When I first started working with Tandana in March of last year a one-day, quadruple drug regimen for Helicobacter pylori was brought to my attention. At the time, I was familiar with the 10-14 day, triple-drug regimens, the current recommendations by the American College of Gastroenterology. The ACG recommendations are the current standard of care for H. pylori in the USA even though there is preliminary research showing it may not be superior to short-term treatments. With the constraints of a one-day mobile clinic, the one-day treatment has become the standard Tandana protocol. I was curious about cure rates between the two regimens and have been able to find only 2 or 3 publications on the topic; One is a review article and the others have very weak n-values. Additionally, no comparison studies with large statistical significance have been done, to my knowledge, during the past 5 years. After using the one-day treatment at Tandana clinics, observing which patients return (or do not return!), and reviewing patient charts, I have become increasingly convinced that the short-term treatment is equal or superior to the long-term treatment. On the next day, in Mojandita, I encountered one of these patients that encourages my belief in the superiority of the short-term regimen. This young man brought with him a bag of mixed pills and said that he had been prescribed them the previous week for “stomach pain” and stopped taking them 3 days later after he had felt better. Now the pain had returned and he was seeking further help. I could identify the omeprazole tablets (part of H. pylori treatment) and immediately sent him for confirmation of H. pylori. It came back positive as suspected and then the task was to educate him on the infection and explain the one-day treatment. It has been suggested that GI upset is more severe with the one-day treatment although there remains no scientific evidence to support this; however, a more complex schedule for pill ingestion is a part of the short-term treatment so making sure patients understand as much as possible is an important part of the treatment. One trick in making sure a patient fully understands the instructions for taking a medication is asking her or him to explain how, when, and with what the medications will be taken, without any help or hints. After he was able to do this he was on his way and I really, really hope to see if his H. pylori infection has cleared. In essence, reducing the time period that a patient must remain compliant to a regimen, should reduce the failure rate of the regimen. Naturally, it is important to put some hard data behind such anecdotal evidence, and I look forward to doing so in the future. Below is a table showing eradication rates from the 2003 paper.
Another patient in Mojandita was a 12 year-old girl that had suffered from right, temporal headaches and decreased vision since 5 years. She was able to trace these symptoms back to a specific incident in which she had been hit by a rock, thrown by another child, and the symptoms had been there ever since. The Snellen acuity exam confirmed a discrepancy between the eyes and she had never sought medical help besides NSAIDs so Tandana was able to organize an Ophthalmology appointment for her. The clinical thinking here was that if we can get glasses that correct the vision in the one eye, we can reduce the headaches since they were likely being caused from each eye having a different acuity. This is one more patient that will hopefully have a resolution to a seemingly chronic problem.
Moving on to the next day in the town of Achupallas, I came across a case that really got to me. Delivering bad news is as much an art as it is a science and this is the main learning point I took from this clinic. The patient was a G7P7, postmenopausal 55 y/o woman presenting with worsening left lower quadrant pain. The history became increasingly troublesome after she reported approximately 500 mL of vaginal bleeding the previous weekend. The most serious concern with post-menopausal bleeding is endometrial cancer. A study showed that 5-10% of such presentations are subsequently found to have endometrial carcinoma. The differential diagnosis is also quite extensive, including cervicitis, cervical cancer, atrophic vaginitis, endometrial atrophy, submucous fibroids, endometrial hyperplasia and endometrial polyps. So, this patient would have to get a further workup, but first she would have to be informed of the concerns. I found this algorithm while reviewing the topic and included it here for any colleagues that are interested:
Education is often a large part of the process of delivering bad news. Before I spoke with the patient, I sought out the opinion of Dr. Varma, who by this time in the week had become more and more of a mentor. Part of me wanted Dr. Varma to find another, more likely diagnosis, or even say something like, “….there is ‘xyz‘, of course, which would be much more probable and less scary for the patient.” I could then avoid the conversation I was worried about having, but these weren’t the words I heard. He concurred with my assessment and, for the first time in my medical career, I had to go deliver bad news to a patient by myself. I had previously been part of a team: another medical student, a nurse, resident, or attending, and I appreciated during this clinic how delivering news as part of a team is easier. I have read about the science of delivering bad news but learning from experience is by far the best way to improve the art of it. Especially since it is such an important moment of human interaction. In the hospitals the worst news, of course, was delivered by the attendings and those I admired most were compassionate, yet remained focused and a little removed. The latter does not imply any less of the former. They cared about the family and patient’s well-being but most reserved expression of it to a handshake. Otherwise, it would make it difficult to function at work. They were also respectful of the outcome possibilities, yet clear and direct communicating what they could, using definitive words so as to leave no ambiguity. Paralysis. Severe Brain Trauma. Dead. I was glad this conversation would not include such definitive outcomes as these, but as I explained why we were concerned she started crying and was visibly scared. She became more comfortable as we developed a plan but after this patient I needed to take a few minutes to get some fresh air.
Fortunately, the Ecuadorian physician responsible for Achupallas was the same with whom I had worked last March. I was able to speak with her on the phone, explain my concerns, and she was also eager to investigate and follow-up with this case after we had gone. I remained in contact with Dr. Jess and she later informed me that the hospital had attributed the bleeding to fibroids; however, I hope to see her again in March and see how she is doing.
This brings me to the last clinic of my trip. In Agualongo, I saw a patient that was known by staff of the Tandana Foundation. He was an elderly man that had been hit by a car 40 years ago. His right lower extremity had been snapped like a toothpick, as I could ascertain from the history. I can’t remember if surgeons had attempted to salvage the fibula or how extensive the surgery had been, but what was clinically important at the moment was the foot. He had undergone skin grafts to replace tissue on the right foot but the damage had been so severe that it had never completely healed. The scar tissue was quite extensive distal to the ankle and most concerning was an ulcer on the heel. There was not enough granulation tissue to completely regenerate skin on the ankle and without the protective barrier he was constantly vulnerable to infection. This risk was amplified by decreased sensation in the foot and also because he continued to work in the fields on a daily basis, most of the time with no socks and porous footwear. Tandana had helped him with wound care over the years, and despite the medical desire to do something to completely resolve the open ulcer, I came to accept that the best we could do is clean, debride, and dress the wound. We tried to teach him how to use crutches but it was not possible to remove the weight-bearing habits he had become accustomed to. So, educating a family member on cleaning and dressing the wound as well as flagging his chart for follow-up at the next visit was the best long-term planning possible in this situation.
I started out my accounts of my trip with the unexpected case of the woman that was attacked by a swarm of bees. I mentioned that there was another unexpected, emergent case and this came unexpectedly on the last day. After the clinic on Friday we went to visit a natural healer who was called ‘Abuelita’ and was a long-time friend of the foundation. She was a sweet elderly woman and it was entertaining to listen to her, especially her comments on marriage. She said I needed to be healed, so I thought, “why not?”. I have included pictures below and it basically entailed sitting on the lap of a tiny, elderly woman. She recited a traditional rhyme and poured cheap cologne down my back. The unexpected case came after the group had left. Abuelita needed a checkup and as I was putting my instruments away, a boy standing next to me dropped to the floor. It was completely out of the blue, but he was exhibiting a classic tonic-clonic seizure. His family had brought the boy to be cured by Abuelita for his seizure disorder. There was not much to do in the moment except keep him in the lateral decubitus position, monitor the ABCs, and reassure the family who had become quite scared and a little hysterical. It was the longest episode I have seen in my short medical career and as time went on I became more concerned. From the little history I was able to get, it seemed as though the boy had epilepsy and I did my best to explain the disease to them and suggested they see a specialist. This incident reminded me of a phenomenal book I read called: “The Spirit Catches You and You Fall Down”. I highly recommend the best seller which provides a good account of differences in cultural beliefs regarding medical conditions and modern medicine.
I had wonderful experiences during the previous year and have immensely enjoyed sharing some of the events and interesting cases. The cultural experiences and people I encountered, both from my country as well as Ecuador, made a great impression on me and I have always returned a little different of a person than when I left. This has proven the rule more than the exception during my life travels and many people know the feeling of returning home after an incredible experience. The feeling is well-stated by Jennifer Connelly’s character in one of my favorite movies, “…It’s hard to go back to sipping lattes and talking interest rates”.
Below are some final photos from my last days on the trip…