Ultrasounding the Intestine

Misón de Candelilla is well-known throughout the northern regions of the Mexican states of Coahuila and Chihuahua for the excellence of our medical care. Our reputation was established early on, back in the 1980’s, by a few special cases that became famous throughout the region.

As a result of being known in the area, we have had many, many requests over the years from people from other towns in the region to please come to their villages for clinics. Along the way we have also had requests from officials of the State of Coahuila to expand our ministry, including one from a comandante of the state police. This came back at the time when we were still crossing into Mexico through Big Bend National Park. The Rangers had begun to resist our crossing the river these and the comandante came to try and help us, hoping we would not only keep coming but expand our ministry there.

Over the years we have not been able to grant most of these requests for expansion, but we do now go to a town that was suggested by the comandante.

Sara recently talked to some women in the town of Paso de San Antonio about why they like our coming there. Paso de San Antonio is one of the newer villages we go to, this one on our far western route that crosses the border at Presidio. Sara learned (once again) that they are aware of the excellence of our medical care, but they also told her they find the medications we bring are more effective than the ancient generics that are provided by the Mexican social medicine system. Sometimes I get to see the medications used by the social service doctors, and many are drugs we haven’t utilized in the U.S. for twenty-five years or more.

These ladies also mentioned specifically they like that we have ultrasound available for their medical evaluations. I fact, we commonly have patients come to the clinics to request a specific ultrasound study. Their requests are not always the right study to do from a medical standpoint, but they know we have ultrasound and it makes sense to them.

I encountered one such request in Las Norias. It came from a twenty-three year-old woman named Adelina. She came to the clinic with her two sons, ages eighteen months and two and one-half years, with her mother there to look after the boys while she had her consultation. It was good she brought grandmother, because both boys were high-spirited and active, crawling under the pews in the sanctuary where we held clinic and picking items off the table where I kept my otoscope and other diagnostic items for examining my patients. They were hard for us to keep up with, even with their grandmother there to help manage them. They were handsome and delightful boys, just curious and highly active.

Adelina was tall for a Mexican woman, about five feet seven, and she had a slim elegance to her presence. She wore a simple white blouse over a denim skirt with a leather belt. Her hair had a soft wave, and later, when I pushed it back to examine her ears I noted the fresh fragrance of shampoo and I felt her hair was still damp. She had simple silver hearts for her earrings and she wore no makeup, which is usual for the women of the area.

She opened her conversation by telling me she was there for me to do an ultrasound of her intestines. I asked her for some details of her request and she told me she had been having some lower abdominal discomfort off-and-on for a few weeks. There were no other symptoms, but she explained she’d like for me to take a look inside with the ultrasound to see what the problem might be.

The difficulty with her request was that ultrasound doesn’t show anything about the intestines. We can get a good look at the liver, gall bladder, pancreas, kidneys, aorta, uterus, and ovaries on a full abdominal and pelvic evaluation, but sonograms don’t give any useful information about the intestines. In fact the intestines sometimes get in the way and block the view of organs we want to see, especially the ovaries.

We have had ultrasound for about ten years now, and in the early part of that period of time I was usually the only one on my trips who could do the sonograms. It can take a cause a significant delay in the clinics if I get bogged down in a lengthy ultrasound exam, especially if I’m the only doctor on that trip. For this reason, my usual practice for dealing with request for needless ultrasound exams has been to explain why ultrasound won’t be helpful in the specific case and then go on with the usual medical evaluation for that patient.

But this situation is different now, because in 2013 we had an ultrasound course for the group of doctors and nurses who regularly come on our trips. Judy Hutcherson was with us on this trip, and she is one of the nurses who took the course. Doing an ultrasound on Adelina’s intestines would not slow the clinic because Judy could do the sonogram.

I thought briefly about the medical situation back in the U.S. At home if I ordered an unneeded study, insurance would deny payment and I would have to write letters or make long phone calls to try to justify why I ordered the exam. Sometimes the letters and calls have to be done even if the study is justified, and a number of insurance companies now require preauthorization for some of the more expensive examinations, such as MRI. I probably smiled briefly as I thought about the fact I didn’t have to deal with insurance companies here south of the border. So, why not?

Judy took Adelina into the back room for some privacy to ultrasound her intestines and I went on with another patient. It wasn’t long before Judy pushed through the curtain in the doorway and called out, “Dr. Layne, I have something for you to see.”

Judy smiled broadly as she put the ultrasound probe on Adelina’s lower abdomen, then turned the machine so I could see. There, in black and white on the screen was an eighteen-week fetus, waving both hands.

Adelina asked if she would have another son, but it was too early to tell the sex of the fetus on ultrasound. That would have to wait. She’s probably worried she’ll have another over-active boy.

Adelina was in a state of shock, her mother couldn’t stop smiling, and I was happy I had requested an unneeded medical study. Adelina got prenatal vitamins, treatment for a minor urinary tract infection (something that can easily get out of hand in pregnancy), and she got acetaminophen for the abdominal pain. I suspected the pain was probably just from stretching the suspensory ligaments of the uterus as it enlarged with Adelina’s pregnancy.

            I have told this story to a number of people, and a consistent question from the ladies who have heard it has been, “Didn’t she know she was pregnant?”

            The answer to this question appears to lie in the different way people view the passage of time in Mexico. There it seems one day is the same as the next, and people live in the present more than we do north of the Rio Grande. I have also noted that the people who come to our clinics don’t complain about waiting and they don’t mind if we somehow take someone out of turn.

At the time, I asked Adelina for the date of her last menstrual period, a question that is less significant these days, now that we have a way of determining the age of the fetus with ultrasound that is far more accurate than dating the pregnancy by the timing of the last period. She simply didn’t keep track. Time is perceived differently there, and this is one of the many reasons I love to go to Mexico.

I suppose I might have found out Adelina was pregnant if I had gone about her evaluation like I would have in the U.S., taking it step-by-step, waiting for the results of a pregnancy test before ordering the ultrasound. But it was much more fun to discover her pregnancy through an unnecessary ultrasound

%d bloggers like this: