[HSF] Heart Failure

[Tea Acuff]

It is good to see that in my absence from HSF, HSF is at least as testy and active as when I add my half a cent worth. It gives me the proper perspective to continue my efforts.
 
I was saying that there seems to me to be a lot of unconnected thinking in the subject of heart failure (HF). Much of the data I will use is a decade or much older, and the most the rest not new or obscure. Certainly I bring little actual new evidence worth noting. I would like to talk a little (ha!) about how we think about the problem. Here, too, I am not big on new answers, but would like to ask a few questions that may allow the smarter of us to come up with better answers. That, of course, assumes that they are not just stupid questions? You be the judge.
 
The best way to get people to think differently is to tell a brief story or happening and then ask a few questions about the same. 
 
As it happens I just returned from a trip to Nicaragua where I ended up offering a few medical clinics in some rural barrios. How that came about is an interesting story, but the point is what happened after I arrived.
 
Our medicine which we had arranged to be brought in with us took six days of trips from our site 2 hours away from customs and the capital city. After a couple of days of this frustration, my wife and college chemistry lab assistant, the latter who had set this trip up, went to a farmacia to buy a couple of hundred dollars worth of medicine mostly analgesics, antacids, antibiotics, intestinal parasitic medicines, a hundred lopressor, and a few creams. I did bring a stethoscope (which I forgot to bring the first day) and a blood pressure cuff. We also had some thermometers and alcohol.
 
The only other team member besides myself was my daughter who visited Nicaragua last year and speaks fluent Spanish but knows little medical words in Spanish. My Spanish consists mostly of no, si, aqui, dolor, and cerveza. 
 
The clinic was set up in a church(s) which is not what you might familiarly imagine, but a single 30X50ish ft single mostly stone and cement room with a door or two and a window or two neither with windows. Two single wires connected with electrical tape ran along the shallow ridge under the roof to supply all power needed when available. I insisted that a sheet or two separate the waiting room and triage station which took three complaints and BP, temp and pulse (except that the adult BP cuff meant nothing for the kids who where nearly half the patients) from the exam room. I was told that I got a lot more information from the patients behind the "privacy" curtain. I took off no shirts, and certainly no pants. I saw a few lesions and listened to my daughter talk to the patients and they talk back. After a while the questions and answers became somewhat styled. I never could tell how one could tell if one had intestinal parasites, but ended giving out
 medicine for the same to nearly half the patients. 
 
I asked one of my hosts before I started what "happens" when someone has a serious problem like all of those with which I am not prepared to treat. His answer, which I found in the process is not the whole story, is that nothing happens. It was an interesting baseline on which to start, however.
 
I saw nearly 50 patients the first day in 5 hours and 125 the next day in eight hours. Thankfully I saw no acute injuries and no one, that I recognized, as toxic. Some patients waited for hours for perhaps three doses of amoxicillin for the diagnosis of UTI, ten or twenty doses of H2 blockers for diagnosis of heart burn, and/ or 20-50 doses of analgesics eg tylenolol or ASA. Although many said "gracias" I have no idea at present whether I did any good objectively what so ever. I did ask, or rather had the "hosts" ask, for a donation of one or two Nicaraguan dollars (cordobas = about 10-20 US cents) to make this an exchange and not a gift per se. I don't know much about the results of this component either.
 
Some of you at this point may see where this is going. Most of you are wondering what in the world this has to do with HSF. I was pretty much in the latter group, until I started trying to understand what it was that I was doing. It helped that I was having a personal conversation with the late Gregory Bateson via his book, Mind and Nature. 
 
The beauty of this happening is that in the details it has almost nothing to do with what I do normally. There is for me little understanding of the diseases, little understanding of the language and culture, no team, no hospital, no tests, no heroics. Just me and a patient. Actually the patients and their support, as it were, family, culture and "supportive government", and my team and our makeshift culture.
 
It was a beautiful chance to think about what it is that I (we) do for a living. As Dr. Novick suggested about cardioplegia (rightly or wrongly), it allows one to think about the medical relationship of doctor and patient not the "cultural" details which must exist in every real world happening. In this case (as in all cases actually) what is different is most (only) noticed, while what is not noticed as different falls out. In this intellectualized situation what falls out is the patterns or connections that we never notice for all the details and formalized contexts in our customary observances and interactions. This refraction of difference is based on the biologic fact that our perceptual (sensory) organs can only note a difference, and it is us (and likely all living things) who somehow put the patterns together to connect the noted differences around us. It is as if the harmonics remain from the stream of differences.