Well, we wasted no time in getting ourselves busy here with a flurry of various interesting activities. We woke up early Monday morning and headed out to the Universidad Catolica, one of the several universities in Santa Cruz that has a medical school, to sit in on a lecture and take a tour of the campus. The first thing we noticed walking around campus is how much it looked like a high school, not only the facilities, but the students. The education system is somewhat different out here than back home. After elementary school, most people go to “colegio,” which is like our high school, and then those that are able start “universidad” when they are about 17 or 18. Universidad is like our undergraduate school, except that it seems to be a terminal program in whatever field is chosen, rather than a preparation for graduate studies. Medical school is a universidad program which lasts 5 years and is followed by a mandatory one-year internship and a “provencia,” which is another required year in which the student is apparently sent out to a very rural Bolivian community for one year by themselves, with little or no support or resources. Actually, I believe that the current president Evo Morales has recently shortened this requirement to 3 months. At that point, doctor can begin practicing as a “generalista,” which is something that apparently used to exist in the US as well. However, any specialization – including those specialties which we consider primary care like pediatrics, internal medicine, etc – require further training in residency programs of various lengths at a hospital. So a function of the structure of the system here is that the first-year med students are 18 years old at best. We also learned that the cost of medical education here is a pittance compared with that in Brazil, which is priced comparably to the US. Because of this, 50% of all medical students here are Brazilian students that come here to study and then return to Brazil to practice. The professor, Dr. Kuchner, joked at the beginning of his lecture that we would need to understand Portugese to be able to follow his lecture, which is evidently true most days. The classroom where lecture was being held was quite small relative to those we have at Stritch, especially considering the fact that each of the classes at this particular school has about 300 people. There were only 50 or so students present, so it must be that they are divided up for their lectures. It was also very modest in terms of amenities – old fashioned chalk board, wooden desks, no central air conditioning - and very echo-ey, making it difficult to hear the lecture, especially once it got so stuffy that they decided to turn on the loud window AC unit. That in combination with the professor’s somewhat challenging accent meant that most of what I got out of the lecture was from the context and the pictures he was drawing, rather than understanding the Spanish. However, that was sufficient to get the gist of what was being discussed, which was gastric physiology. My overall impression was that the material was being covered on a much more superficial level than we are expected to know back home. I’m not sure whether this was a function of the fact that these students are essentially fresh out of high school and need to start with the basics and will return to more depth later, of if they simply don’t spend as much time on their basic sciences as we do. The structure of the sessions seems to be that a group of about 10 students give a presentation on the topic and the professor fills in the details. However, Dr. Kuchner interrupted the group with length explanations about every 2 minutes, resulting in a lecture that was almost exclusively delivered by him. Dr. Kuchner himself is an interesting guy. He did his undergraduate work in Arkansas and then came back to Bolivia for medical school in Cochabamba. He then trained in internal medicine and then ICU and apparently specializes in pulmonology. The ironic part there is that immediately after lecture, he lit up a cigarette while he was talking to us. I made a joke about it to one of the other docs – a public health specialist – and she said that he often smokes DURING his lectures. Nonetheless, he is extremely passionate about teaching and practicing and was obviously very excited to have us there. He invited all of us, as well as his entire class, out to dinner with him to get to know one another and talk about the differences between our medical education systems. I think part of that excitement was for the opportunity to “show off” the university and the other part was for the potential for developing partnerships with Loyola in the future. After talking to us at length about the Bolivian medical education system and the problems facing Bolivian medicine, he insisted on taking us on a lengthy tour which included sites as mundane as the cafeteria and the administrative offices. He also barged us into the office of the president of the university as well as the director of the school of medicine for impromptu meetings, seemingly just to present us and allow the administrators to tell us a bit more about the school. Although I’m sure these were very busy men, they were all just as gracious and excited to have us as Dr. Kuchner was.
