Culturally Appropriate

The way different cultures deal with things, the way they think is profoundly different.

In our pre-field training we were taught. "The extent to which you succeed in cross-cultural work is the extent to which you are willing to make yourself uncomfortable."  

As an extension to that, they taught us some warning signs to helps identify when we were treading on the edge; they said:

"Do you feel angry, bothered, irritable?  Then think: are things around you, abnormal, wrong and bad?"

"If you are feeling that way, remember, most of the time what you are experiencing is normal, right and different - it's normal and right for the people around you."

Today my first clinic patient was a second opinion.  a 27 year old young man presented with a large upper abdominal mass, jaundice and lots of lymph nodes.  He also had bunch of previous testing which showed: a) widely metastatic cancer  b) that it was a cancer of unknown primary.  He was accompanied by an older brother and his uncle.  They wanted to know:

1. Where it came from. (I don't know and can't know with available testing).

2. Whether it was cancer. (yes)

4. Was I sure. (yes)

5. Was I 100% sure? (yes)

6. What was the prognosis.

Here I bumped up against our training.

It is not culturally appropriate for me to discuss the prognosis with the patient.  Instead, I'm to dismiss the patient with a thinly veiled excuse and lay it out for the family.  I like to then pretend that they will gently break it to him in their own way, but what really happens is that they tell him he's going to be OK and that the treatment I gave him (valium and painkillers) is going to make him better, but needs time to work.  This thinly veiled charade will continue until the day he dies.

That makes me angry.  It bothers me.  I feel irritable.  It's not normal.  It's wrong.  It's BAD.

ding ding ding.  Yep.  I recognize that.

Here this is normal.  Here this is the way it's done.  Here this is right.

The patient I send out of the room is from this culture.  He has been raised here and knows all the rules,  He understands what it means when I send him out of the room (and if I had any doubt about it, it was erased when I saw his face as he left the room, alone).  And he wants to be told he'll be OK. This is how it works here.

Char in the Padma

We visited a large sandbank in the middle of the Padma (Ganges) with some friends.  For eight of us it cost about $1.40 each way.

I thought about the fact that I was standing on sand eroded from  the Himalayas.   It was a beautiful time and a sweet place to sit, visit and catch up (we hadn't visited them in a year!). We spent just over a day with them - far too short!  But this was a highlight.

The children ran off to play as a group.  In the distance I heard a few scraps of conversation:

"No, I'm Scottish!"

"The pirates are spies"

"Look out! get down so they don't see you!"

"Think we'll ever be rescued?"

*

Our childhood is shaped, in part, by the landscapes around us.  

This is a sandbank ('char') in the Padma (Ganges).

*To get the sense of scale, click the top photo.  All four children are visible.

ঠান্ডা পর্তেচে - Thanda portece

Photo Credit: Conor O'brien

A few months ago I posted a 'realfeel' temperature of 125degF.

It will hit 47degF tonight (with no central heat!).

Several times today I said, "জি, অনেক ঠান্ডা পর্তেচে ; আজ্সকলে আমিও বিচান্নার থেকে উতে চাই নি !"

roughly, "Me too - it's so cold I didn't want to get out of bed this morning!"
People chuckle at my attempts to be friendly in Bangla.  

Animals

An important culture medium in the lab is sheep's blood agar.

There are animals everywhere. Cows in the paddies, sheep in the yard, pigeons in the ceiling, geckos on the wall, goats on the roof etc.

We even get some in the hospital: these sheep have occasionally been seen inside the hospital.  Dogs generally know better (they usually get kicked if they come inside), but my favorite is the cats.  Cats are seen underfoot here and there on the wards, but yesterday I was seeing patients in clinic when a cat came in and curled up on the exam table, barely even glancing at me, "What?  This is my bed, I always sleep here..."

Bhumikompo 2

We felt the 6.8 earthquake (it was a decent plate-rattler and woke us from sleep) but we're fine.   The epicenter was about 500miles away.  It's still winter here, so pray for those at the epicenter whose homes may be damaged.

And sometimes you do know...but not what you're doing.

Follow up to the previous post.  A much longer narrative, sometimes a bit technical.  Happy ending, though.

What could've happened.

And sometimes you do know which ones you help, however surprising it may be.
The night after I posted the last post the following happened.

I was called at 1:05 AM by the junior doctor about a patient 'gasping' which, here, usually means their heart has stopped already; I was pulling my pants over my pajamas before I was off the phone and sprinted at full speed to the hospital (about 100yds).

I arrived to CPR and, fortunately, a heart monitor already hooked up behind them showing ventricular fibrillation ('Vfib').   He had arrested shortly after arrival (he only managed to say, "I've been having chest pain since 8 PM" before his heart stopped) and only 5 minutes had elapsed - all with good quality CPR.  I grabbed the defibrillator paddles, pausing only to put a little jelly on them, and said, "CLEAR" and .... Ka-Thump.  We really do it just like TV.  We promptly had a rhythm back and, shortly thereafter, a pulse.

Next an ECG confirmed a large heart attack (a 'widow-maker' sized one).  Exam revealed total flaccid paralysis and almost no brainstem function, but, despite the appearance of brain death, you have to wait: it can take a while for everything to 'reboot' after a full cardiac arrest.  We confirmed details with the family and began streptokinase to try and reopen the artery.*

Over the next 20" or so the patient began to move a little (hooray!) so I returned to the bedside to repeat the neurologic exam.  He was moving his right arm, but not his left.  (that's not good..) He had blink reflexes on the right but not the left (oh no...not again).  It appeared he was having a stroke - and you'll recall from my last post that the biggest risk of streptokinase is a massive hemorrhagic stroke.  I shut off the infusion of streptokinase - he'd received 30% of the dose.

