Algo Mal, Algo Bien, Algo que aprendí

The daily rainstorm came late at night this time, the impressive lightning bolts brightening up the sky over Cali, while rain pounded the roof and drowned out the voices. Suddenly, the ten people enjoying Shabbat dinner were thrown into darkness, the only remaining light from the flicker of the dying Shabbat candles in the center of the table. The lively conversation continued, barely missing a beat. We dined on salads, chicken, brisket, vegetables, potatoes, homemade challah bread. It felt very much like a regular Shabbat dinner at home, way too much food, and even the same recipes and complete with Kedem grape juice. This was not a typical Colombian meal. But as the darkness settled, and stomachs filled, the conversation died down briefly. In the quiet darkness, one of the other guests turned to me and said, “Díganos algo mal, algo bueno y algo que aprendió esta semana, ” “Tell us something bad, something good and something you learned this week.” What a question!

Algo mal
I spent Thursday afternoon in the emergency room. Together with the residents and interns, I saw countless patients, some having just arrived and others having already been there for quite some time. Some of them were no different than patients I would see at home, and were getting the same care- COPD exacerbation in bed 3, getting steroids, albuterol etc. Chest pain in bed 4 has a troponin of 2, getting aspirin, Plavix, heparin, an echo and a cath lab activation. Bed 5- And here we have a gentleman who is unconscious, disheveled and dirty. He has several IVs and oxygen. This guy was found on the street, no personal information, no family information. Apparently he’s in renal failure and uremic, with a BUN of 150 and continued altered mental status. Is he going to get dialyzed? Not anytime soon. Why not? Well, setting somebody up for dialysis is expensive, and they need good support, and good continuity of care, and we have no idea where he’s from, or who his family is, and if he can pay. But he’s not even going to get dialyzed just this once? Apparently not, I couldn’t really understand this, and didn’t really get a good answer.  So he’s going to die like this? Maybe so.

Just 30 minutes later, a new patient appeared in the more critical section of the Urgencias.  He too was completely unconscious, with shallow and wheezy breathing. He was one of the most emaciated people I’ve seen, think National Geographic Somalia famine pictures. I could almost see his entire pelvis sticking through his skin. He, surprisingly, had a G-tube coming out of his stomach. Clearly, he’d been in the health system recently, although goodness knows what his story was. At home, I feel like there would have been a lot of action around this patient, immediately placed on the monitor, nurses taking lots of labs, a resident grabbing a blood gas. In this case, everybody seemed calm and kind of slower. This guy already had an IV placed at triage, but that was about it. One of the residents wired up a makeshift pressure bag with a blood pressure cuff to get some normal saline into him quickly. A finger stick showed a blood glucose of 29, and they gave him some dextrose, and then hung a bag of tube feeds and hooked it up to his g-tube. There were so many labs I wanted to send, but nobody seemed to be doing anything. The resident pulled me away to see the next patient. Perhaps the orders were already in? I really don’t know.

I know there are finer points I must be missing in translation. And in this case, not knowing the system, I was more of an observer. But it was hard to watch these very sick people get interventions so slowly, or perhaps, not at all. Yet somehow, we seemed to be seeing a lot of patients, all getting some interventions for their various problems.

I imagine the funeral home industry must be well aware of this level of mortality, as they have opened their storefronts directly across from and next to every large hospital in town. Some are even open 24 hours a day. Need to plan that funeral at 2 am? At your service! I could even tell that some of the funeral home businesses that are chains, as I’ve seen similar logos near different hospitals. Each has a large sitting parlor, with several coffins on display, as well as examples of flower arrangements. How discomforting must it be to see several funeral home signs while feeling ill and being wheeled through the door of an emergency room? Still, I guess it is good business model.

Algo bueno
Discovering the Jewish community in Cali. What a lovely surprise. I should know by now that if there is a synagogue in Lusaka, Zambia then there will be one in most major Latin American cities. But what a fortunate chain of events to meet the a member of the executive board at Universidad del Valle, who asked if I needed to be connected with a church (or a synagogue) who then did connect me to a woman at the large shul in Cali, who then arranged for me to come to Shabbat services, and to dinner at the Rabbi’s house. The synagogue is large and lovely, in a grand old mansion, with a very modern and comfortable sanctuary. The rabbi and his wife hail from Israel and Mexico. On a Friday night, the women dress up, in flowing large shirts, dress pants, high heels and large jewelry, while the men dress down in jeans and polo shirts. Little kids run around and under the seats, while the men chant, and the women chat. Surprisingly, all the melodies for kabbalat Shabbat were exactly the same as at home.  After services, the entire congregation does Shalom Aleychem, kiddish and hamotzee together. 