The next item on our agenda was a trip across town to an orphanage that is run by a Catholic organization. Before we went, Nikki told us a bit about the place, including a number of very sad stories of abuse and neglect that resulted in the placement of a number of children there. The system for handling children without homes either because of abandonment or removal by the equivalent of the department of children services is not well developed here. The idea of adoption is not culturally accepted and foster care placements are extremely uncommon. Because of this, most parentless children wind up living in large group homes until they are old enough to go out on their own. This particular program though is somewhat different in that it is set up in pseudo-family units in which the children live with small groups of parents and other children. They provide schooling and social activities for the kids, as well as training in various trades (woodworking, welding, etc) for the older ones so that they can get a job when they leave. When we arrived, we went on a tour of the facilities and met some of the children. Particularly cool was a classroom of 4-year-olds that spotted us through the window and immediately came running over to greet us. We spent 15 or 20 minutes just poking in at them and playing through the open window. They had such enormous smiles and were so excited to have some temporary playmates. Afterwards we played on the playground for a bit while we waited for the children to be done with school so we could join in the daily soccer game. After the bell rang, a mob of probably 20 Bolivian children ranging in age from 5 to 15 came running out, looked at the 4 males we had on the field and said “ok, Bolivians vs gringos.” I probably don’t need to waste too much verbiage explaining how that game played out. Needless to say, I was a bit sore the next day.
After the game, we collected ourselves and headed out to meet Dr. Kuchner and the med students for dinner. It was really interesting to talk with them about their experiences and how the system is different here. It was again shocking how young these kids seemed. The one guy that I talked with most during the meal was in his 5th year, meaning he was just about to graduate, and planned on entering a neurosurgery residency after his internship and provencia. The issue of age eventually came up and he told me that he was 21. Can you believe that this guy will be operating on people’s brains here at age 22?? I think he was equally aghast to find out that I was 29 and a 1st year student.
The next morning, half of us were scheduled to go on surgery rounds at the public hospital – called Japones - while the other half were to go on “consults” there. The consults are when there are patients out at the clinic in Palacios that have been referred to a specialist in Santa Cruz and Mark and Nikki meet them there to explain their case to the physicians. I was on the group that went for rounds. We started with a meeting of the residents and attending in a classroom where 3 of the residents each presented an interesting case to the group. One of them was a man with megacolon secondary to Chagas disease who was about to die from systemic organ failure. They showed a bit of the video of his bowel resection and it looked like his colon was easily the diameter of a 3 liter soda bottle. Afterward we met briefly with one of the surgery attending, who was just as gracious and happy to have us as Dr. Kuchner had been. He explained a little bit about how the hospital works and answered questions about the cases that had been presented. Apparently at the public hospitals here, the rule is that NOTHING happens unless it is paid for in advance. There are no “appointments” so people line up out front starting at 2 or 3 am and are given a number. Then around 7am, they are checked in and scheduled to see whatever doctor they need to on a first-come first-served basis. Everyone then goes to the cashier and pays the 18 Boliviano fee and those that are eligible bring their bill to the social work office and apply for a partial reimbursement. This gets them in to see the doctor but does not cover anything else. Whatever tests or procedures the physician orders must be paid for out of pocket. This apparently applies to emergency situations as well. Mark told us that unless you are literally dying on the table, they won’t do anything for you unless you have paid. Even more bizarre is that the patients have to actually purchase any medications and supplies that are needed and bring them back to the hospital. This even applies to things as basic as sutures and bandages and if the patient is not able, or doesn’t have someone who is able, to go purchase them, the procedure doesn’t get done. For surgeries that require blood transfusion, they even have to supply their own blood! If they do not have a compatible donor to provide blood for them, they cannot have their surgery. Another problem at this particular hospital is theft of equipment. Lisa had told us in Cochabamba that her host father, who is a physician, had told her a story about a time when they had set down a pace maker in a patient room just long enough to talk to the patient and prepare to take them surgery when one of the other patients stole it and was out of there. This sounded incredibly bizarre until we heard that Japones was currently without a CT scanner because it had been stolen. How in the world do you walk off with a CT scanner?? After talking with the attending for a little while, he took us onto the floor with him for rounds. This was a very large group for rounds, probably 20-or-so white-coated people including attending, residents, med students, and nurses, plus Dr. Sterling and four of us. It was amazing how despite the huge number of people present who were directly involved in patient care, the doctors presented each patient to US, telling us all about the diagnosis, what studies had been done, and what treatments were being implemented.