Over the next hour or so, as various bits of his system began to come 'back on-line' (he could sit up and try to pull out his nasogastric tube) it became clear he had profound left-sided paralysis.  I was afraid we had two in a row.

But...it was just a bit too quick.

I asked the staff if anyone had noticed any weakness before he collapsed.  Most said no, but one had noticed that he hadn't seen him use his left hand.  We asked the family if they'd noticed anything; sure enough, he'd had trouble walking and complained of weakness in the left leg before arriving.**

Now I was upset.  Not because our medication had harmed another patient, but because I had no CT scanner to confirm for me whether his stroke was a blood clot (which could helped by streptokinase) or a hemorrhage (in which case streptokinase would kill him).  I couldn't risk the latter.***
We stabilized him and I eventually went home at 4 AM.

I arrived on the ward the next morning to check on him and from the door saw his left arm in the air.  He still had some weakness, but his paralysis was almost 90% better.  His ECG was also improved.  We had, with 30% of a dose of thrombolytics, accidentally fixed both a heart attack and a stroke we didn't even know about.



*For any of you medical types who know that recent CPR is a relative contraindication for thrombolytics, the risk benefit ratio is generally considered positive if CPR is less than 10 minutes. Given the size of the MI, we felt the risk worthwhile.  Angioplasty is not available here.

**An illustration of Benson's rule #4.  The family didn't know the symptoms of a stroke and didn't think it important.  
    Now you medical types know, simultaneous stroke and heart attack make you think aortic dissection.  He had equal blood pressures in both arms and no murmur.  That was the best I could do given our limitations.

*** primum non nocere means, 'First, do no harm'.  

Finally...yes.  We're seeing a LOT of heart attacks.  Currently about one big one each night.  It is winter, but it also represents a move away from infectious disease toward 'non-communicable' disease in the developing world.  With developing world governments (in some places, anyway) having to focus less on simply feeding folk, they are able, with the help of the WHO, to create massive programs to treat things like TB.  Don't imagine TB isn't an issue any more - it's still #1, but with Bangladesh's economic improvement, we're having more and more 'first-world problems' like heart attacks and diabetes.

Risk/Reward ratios in Medicine

Warning: medical post with an unhappy ending.  Also, statistics.  (eeek!)

Streptokinase.  Credit: Wikipedia

  Recently we had a patient who had a heart attack.  Actually, that's quite common - we often have several in a week.  Absent good reasons not to, we typically treat with streptokinase.  Streptokinase (SK) is an enzyme made by some bacteria (see if you can guess which!) that has an impressive ability to dissolve blood clots.  This makes it useful to dissolve blockages, say, in one of the heart's own arteries (aha! a heart attack).  Miracle, no?
   Well, it's not specific to the coronary arteries, so it can cause blood clots to dissolve everywhere in the body.  There's a constant balance in your body between the clot-dissolving system (which keeps your blood vessels from solidifying) and your clotting system (which keeps you from bleeding from every pore).  SK massively shifts the balance in favor of clot-dissolving.  You can imagine some of the other risks, but the most serious risk is intracranial hemorrhage (a huge, bleeding stroke, often lethal, always horrifically destructive).

The generic risk of dying from a heart attack is roughly 12%.  The risk of intracranial hemorrhage from SK is approximately 0.5%.  Giving SK reduces risk of death by about 4%.  To put that in easier terms:
For every 200 patients I give SK to...

175 patients will receive SK who would've lived anyway. though I like to think they'll have less heart damage.
8 will live who would have died.
16 will die anyway, despite SK, and...
1 will die who might otherwise have lived.

Well. The patient I began with was the one.

Sometimes you know who it is you saved.  In August, and again in September, I had two patients in cardiogenic shock whom I nursed through the night until the SK had its effect and the heart started working again.  Other times you just don't know and you have to trust the statistics that say you've done some invisible good.  But you always know which ones your treatment harmed.

Minority Report

A swiss friend invited the kids over to make special breads for St. Niklaus eve (Dec  5th)

    Last night I took care of an older gentleman (with a heart attack).  His wife related an interesting story.

   Many, many years ago, they were married.  Then he left and moved to India for 20 years.  There, he met and also married another woman.  A few years back he returned  again to Bangladesh and moved back in with his first wife.  She looked me straight in the eye and, clearly imagining what I might be thinking, said. "What should I do? This is Bangladesh."  Her tone was even and completely unaffected.  It wasn't even resigned - just matter-of-fact.

   The subtext was, "What? He's my husband.  He is my standing in society.  No, equality is not a thing to be expected.  Without him I have nothing.  So, I accept that he had/has another wife."

   I knew polygamy existed in BD; this is merely my first up-close exposure to it.  I came home and discussed it with our house helper (who is christian - a small minority here).  She said, "Yeah.  Muslims have too many wives.  1, 2, 3. sometimes more!  Christians and Hindus don't."  That makes it sound like it's everybody - it's not, but it's around.
   What struck me about her comment was the exact same matter-of-fact tone.  Living in a society where you are a small minority (or a powerless group) you can have an identity or set of rules that are completely different from that of society at large, yet you must accept the larger society's rules as fact.

  This is probably how minorities have felt throughout time, from first-century Corinth to modern-day Bangladesh.