Terremotos

Terremoto is the spanish word for earthquake. There's the Nazca tectonic plate that is along the coastline of Peru and it likes to move around and cause earthquakes, much the same as the North American plate does in California. Most of the biggest quakes happen closer to the coast, especially around Lima. Once in a while a doozy will hit in the mountains though. In 1984 there was a huge one that shook Cusco and the entire Sacred Valley. Buildings fell down, roads collapses, bridges crashed, and a lot of people died.

Some buildings in Cusco are constructed in a more traditional way- with adobe blocks made from dirt and dried in the sun. Others are made in a more European style with more solid concrete. In the spirit of Gandhi and Mandela and all those who have rejected that European = better; the traditional buildings actually hold up better during earthquakes. The adobe blocks have wiggle room and can absorb the shifting earthquake better. Other buildings collapse because they have no wiggle room. Obviously the poorest people get the worst of the deal because they just live in cardboard shacks which stand no chance at all.

The buildings of Hospital Lorena (multiple buildings because they couldn't build up at the time of construction 70+ years ago) are made in the newer, worse way. Therefore today we had an "earthquake drill." Everyone got called out of their work and had to stand between the buildings. They drove an ambulance up a sidewalk to use its loudspeaker system. Several people talked about the need for earthquake readiness for quite a while. There were several patients out there too- in wheelchairs and gurneys and hospital gowns.

I couldn't help but thinking as I was standing there that an earthquake drill is not inherently weird. But it would never fly in the US to call outside over half the staff away from their work. Especially in the morning when rounds are happening. Just another way different countries are different.

As we were waiting I was talking to the peds intern. He was quite surprised to learn we don't do earthquake drills regularly. We talked about where earthquakes are common in the US, and hurricanes and tornados and what drills we usually do in school. Fire drills are apparently unknown here, where at home they are the most common.

Pediatrics in Peru

So I spent the last two weeks working on the peds floor. Below are some of the things I've observed/thought about while there. Mostly medical stuff.

They use the light from the windows to read films.

There are usually three attendings on rounds.

Nurses keep track of weight, temperature, heart rate and respiratory rate on flow sheet. They also have daily logs for each patient’s fluid plan, if they need ins and outs recorded, and what tests are pending.

Lots of oxygen is used but pulse ox (oxygen level in the blood) readings are rarely tacken or recorded. There is no continuous pulse ox monitoring even in the ICU bed. I've never even heard of an ICU patient in the US without continuous pulse ox monitoring. The ICU beds do have continuous heart rate and respiratory monitoring.

The most common treatment for UTIs is ceftriaxone. When they want better gram negative coverage they add amikacin. I only saw VCUGs scheduled for patiets with prolonged urosepsis. I did not see VCUGs scheduled for repeated UTIs, UTIs for patients under 2, or for boys with UTIs as the recommendations suggest in the US. (VCUG is a test to look for structural problems as the cause of urinary tract infections in kids.)

For pneumonia there is not a standard first line treatment. I saw amoxicillin, azihromycin, and amikacin used most often. Gentamicin and ceftriaxon were used rarely. Kids were hospitalized for 7-10 days for pneumonia treatment.

Paracetamol was used preferentially for fever. When fevers spiked repeat blood cultures were not drawn even if it was more than 48 hours since the last cultures. This was patients didn't want to pay for this or doctors assumed patients wouldn't want to pay for this.

There are no pediatric specialists for organ systems such as pulmonology, gastroenterology, or cardiology. The adult specialists consult for pediatric cases too. Consults do not write full notes with their exam findings, only their diagnosis and recommended treatment plan. This makes understanding their thinking very difficult and caused some confusion.

Interns write their exam and subjective part in the morning. Attending dictate their treatment plans during rounds. There is no assessment. The list of diagnosis includes both confirmed and possible diagnosis (usually with d/c proceeding it but always.)

Attendings make all changes to oxygen levels and also swith out oxygen tanks when needed. These are giant 4.5 feet tanks. There is no wall access. Other people seem afraid to touch the oxygen.

There are signs everywhere asking people not to charge their cell phones. The hospital does not want to pay for the electricity usage.

There is a poster from a child's point of view sayig they wish they were a t.v. so their parents would love them and pay attention to them.

The resident has an on call room and the end of the unit next to the TB isolation room. The TB isolation room has 10 feet of open air space that communicates with the rest of the unit. Not ideal for preventing transmission of an air-borne disease.

In the campos (country) closed houses with indoor ovens are a common exacerbating factor for asthma. Asthma is more common in cities though because of car pollution.

People are very upset that now there is one obese child in every classroom (about one in twenty). They say in the past there were never obese children. People blame different things but the list includes video games, t.v., pop, bad parental example, and not walking as much.

Salumedrol is the first line beta agonists used for asthma. Albuterol (used all over the place in the US) does not exist here.

Lumbar punctures are rcommended for any child with suspected meningtis infection, Glasgow coma score less than 15, or other focal neurological findings. Betamethasone (steroids) is always used with the initiation of antibiotics for bacterial meningitis. It is also always used for suspected or confirmed TB meningitis. They seem to be on the side of debate that it is always helpful. No one argued the other side that it might not be that useful.

One parent is allowed to stay with their child at all times. Other family can visit during visiting hours, which is only between 1-3 pm every afternoon. On weekends this is extended from 1-4 pm. Patient's whose families come from the country simply sit outside all morning waiting. Parents bring their own food, diapers, clothes, toys, for their kids.