The rooms were very crowded – 6 or 8 patients in each – and many of the patients were difficult to look at, such as a young man who had been severely burned, whose head bandages they insisted on removing to show us the worst of his wounds. There was also a brain tumor patient who was post-op and whose arms were restrained to the sides of the bed with ropes, presumably to protect him during seizures. There was another who had undergone some form of gall bladder surgery which required that a drain be inserted in the side. Apparently due to lack of actual surgical drains, it is pretty common for them to use rubber gloves or, as in this case, condoms on the outside of the body to catch the fluid. I was able to easily diagnose one of the patients with acromegaly just based on looking at him. After rounds, we got handed off to a neonatologist who took us on a tour of the NICU where we saw many very tiny, very sick looking babies struggling to breathe. Afterwards the neonatologist took us into a classroom and spent a long time talking with us about the struggles he faces in trying to treat very sick babies with the terrible lack of resources available to him. After rounds we went back to the house for lunch and got ourselves ready to leave for the clinic.
The road to out to Palacios is significantly less rural than I was expecting, consisting of 2 lane paved highway for most of the way and passing through about 4 different small towns on the way. However, the last 20 or 30 minutes of the drive to the clinic is on a very bumpy dirt road through jungley landscapes. We arrived at the clinic at probably 10pm or so, just in time to get our stuff put down, have a little tour of the clinic, and head to bed. Our time at the clinic was to be divided up as follows. Each day, 3 of us would do patient education with people on various topics after their appointment with the doctor and the other 4 would be distributed to the two 4th year students, each of whom was in turn assigned to one of the two physicians. The first day, I was assigned to Nikki and Dr. Sterling. The pace of our first two patients was quite manageable. I took the history with Nikki in the room and then we did the physical exam together (my first time doing a physical exam!). Then, we would leave the room and go present our findings to Dr. Sterling, who would spend a while teaching us a bit and then go through his own exam with us. Afterwards, we would write the progress note in the chart and write the prescription to be sent to the pharmacy (my first time writing a prescription!). This was great and I was learning a ton. However, we quickly realized that it was already noon and we had only seen 2 patients and had probably 20 more to get through in the afternoon. So from that point on, our pace was frantic at best. Normally there are 2 of the 17 nearby villages we serve scheduled to bring patients in each day but for some reason, we had gotten hit with a 3rd one. It was very overwhelming at times, trying to be time efficient while also dealing with the language barrier, learning the clinic flow, and learning the physical exam steps all at the same time. It was definitely a wonderful day for learning, but I was exhausted by the end of it.
