Without going into too much detail (always, it seems, uncomfortable for people who haven't spend prolonged periods of time around hospitals), Sam's symptoms consisted of pretty much exactly what you'd expect of a person newly moved from the US to a developing country. They were in not unusual in kind- most of our fellow Peace Corps Volunteers in Training (PCT's for short) were feeling similarly poorly to one extent or another- but when it got to the point where Sam was no longer able to hold down his oral re-hydration salts, I thought that enough was enough. The medications which were at our disposal had failed to alleviate Sam's symptoms, and without an anti-emetic in our med-kid, there really wasn't a way for us to adequately keep him hydrated on our own. A person who is loosing fluids with no way to replace them is only going to get worse, so I called the PC Medical Officers.
In my mind, this solution to our predicament was simple: pick Sam up, get him to a medical facility, dose him with Zofran (a drug to help with nausea), stick an IV in him, hang some saline, and within a few hours Sam would be feeling better. Where I come from, this is pretty much standard procedure- so much so that the nurses anticipate the orders from the doctors almost as soon as they see the patients. That is not the case in Armenia.
At first, we were urged to attempt to make use of our medical kit supplies, which we had already attempted without success. This did not surprise me- even the most sympathetic doctor back home tends to be at least a little wary of care given prior to their involvement (this serves to protect the patient from undergoing unnecessarily aggressive treatments if they merely failed to properly utilize more conservative methods earlier in their self-treatment). Even so, it was several more hours of unremitting symptoms before the doctors agreed to arrange transportation separate from the rest of the group to take Sam to their office in the capital city.
During this time, I found myself in the role of patient's family member really for the first time since leaving my job in the ER. Yes, I had helped a little when my grandfather had become very ill over the summer and passed away under the care of the kind and understanding hospice workers, but there really wasn't much patient advocacy to be done under those conditions: the hospice nurses anticipated my grandfather's needs better than any of the rest of the family- who were dealing with our own emotions and attempting to support each other- could. And so I found myself in a new position: as the wife of a person too ill to advocate for himself, and with the responsibility of representing those needs to medical staff. I admit, I prefer to be on the other end of the relationship. It is frustrating to be outside of the medical team- to have my carefully drafted reports, not disregarded precisely, but taken with a dose of skepticism. I was told to repeat watchful waiting protocols I had already enacted, delaying what, to my mind, was the clear and appropriate course of treatment.
This continued when we arrived in Yerevan. I don't know how Sam made it through the car ride- I can only imagine how miserable it was for him. As we got out of the car and got Sam inside, I thought that at last, he would be given an IV and an anti-emetic and be allowed to sleep. Instead, we waited for the rest of the morning and well into the afternoon as the PC doctors assured for themselves that Sam truly could not tolerate oral fluids. Admittedly, this process was drawn out by Sam who at this point just wanted to avoid more painful retching and refused to drink the salt water offered him by an increasingly distressed me. As the day progressed, Sam became more and more dehydrated, and began to develop resulting muscle cramps. But it wasn't until an objective drop in blood pressure was established that things were taken to the next level.
As I had hoped, Sam was given an anti-emetic injection and an IV was established. It took the better part of an hour to accomplish these two interventions. I sat outside Sam's room while it was done- feeling entirely out-of-the-loop. I am not used to being on the outside of these things, and it was extremely unsettling. Sam later would describe the process as "involving four hands at all times, half-a-roll of tape, and much heated discussion in Armenian".
When Sam's drop in blood pressure was noted, it had been decided he would stay overnight in the PC medical office while I would travel alone to our host family's home in Shahumyan. I was not happy about this decision, but there seemed little I could do about it.
After the IV was placed, I was allowed to say goodbye to a still very ill Sam, and got back into the van which had taken us to Yerevan from the resort earlier that day. I sat in the back of the van, watching the flat, rapidly darkening landscape pass by. I felt very alone, and a little afraid. I had not expected to be without my partner, heading into a new and unknown place. A small part of my mind found new empathy for the rest of the volunteers in our group who were taking on this challenge alone.
But most of my mind was occupied by a settling resentment towards the PC medical office. Why had they not believed me when I called at 6 o'clock that morning and told them Sam was unable to tolerate oral fluids? Why had it taken them until 4 o'clock in the afternoon to give him what I thought of as the clear, immediate, and appropriate treatment? Why had it taken them- two doctors working together- so long to place a simple IV? Even in his dehydrated state, Sam had great veins- why had placing the line been such a production?
It took me most of the hour ride to Shahumyan, stewing in anxiety and negativity before the answers to my questions came to me: The PCMO's behavior was only flawed when compared to my expectations based on a first world level 1A trauma center. It wasn't the PCMOs that needed to change, but rather my perspective.
Things here are not the same as they are back home- that's really the reason I wanted to join the Peace Corps in the first place. While I was correct that an anti-emetic and an IV would have been considered initial treatment back at the huge and bustling ER of Rhode Island Hospital, that does not mean that these measures are the most appropriate form of initial treatment at the tiny PC medical clinic in Yerevan. The truth is that for the PC medical office, an injection and an IV were a big deal. The doctors there were practicing the most responsible medicine they knew how by not rushing into invasive treatments. And when it was determined that such treatments really were necessary, they carefully took their time, seriously engaging with the process, to ensure that it was done properly. The fact was that my opinion on what was appropriate medicine here was flawed: although the interventions eventually taken were the ones which I had originally wanted, their significance here is not the same as it is back home.