Shabbat dinner was like Shabbat dinner anywhere. Same melodies, same food. A group of fairly young people, mostly couples, talked about music and school and TV and having babies. Surprisingly, I found I could understand their Spanish so much easier than at the hospital. Were they speaking more slowly, more clearly? Is it the rapid chatter of residents discussing patients and attendings just a little more mumbled?

Algo que aprendí
Okay, here’s a bunch of things I learned this week…
Did you know that Star Fruit, also known as carambola, can cause acute renal failure and rapid death if you already have kidney disease? Star fruit has always been a favorite of mine, a special treat, appearing in our grocery stores only a few months per year, and fairly expensive to boot. Here, like so many Colombian fruit, you can buy them everywhere, cheaply, all the time. You better believe I’ve been enjoying them. Then I heard from a resident, oh, those can cause renal failure if you eat a lot of them. What, really? How much do you have to eat? I don’t know, a lot. This was further confirmed by my landlady, who does her own peritoneal dialysis four times per day and when she was me eating a star fruit said, “Oh, I really like those, but I can’t have any because of my kidneys.”  More online research on this matter has made me feel okay that I, with healthy kidneys, will not die from eating a star fruit but that my landlady should indeed not be eating them.  But still, now I’m enjoying them a little less. Worrying about the rapid onset of hiccups and nausea with each bite.

Colombians have more fruit than they know what to do with, so they do as many things as possible, to consume as much fruit as possible, each day. I already wrote about the cholado. Other fruit delicacies include:
-Salpicón- a drink you can think of a fruit cocktail. Cut up as many fruits as possible into tiny little pieces and add a small amount of soda water. Better yet, make it in a huge 5 bucket and then ladle it out to passersby seeking refreshment.
-Chontaduro- Okay. I don’t like this one as much, I guess it’s an acquired taste. This is also a fruit. It’s about the size and shape of a large egg, with a tough yellowish-reddish outside. There are carts all over the city with people selling chontaduro. All day, they stand there and peel them, and put them in bags. People walk up to them, buy a bag, top the fruit with honey and salt, and enjoy. The best I can describe it as almost like winter squash that has been just cooked enough, fairly starchy and almost tasteless. Not really my favorite.  
-Lulo- Another awesome fruit. I swore it was a persimmon when I saw the outside, but it’s much tougher, and tastes nothing like it. The flesh itself is usually too bitter and tough for people to eat as a fresh fruit. But, peel it, cut it up, run it through a food processor, strain out the pulp and seeds, and maybe add a bit of sugar (optional) and you have a fabulous fresh juice drink.

I have yet to try the champús, a drink of fruit, maize, cinnamon and cloves. I’m a little reluctant. Does corn meal really belong in drinks? I’ll let you know how it is.

Colombians also like breakfast on the go.  Although you actually can get your Egg McMuffin or Dunkin Donuts donut, far more popular and fun are the arepa vendors on every street corner. Every morning, they set up an entire coal grill, and when it’s piping hot, they grill arepas (corn cakes) along with sausages and eggs. Sometimes they even set up little stools next to their grills, for customers to sit on while they enjoy their arepa, egg and cheese sandwich, washed down with a little hot cocoa. Or maybe you just want an arepa with butter. They can do that too.  Warm and satisfying.

Colombians are excellent recyclers. They put our reduce, reuse, recycle campaign to shame.  Maybe your city has the blue box for your house, and you put your recycling on the curb every week. Maybe your school/office has some recycling bins? Here, every office/institution/hospital has an entire rack of bins at every garbage point – paper, plastic, compostable, other. Even on the street they have extensive recycling. Sometimes I have trouble figuring out which bin to put my item into, as opposed to not having any bins at all.

Drug reps are bringing OxyContin to Cali. I was invited to a session next week to learn all about his exciting development in treating Colombians’ pain. There is hope! I asked one of the residents if there are issues with pain medication abuse here. He hadn’t heard much about it. Don’t know how much of a good thing this is.

I also discovered that there's enough medication samples in the resident room to supply several patients for several years.