I quickly realized that there would be certain problems that would repeat themselves over and over with this population, making diagnosis a bit easier for a novice such as myself. With the pediatric population, one of those things was “bichos,” which is a Spanish word for bugs that the people use to refer to intestinal worms. Often times the worms are an inch or two long and are visible in the toilet after a bowel movement, making diagnosis a cinch requiring only that you ask “have you seen bichos in the stool.” Infestation with bichos seems to cause general GI discomfort including diarrhea and anorexia and is so common that it is recommended that all children be treated every 6 month regardless of whether or not they have symptoms. It was common enough with the kids in the clinic that I pretty much started to assume that was the diagnosis until there was significant evidence otherwise. The other diagnosis that was safe to assume every kid was going to have was scabies. Scabies is a cutaneous parasitic infestation that causes little bug bites all over the skin and severe itching and is fairly common in the US as well. But beyond these rather mundane and easily treated complaints, there were also a number of very interesting conditions that presented that first day. One of Dr. Stirling’s patients was a 1 year old girl with hydrocephalus. She had had a shunt-placement surgery after birth but the shunt had become obstructed, causing further cranial swelling. The diagnosis was easily made based solely on visual inspection. The girl’s head was easily the size of a basketball and looked impossibly large sitting atop a body of normal one-year-old proportions. The girl’s only possibility for survival would be a costly surgery to “unkink” the shunt or insert a new one, which the family certainly could not afford. We decided that the case would be presented to Dr. Hou and her husband (Dr. Molich) to ask for their help in funding the procedure. As an update, I just learned today that the surgery will qualify for a program provides insurance of some kind for children under 5 and that the device itself will be donated by a charitable foundation, leaving only the medications to be paid for by Drs Hou & Molich. We also had a young girl (I think maybe 8 or 9?) that day who presented with symptoms of dengue fever, a serious viral illness transmitted through by mosquito bites which is endemic to the region. Nicki taught us a pretty cool test for the disease, which proved positive for this girl. You calculate the person’s mean arterial pressure and then inflate a sphyg cuff around the arm to that level and leave it for 5 minutes. In cases of dengue, “petichiae,” which are little red spots from burst capillaries, will develop in the antecubital fossa. The girl was symptomatic enough that Dr. Stirling recommended that she go to the hospital in Portachuelo, though we later found out that she did not follow up on that recommendation.
Another interesting case from day one was a 7-year-old girl whose mother was concerned about a lump on her chest. The girl had taken a couple of different falls during infancy and may have fractured one or more ribs. When we examined her, we found a hard (possibly bony) mass under her right chest, as well as splotchy hyperpigmentation of the skin in the same region and extending over shoulder and upper arm, but sparing the axillary fossa. There had apparently been an xray done several years earlier and the mother had been told that the mass was a result of the previous injuries and would resolve on its own, but it had not changed since then. The mother did not have the xrays with her and without seeing them, there was no way that we could speculate about what it was or what (if anything) needed to be done about it. We told the mother that we would attempt to get the xrays from the hospital and that she should bring the girl back on Saturday to discuss them. The only update I have on the case at this point is that, after several attempts, we were not able to locate the xrays (due to the horrible lack of organization in their medical records office. . . ) at the hospital and that the girl did not return on Saturday. One more rather exciting adventure came that first day when a 4-year-old boy I had seen first thing in the morning took a spill while outside playing and opened up a serious gash in the back of his head. I spotted him walking back towards the clinic crying and went over to check him out and immediately saw the wound. I grabbed Mark to try to locate some antiseptic solution to clean the wound and, after looking at it, he said that the child would need a stitch to close it up. He assigned this task to Nicki and I and I was sure that I was about to have suturing 101 on a squirming, screaming 4-year-old. Unfortunately (maybe fortunately for the boy), we were so busy at that point that I couldn’t be spared and had to go start with my next patient so Nicki took the boy into one of the rooms to start with him. I checked on them a few minutes later and found a group of probably four adults attempting unsuccessfully to hold the child down while Nicki sutured. Just as I was walking in the room, Nicki decided that this particular job was better handled by one of the physicians, and Dr. Stirling took over. He managed to get the suture in and before long the boy was back to playing like crazy with the other kids, though I suspect slightly more cautiously than before.
