30 y/o woman presented to a rural clinic for prenatal follow up: G2P1 at 25
weeks. As I used the ultrasound to check dates, look for anomalies, and measure
amnionic fluid, I thought of the patient’s lack of sufficient identification in
this country to allow her access to complex OB care. Instead, a volunteer
internist was doing her ultrasound. The baby appeared healthy, but I later
noted that she had not gained weight for several visits and that she was on
prednisone. She had started having joint pains when she first got pregnant, was
diagnosed with rheumatoid arthritis, started on steroids, and the labs that she
could afford were sent off.
translators, the patient reported oral ulcers that were now healed, but no
rash. Exam confirmed persistent pain and limited range of motion in the elbows,
knees, wrists, MCP and PIP joints. Anemia down to a hemoglobin of 5 had
improved to 8.5 with iron and steroids, but the WBC was still low at 2.7. She
had negative rheumatoid factor, positive ANA and dsDNA, and negative
anti-Smith. The creatinine was normal and urine protein was 3+. She met
criteria for lupus.
explained to the patient how a lupus diagnosis put her and her baby at risk,
and the medications had risks as well. I increased the prednisone and asked her
to come back in a week, hoping I could get some advice via email as to what to
do. Thankfully, rheumatology friends overseas emailed back. We then developed a
plan including medications that we could obtain and that were considered
relatively safe during pregnancy, hoping to reduce the steroids at some point.
Three weeks after I first saw her, the patient had gained some
weight and her joints were nearly normal, though she still had proteinuria. I
outlined an ongoing plan for the staff as I left and prayed for her and the
One wonders when helping people who are outside the “system” and
its resources for whatever reason, at home or abroad: am I doing the right
thing? Am I practicing beyond my scope if no one else will see them? How
can I get better at doing this when medical progress seems to require more and
more sub-specialization? And how can I protect these people’s privacy and
security and still advocate for improved access to care?
The newspaper press is a great power, but just as an unchained torrent of water submerges whole countrysides and devastates crops, even so an uncontrolled pen serves but to destroy. If the control is from without, it proves more poisonous than want of control. It can be profitable only when exercised from within. -Gandhi (autobiography Beacon, 1993 p. 287)
Biblical Truth does not change. Humankind’s understanding of God, the universe, and
personal human experience before God does change. God is an absolute truth while
humankind’s statements about God are in the form of theological presuppositions.
The people did not follow Moses because they thought he had a good idea. The people followed Moses because they sensed that God truly sent him, that his mission was God inspired. They believd that God was behind the mission, and so they followed the one who articulated God's call.
- George Cladis, Leading the Team-Based Church (p51)