Iatrogeny

Pretty sure I made the title up, but that hasn't stopped me yet.  Iatrogenic refers to an illness or condition that can be directly attributed to actions of medical personnel.  The easiest way to picture this is a surgery gone wrong.  For instance, a woman goes for a c-section and ends up with a hysterectomy because they couldn't stop the bleeding any other way.  Certainly an extreme case, but one that most definitely happens.  I bring this up mainly because I found out first hands that you shouldn't handle a bunch of pills and then touch your face.  You basically end up snorting or eating whatever powder residue sticks to your fingers.  I definitely ingested low levels of ciprofloxacin, aspirin, and even some calcium channel blockers.  "What did you give me?  My heart stopped racing and I can't pee."  To borrow a line from one of my favorite tv shows, Community (#sixseasonsandamovie).  Granted the medicines that I inadvertently ingested were at extremely low levels and never a real concern to my well being.  But it got me thinking about the topic, well my filthy hands and a patient this morning.

I was greeted in clinic by a very nice lady who came in complaining of pain in her leg and back.  Come to find out she had been hit by a moto, or fell off a moto #LostInTranslation, I don't really know.  And this occurred a few months ago.  She could walk.  I saw her walk in.  I looked at her knee and there were no bones sticking out.  Two for two on my ortho exam.  Naturally, I asked her if she saw a doctor when it happened.  "Yes."  Perfect.  Nothing for me to do probably.  "What'd he/she do for you?"  "He saw me and wrote me a prescription but I couldn't pay for it."  That certainly isn't uncommon around these parts from what I can gather.  They'll get a "prescription" but assume the costs for obtaining the medication far exceeds their means.  Sometimes that might be true.  Other times it isn't.  Regardless I ask some questions about the workup and diagnosis, which of course she doesn't know.  And then she jumps ship and starts talking about a rash.

The rash was "all over her body" and she couldn't stop scratching it.  She had some spots on her arms and legs.  I really couldn't convince myself that they were scabies, but I was trying to talk myself into it.  But she had nothing on her trunk or the distal aspect of her extremities even though she complained of pruritus over them.  After she had laid out the rash idea, then she started jumping back and forth with "acid" and a headache... Same old same old.  If you have it, it hurts.  Or at least that's what you tell the doctors in Haiti.

I was kinda stumped.  So I asked her if the spots on her legs were what itched.  "No.  Those have been there my whole life."  Hmmm.  Not helpful.  "Do you take any medicines?"  "No."  Okay.  I go back to examining her right knee to buy myself some thinking time.  "The itching is under/inside my skin."  Well that doesn't seem natural.  Even dry skin wouldn't give that sensation.

The knee is unremarkable.  Definitely tender.  Ligaments are grossly intact.  No crepitus or palpable fractures.  But it is stiff with passive range of motion.  I try again.  "Do you have anything that helps your pain?"  "Yes."  Really...  Turns out the doctor had given her something for pain that she takes three times a day.  I'm gonna go out on a limb and say it's a morphine derivative.  And I'm also going to wager a guess that the 'rash' 'inside her skin' is due to the pain meds.  I try and give her a lesson about why it's important to tell us about all medicines she's taking and how if I would've given her medicines without knowing she could've died.  Probably an exaggeration.  But who knows?  Maybe she was rocking 2500 mg of Tylenol a day already and I tell her to take 3000 mg.  That could knock her liver out and kill her.  Then I tell her that her itch is likely due to her pain medicine.  I offer some benadryl as that's the only medicine we have for itch.  And she eventually leaves, likely unsatisfied with the outcome of her trip.  As a side note, I think she might have had a carotid body tumor.  #LearningIssue

I mention this story because iatrogeny is rampant in Haiti.  Especially if you expand iatrogeny to include side effects of medicines.  In my jaunt through the market today I saw a number of walking "Walgreen's"  where people just had blister packs of pills strapped to a small stroller.  I've looked them over to see if there was anything worth buying for our clinic.  Most of the pills are tylenol or anti-histamines.  But I saw one table with boxes upon boxes of medicines.  Antibiotics, anti-inflammatory meds, and sleeping meds.  Didn't see any more Sildenafil today unfortunately.  But I did see a lot of ampicillin, amoxicillin, and even come chloramphenicol.  This is important for multiple reasons.  First off, as physicians we have to compete against a bunch of bacteria that have been teased with small but steady amounts of amp and amox.  Even the weakest bugs are probably resistant.  Turns out a lot of people also take doxycycline on a regular basis as "prevention" against cholera.  Sweet.  Drug-resistant cholera will be awesome this coming rainy season.

But the problems with free range of antibiotics goes beyond drug resistant bugs.  Although that is a huge problem that shouldn't be dismissed.  But antibiotics have other side effects.  In only one week down here I realized that every woman, if given the opportunity, will complain of vaginal discharge.  Probably because they know I won't take the time to look and they'll just get free medicine.  And also because they probably have vaginal discharge.  Keep in mind, this is coming from someone who has never had vaginal discharge.  This is coming from someone who has never had a vagina.  But I can imagine it's pretty distressful.

So we handed out flagyl and fluconazole like it was our job.  We treated empirically because we didn't want to take the time to determine what was going on.  The few times I went more in depth with my history, mainly for my own investigation, I found that most routinely take ampicillin as well as "wash" themselves up to 3 times a day.  Talk about irritating.  So we're killing off communal flora and we continue to irritate the mucosal lining on a regular basis.  Sounds like a recipe for discharge.  And it also sounds like a perfect epidemiological survey to find out what exactly is going on.  What is causing the discharge?  The discharge that our group alone spent at least a thousand bucks on treating in our one week trip.  Maybe the community would be better served with a little education.  #NeverEasy  #PillsAreTheEasyWayOut  Unfortunately, pills are seen as a complete necessity down here.  People take pills because of this perception that you won't be healthy if you're not taking pills.  The disheartened look I get when I tell parents that their kids are healthy and don't need medicine strains my will to practice medicine.  It's tough.  You wanna do right by your patients, but you also want to try and change the culture and perception.  And neither seem probable to happen in a four-day clinic.  But, that's why we're here and that's why we want to develop a long-term presence.  That's why we're training Community Health Workers so they can go into the community and educate everyone about healthy living.  The CHW's will continue on our work long after we head back to the states.  Hopefully the rest of these 7 weeks can help to determine the important health issues relevant to the community.