Immediately afterward, Alex and I got in the car with Mark to head to Portachuelo, both excited enough for our first night of call to cancel out the fatigue from what had just been a very long day for us. On the way there, we talked about the day and Mark told us a bit more about the operation of the clinic. Most surprising to me was that the clinic is funded nearly entirely by Drs. Molich and Hou. They started the clinic with money out of their own pocket and also continue to pay for its operation, supplies, staff, etc. The services and medicines provided there are free to the patients with the exception of a 5 boliviano fee that they must pay for the transportation to bring them there from their villages. I had already known that Dr. Hou was basically a saint after I heard that she had donated a kidney to one of her patients (amongst other similarly legendary altruisms I had gotten wind of over the course of MS1 year). I wondered whether the contribution of as much money as must be required to operate this clinic year round might be just as significant a contribution. When we arrived at the hospital, Mark introduced us to Dr. Vargas, the Bolivian attending that we would be shadowing for the night, and then departed. The hospital is a rather small place with nothing more than the minimal structural features. After discussing the fact that we would be taking motorcycle taxis back to the clinic with Dr. Vargas the next morning, we wasted no time in getting to work. There was an infant that had come into the ED and needed to be seen (I say ED as if there was any other department. The hospital basically consisted of maybe 10 or 12 patient rooms that quartered the patients who had been admitted on an emergent basis). Dr. Vargas discussed the baby’s symptoms with the mother and then examined her while the mother held her. After a brief listen to the lungs, he nodded his head as if internally confirming what his diagnostic hypothesis had been and told Alex and I to listen. As soon as my stethoscope touched the baby’s back, I heard exactly what Dr. Vargas must have intended me to. There was a sort of grunting sound (rhonchi?) evident every time the baby breathed. He made the diagnosis of bronchial pneumonia, explained to us a bit about why he had done so, and then turned to the mother to discuss treatment options. He was to use a bronchodilator (similar to albuterol) to treat the airway obstruction and an antibiotic to treat the infection. The mother preferred not to keep the child in the hospital for treatment and so he opted for an oral, rather than IV, antibiotic and sent them on their way. Next, we went over to the nurses’ station and reviewed the charts of the 5 or 6 patients that were currently inpatient. Dr. Vargas really seemed to enjoy teaching us and was great at doing it. He presented information nearly exactly at our level of understanding and patiently answered questions and drew pictures for us until everything was clear. Next step was to make rounds to check in on everyone one last time for the night. As we walked, I asked if there was a place to wash our hands, since we had just touched the baby with pneumonia and were headed to see someone else. He gave a kind of chuckle and explained that there was insufficient resources at this hospital for us to wash our hands or sanitize after every patient. As it turns out, the public hospitals frequently shut down for a day or so at a time when the government chooses not to pay them enough to cover their operation. We first saw a woman who had come in 17 weeks pregnant with some vaginal discharge and sensations of labor pains. We went in and talked to her and checked the cervix to make sure that she was not dilating and going into premature labor. “Evolucion favorable” he said as he signed the chart and we moved on to the next patient. The next one happened to be a drunk man who frequently comes into the hospital with various complaints so that he’ll have a place to sleep. With him we did no more than to peak in the room and make sure he was still breathing. The man had in fact departed on his own accord by the time we checked on him the next morning. Before we could make it to the next one, an alarm went off to signal us that another emergency had come in. It was another child, maybe 2 years old, accompanied by mother and what was probably grandmother and grandfather. The mother held the child close to her chest, rocking her and looking distressed. As soon as Dr. Vargas began to talk with her, the child started spewing up a milky white vomit all over the floor repeatedly. Though I was quite surprised and startled by it, Dr. Vargas simply got out of the way and continued his interview. After some more questions and a brief examination, he concluded that the child most likely had dengue fever. He assessed for the stage of the illness and then