This was the first time I had really had to confront the fact that we had traveled to somewhere very different from what I was used to. I admit that it's not easy to maintain this shifted perspective and I still find myself slipping back into judging the PCMOs performance based on standards which aren't really applicable here. But I try to retain the clarity with which I saw the situation while sitting alone in the back of the PC's van as much as possible. I suspect that I will come across many more such situations before our time in Armenia is up. I hope I am able to recognize them as easily.
In my mind, this solution to our predicament was simple: pick Sam up, get him to a medical facility, dose him with Zofran (a drug to help with nausea), stick an IV in him, hang some saline, and within a few hours Sam would be feeling better. Where I come from, this is pretty much standard procedure- so much so that the nurses anticipate the orders from the doctors almost as soon as they see the patients. That is not the case in Armenia.
At first, we were urged to attempt to make use of our medical kit supplies, which we had already attempted without success. This did not surprise me- even the most sympathetic doctor back home tends to be at least a little wary of care given prior to their involvement (this serves to protect the patient from undergoing unnecessarily aggressive treatments if they merely failed to properly utilize more conservative methods earlier in their self-treatment). Even so, it was several more hours of unremitting symptoms before the doctors agreed to arrange transportation separate from the rest of the group to take Sam to their office in the capital city.
During this time, I found myself in the role of patient's family member really for the first time since leaving my job in the ER. Yes, I had helped a little when my grandfather had become very ill over the summer and passed away under the care of the kind and understanding hospice workers, but there really wasn't much patient advocacy to be done under those conditions: the hospice nurses anticipated my grandfather's needs better than any of the rest of the family- who were dealing with our own emotions and attempting to support each other- could. And so I found myself in a new position: as the wife of a person too ill to advocate for himself, and with the responsibility of representing those needs to medical staff. I admit, I prefer to be on the other end of the relationship. It is frustrating to be outside of the medical team- to have my carefully drafted reports, not disregarded precisely, but taken with a dose of skepticism. I was told to repeat watchful waiting protocols I had already enacted, delaying what, to my mind, was the clear and appropriate course of treatment.
This continued when we arrived in Yerevan. I don't know how Sam made it through the car ride- I can only imagine how miserable it was for him. As we got out of the car and got Sam inside, I thought that at last, he would be given an IV and an anti-emetic and be allowed to sleep. Instead, we waited for the rest of the morning and well into the afternoon as the PC doctors assured for themselves that Sam truly could not tolerate oral fluids. Admittedly, this process was drawn out by Sam who at this point just wanted to avoid more painful retching and refused to drink the salt water offered him by an increasingly distressed me. As the day progressed, Sam became more and more dehydrated, and began to develop resulting muscle cramps. But it wasn't until an objective drop in blood pressure was established that things were taken to the next level.
As I had hoped, Sam was given an anti-emetic injection and an IV was established. It took the better part of an hour to accomplish these two interventions. I sat outside Sam's room while it was done- feeling entirely out-of-the-loop. I am not used to being on the outside of these things, and it was extremely unsettling. Sam later would describe the process as "involving four hands at all times, half-a-roll of tape, and much heated discussion in Armenian".
When Sam's drop in blood pressure was noted, it had been decided he would stay overnight in the PC medical office while I would travel alone to our host family's home in Shahumyan. I was not happy about this decision, but there seemed little I could do about it.
After the IV was placed, I was allowed to say goodbye to a still very ill Sam, and got back into the van which had taken us to Yerevan from the resort earlier that day. I sat in the back of the van, watching the flat, rapidly darkening landscape pass by. I felt very alone, and a little afraid. I had not expected to be without my partner, heading into a new and unknown place. A small part of my mind found new empathy for the rest of the volunteers in our group who were taking on this challenge alone.
But most of my mind was occupied by a settling resentment towards the PC medical office. Why had they not believed me when I called at 6 o'clock that morning and told them Sam was unable to tolerate oral fluids? Why had it taken them until 4 o'clock in the afternoon to give him what I thought of as the clear, immediate, and appropriate treatment? Why had it taken them- two doctors working together- so long to place a simple IV? Even in his dehydrated state, Sam had great veins- why had placing the line been such a production?
It took me most of the hour ride to Shahumyan, stewing in anxiety and negativity before the answers to my questions came to me: The PCMO's behavior was only flawed when compared to my expectations based on a first world level 1A trauma center. It wasn't the PCMOs that needed to change, but rather my perspective.
Things here are not the same as they are back home- that's really the reason I wanted to join the Peace Corps in the first place. While I was correct that an anti-emetic and an IV would have been considered initial treatment back at the huge and bustling ER of Rhode Island Hospital, that does not mean that these measures are the most appropriate form of initial treatment at the tiny PC medical clinic in Yerevan. The truth is that for the PC medical office, an injection and an IV were a big deal. The doctors there were practicing the most responsible medicine they knew how by not rushing into invasive treatments. And when it was determined that such treatments really were necessary, they carefully took their time, seriously engaging with the process, to ensure that it was done properly. The fact was that my opinion on what was appropriate medicine here was flawed: although the interventions eventually taken were the ones which I had originally wanted, their significance here is not the same as it is back home.
This was the first time I had really had to confront the fact that we had traveled to somewhere very different from what I was used to. I admit that it's not easy to maintain this shifted perspective and I still find myself slipping back into judging the PCMOs performance based on standards which aren't really applicable here. But I try to retain the clarity with which I saw the situation while sitting alone in the back of the PC's van as much as possible. I suspect that I will come across many more such situations before our time in Armenia is up. I hope I am able to recognize them as easily.
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