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Great First Clinic Day!!!
What a great day!
Sheyla, the Nicaraguan interpreter, met me at the clinic and we saw five moderately complicated nephrology patients. By the end of the day Sheyla and I were coming together as a team. She will be with me for four days this week and next week a new interpreter will take over. Sheyla is a pre-school teacher. She did a great job. Thank you Sheyla.
In addition to treating the presenting problem, I gave each mother a vitamin supply for two months and some acetaminophen to have at home to use as necessary. The vitamins were courtesy of Health Partners International Canada. Thank you HPI Canada.
The Spanish teaching handouts on common problems worked great. Most of the children had a non-urinary problem as well. Constipation is just as common in Nicaragua as in Calgary. One child came in because of urine infection but had an ear infection and pneumonia. This child also had intestinal worms and as losing weight.
This boy had recurrent foreskin infections, epilepsy, and he smelled like he lived beside a campfire. Many of the children live in poorly ventilated homes with an open fire for cooking. Mom reports he has asthma but his lungs were clear today.
The sickest child was a 15 day-old baby boy. On the third day of life, the day he went home from hospital, he developed fever, fresh blood in the urine, and he cried every time he peed. The blood and fever continued for two days and then stopped but he continued to cry with voiding. Mom reported that he "really" cried with voiding and the voiding took a long time. Mom noted some orange powder in the diaper, likely uric acid, and this lasted two days. Then when he continued to cry she took him to Rivas and he was treated with IV Gentamycin for five days. He improved. His urine was clearer. He was crying less with voiding but still crying. The Rivas doctors sent him home on Clavulin but while in hospital they did not do a blood test or ultrasound. I’ve heard this story before. The standard intervention is to treat the acute issue (infection) and not look for the cause. This was the way things were done in Canada before I graduated in the ‘70’s. Mom also reported that he was tired with feeding and breathing a bit fast. I asked Mom whether she had seen him pee and if so, whether his stream was weak or strong. “Slow and weak,” she reported. He did not look septic but he was breathing a bit fast. His abdomen was softly distended. I put a urine bag on at just the right time (my luck has definitely turned) and he peed within two minutes. I dipped the urine and there was no infection.
This is a classic story of posterior urethral valves, which is a congenital blockage in the urethra, the tube that carries the urine from the bladder through the penis. Male infant, infection in the neonatal period, blood in the urine, discomfort voiding, and a weak urinary stream. We don’t see children present like this anymore in Canada. Prenatal ultrasounds pick this congenital problem up and intervention is planned after delivery. Infection is prevented from birth.
In Canada, if this child presented without any prenatal care, the child would have been referred to a Pediatric Urologist when admitted to hospital, blood work, an ultrasound, and either a catheter x-ray study or a cystoscopy would have been performed as soon as the infection was under control and the valves (blockage) would have been removed to relieve the obstruction.
I asked Dr. Flores how to arrange a good ultrasound and blood work on short notice so that I can review the results during my stay. Getting things done fast is sometimes a concern in Canada so I wasn’t optimistic. However, this might happen. The next challenge was who would pay. The state does not pay for ultrasound. This is only offered by private facilities. The cost is about $25.00. Marta, the clinic nurse, and Sheyla looked at me as if to say, “Will you pay.” I did not offer. If I offer to pay for this ultrasound, I will need to pay for all the ultrasounds. There are limits to how much I can afford. Twenty-five dollars does not seem like much, but in a country where the average wage is $100 a month, where over half the families make less than $500 a year, and where public health clinic doctors make $500 a month, this is a lot of money. The clinic is working hard to raise money to purchase an ultrasound.
So the first day went well, and I am now sitting in a covered area, enjoying the sunset and a cold Tona, the local beer. Time for a Tona.