decided that it was safe to send the child home for the night with the advice to return in the morning when the lab tech would be there to conduct a blood test to confirm the diagnosis. After the patient had left, Dr. Vargas took the opportunity to teach us quite a bit about the assessment, staging, and treatment of dengue using a flowchart that hung prominently on the wall of the “ED.” Next we went in to check on one more patient for the night; a 16 year old mother of a 4 month old baby who was present for the second time that she had tried to kill herself by ingesting rat poison. It turns out that taking rat poison is not so much effective as a suicidal agent as it is in making yourself really sick and miserable for a period of a couple days. The chemical is apparently an anticoagulant similar to Coumadin that causes internal hemorrhaging, as well as an acetylcholinesterase inhibitor that thus acts as a systemic parasympathetic agonist. The treatment for this type of toxicity is atropine, which counteracts the neurological effects by blocking muscarinic acetylcholine receptors. To monitor the patient, Dr. Vargas was checking her INR (a measure of blood clotting time) and looking for symptoms of atropine intoxication, which the girl was currently showing (including mydriasis and hypertension). However, she was starting to improve and was not in any acute distress when we saw her. “Evolucion favorable.” Obviously, this girl was in serious need of psychiatric treatment and counseling, but it turns out that such a thing really does not exist in Bolivia. I think we saw a few more patients that night, but I can’t recall their stories. After we were finished, we headed back to the on-call room. We sat there for an hour or two and talked about the struggles in the Bolivian health care system, drank lots of coke, and watched some futbol. It was a very satisfying night because Dr. Vargas is such a friendly and gracious host, as well as a passionate teacher, incredibly skilled clinician, and perhaps the most easily understood Spanish speaker I had met yet. At around 1:30 am or so, we called it a night and he sent Alex and I into one of the treatment rooms to get some sleep, promising that he would wake us if another emergency came in. Unfortunately, no more came in and we got to sleep until about 7am when he woke us up for rounds. We went around bed to bed and Dr. Vargas presented each patient to the new team, each presentation fortunately ending in “evolucion favorable.” There seemed to be a few other patients there that we had not seen the previous night, but no stories remarkable enough that they stand out in my memory. To get back to the clinic, we had to take an off-road route THROUGH the river because the bridge was out, which was a fun little adventure. As soon as we walked in the door of the clinic, there was Mark standing there saying that we should come take a look at his patient. The man was maybe in his late forties and had his right leg COMPLETELY covered by these large wart-like growths. It was definitely like something you would see on the discovery channel, very bizarre to behold. Our doctors had a few ideas of what it might be but wanted to do a biopsy to be sure. As of now, I have not yet heard what it ended up being. Alex and I were assigned to be on patient-education detail that morning, which was a nice break after the long day and night we had just finished. We basically hung around and talked to patients in between their appointments and taught them a bit about various topics, specifically those Mark had told us to be prepared to discuss: diabetes mellitus/obesity, chagas disease, sexual health, and cancer. This clinic presents a great opportunity for patient education because, since all the patients from a given village come together in a bus or trufi, they are stuck there as a captive audience until ALL of the people from their village have been seen. The one notable story that stands out from that day was a 17-year-old girl that saw Nicki and Dr. Stirling with her mother for what sounded like symptoms of pregnancy. After getting her away from the mother, Nicki asked her repeatedly and in numerous different ways whether she had been sexually active and received only denial after denial. Obviously the denials became less believable when Dr. Stirling ordered a pregnancy test and it came back positive. The girl had apparently been having some symptoms that were fairly concerning so he sent her to the hospital for further evaluation. We learned later that the baby had spontaneously aborted and that the doctors were suspicious that the girl had taken something with the intentions of accomplishing just that. We finished clinic relatively early that day, in plenty of time for me take the horse out for a nice long walk through the jungle, down to the river before daily soccer game.
