village in the heat to the woman. She was visiting her mother who lived in the classic one room wooden house up on stilts. The animals hang out under the house and the family cooks on the porch. This woman was visiting from the city, Managua, which was great because she could speak Spanish well and wasn't shy about explaining everything to us.

She had been spotting blood for a couple weeks and then developed significant bleeding for the last 2 days, getting really weak and dizzy. After a lot of conversation we found out that she had had many irregularities in her menstruation before and had been on some hormone medications in past years. She had quit taking them a while back when she thought she was better, and had no menstruation at all for a while. We did a pregnancy test first to rule out any chance of a spontaneous abortion or other complication with pregnancy, and that turned up negative. So Dr. Caldera had me get out the speculum we had brought and find out if she was still actively bleeding or not. There was a lot of blood and big clots that made it difficult, but I finally found the cervix and could see constant blood leaking through. With that knowledge, Dr. Caldera was stuck in indecision on whether we should be sending her to Waspam yet from too much blood loss, or do something here in the village.

We headed back to the mission and he explained how he really didn't have much experience in this kind of case. He asked me if I knew anything about what to do from a fellow women's perspective. I told him that I had friends with irregular menstruation that had started early on with birth control pills to help regulate, but that's all I knew. So we split up at the mission and agreed to meet up in 30 minutes after consulting medical books. I checked the Where There is No Doctor book first, but in the "bleeding unrelated to pregnancy" section, all it said was to see a medical provider for help right away. So then I went to my Wilderness Medicine manual and found a great little section describing treatment of taking a months worth of contraceptive pills in one week to control bleeding. We met back up and Dr. Caldera said he had come to the same conclusion, but we had none in our clinic.

A long walk to the other side of the village took us to Janet, the MINSA nurse's house. MINSA are the government-run clinics that are in most of the villages, staffed by usually one health worker or nurse. Janet said she had some pills at her clinic, so we trekked over there to get some. In the process of all this, a man had approached us on the road, wanting us to look at his wife who supposedly had a tumor. Many times people tell us they have tumors or a "ball" somewhere in their abdomen or back that they are sure they can feel. But when we check and feel around, often we find nothing and wonder about these imaginary tumors infecting so many. This sounded similar to one of those cases so Dr. Caldera kept saying, "We have an emergency right now. We can't see her. Come to the clinic in another week when we open up again." The man was very insistent, though, and Dr. Caldera finally caved saying, "Go sit at the clinic and we will look at her next time we walk by."

That next time happened when we walked by with the contraceptive pills and saw the man with his wife sitting on the steps of our clinic. So we headed in for what we thought would be a quick exam. As the husband explained once again the problem, we realized he was actually pointing to her groin, not the abdomen. So I got some sheets and took the woman into a room to change out of her clothes and lie down on one of the beds. She was very shy so I did the exam once again and found a large abscess about the size of a softball protruding from one of the outer lips of her vagina. Ouch! It looked painful. We poked it with a catheter and drained out about half a liter of white, green smelly pus. David and Dr. Caldera could hardly stand the smell, trying to keep their heads turned away, but to me it just smelled like the hospital in Bere. We drained so much pus out of people there and so many nasty infections that you eventually just get used to the smell like it is normal.

After draining the abscess, Dr. Caldera took a while to get out some sterile instruments and cut open the skin a little more to pack it full of bandage, leaving a hole to drain out of. I gave her a shot of ceftriaxone, a pack of antibiotics, and then sent her home. We grabbed our medical bags again and hiked back over to our first patient's house to give her the contraceptive pills, explain everything, tell her to check up with a doctor in Managua when she got home, and to see the MINSA nurse if she got worse while we were gone on the river trip. Then back to the mission to continue packing for our week out in Krin Krin on the river.

Later in the evening as it was getting dark, Mrs. Brown, who cooks for our group, walked up the hill with her daughter asking for Dr. Caldera. It sounded like a very similar medical case with her complaining of bleeding over the last couple of days. As we talked more, she explained that she hadn't had her period for 3 months previous before this bleeding started. Dr. Caldera turned to me and asked, "Sarah, I am so busy right now trying to pack and prepare your tests for next week. Can you take her down and examine her on your own?" I jumped at the chance and a few minutes later after grabbing my headlamp and scrub pants, David and I were walking back down to the clinic in the dark with the girl.

First up was a pregnancy test once again. This time it was positive! Good news. Mrs. Brown would be excited about another grandkid. But now the worry about the chance of a spontaneous abortion with the bleeding. David got me a speculum and I checked again to see if she was still actively bleeding. This time she wasn't. There wasn't near as much blood as the first woman and I couldn't see any coming out of the cervix. Good news once again. So after giving her instructions to lie down and rest a lot, and a bag of prenatal vitamins, we headed back to the mission. On the way we stopped by Mrs. Brown's house to tell her the news and tell her to make sure her daughter followed the instructions on resting from work if she wanted to keep the baby.

One day, three patients, all gynecological. Fun times :)

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