The next day was to be another clinic day for me, this time assigned to Dr. Fitz and Mark to work with adults instead of Nicki/Stirling/kids. Most of my patients presented with very typical internal medicine complaints: diabetes, hypertension, UTI’s, musculoskeletal pain, gastritis, GERD, headaches, etc. I don’t remember anything else terribly striking from that day. The next day was slated to be the busiest day of the week because, in addition to expecting three villages that day, Saturday is the day that an OB-GYN, an opthomologist, and a dentist come out to the clinic to see patients. I was back to seeing children with Dr. Stirling that day. Most of my patients that day had complaints typical to those I described earlier: common cold, bichos, scabies, etc. I was very proud of myself that on one little boy I was able to hear a heart murmur on the cardiac exam. It was actually quite similar to mine, although when Dr. Stirling listened to it, he said that it is very common for kids to have this type of murmur and that it was not likely to be a source of concern. I got to learn a bit of the neurological exam on a 14 year old boy complaining of headaches who had NEVER been seen by a doctor before. Another notable case of the day was one that presented to Nicki and Nakyda’s side of the room. It was a 16 year old girl who was present for evaluation of headaches or something innocuous like that but who reported as something of an afterthought that she also had some restricted range of motion in her shoulder from an injury several years earlier. She had apparently fallen from a tree and reached up to grab a branch as she fell, causing a stretch injury to her shoulder which she never got treated. Based on the description of the injury, Nicki suspected a brachial plexus lesion and referred her for a consult with a neurologist back in Santa Cruz (more on her later).
After finishing up clinic, we headed back to Santa Cruz for a day off, then rounds/consults at the hospital on Monday, and back out to the clinic on Tuesday. The first consult was a 24 year old guy who I had not seen at the clinic but who apparently was an epilieptic, presumed to have the diagnosis of neurocysticercosis, a condition that results from parasitic infestation of the brain. His epilepsy had been controlled with meds for the past several years but he had been having some breakthrough seizures so they had sent him for the consult. I immediately noticed that he had a bit of a stutter and somewhat unusual social mannerisms, but didn’t think too much of it. It was really interesting to watch the neurologist’s thought process as she took the history and examined him. She also picked up on the speech issues and embarked on a developmental history, discovering that he had suffered some kind of trauma during birth and had always had some developmental and cognitive deficits, something that those that had been seeing him at the clinic were unaware of. She ordered a CT, which we later found out did not show neurocysticercosis, indicating that the etiology of his epilepsy was likely related to some other cause, such as the perinatal trauma. The second consult was the girl with the shoulder injury from falling out of a tree. Again, it was fascinating to see the skill with which this neurologist questioned and examined her. You could clearly see the pathology of her shoulder as the doctor examined it. It was grossly disfigured relative to the other side, protruding up and backward and showing muscle wasting posteriorally. After checking for sensation, motor ability, and range of motion of the shoulder, arm, and forearm, the doctor concluded that the nerves were intact and that it was likely that the girl had dislocated the shoulder at the time of the injury and then developed more and more articular fibrosis over time, further and further restricting her movement. We took her down for an xray, which we later found out supported the fact that there had been dislocation of the shoulder, as well as a likely fracture of the humeral head which had healed in rather mangled fashion. This girl pops up in my story once more later on. . . .
The next morning was clinic again with me on patient education. It was a nice relaxing day and we finished really early (by about 2pm or so). It was very satisfying in terms of just being able to hang out and talk with the patients. It was a particularly funny group of villagers from a place called Mineros and they all just wanted to joke around with Alex and I and tease us rather than learn about how to better manage their diabetes. But nonetheless, we had some good talks with people that definitely needed our help understanding their illness. Mark later validated our efforts and emphasized the importance of the education we were doing when he got a phone call about a patient who was in the hospital because she had not understood her prescription and had taken her stronger “long acting” insulin in place of the short-acting form that she was supposed to inject with every meal. This had driven her into a dangerous hypoglycemia. It is exactly because of situations like this that having patient educators present in clinics is so critically important. I had another really therapeutic encounter during my patient education time that day as well. Andee and I went outside to talk with a woman who was there for diabetes management (amongst other problems), and she proceeded to just talk our ears off about one thing after another, mostly related to previous health crises she had been though. At first, I kept trying to redirect her and move the conversation back to issues relevant to her current health and things that we could help her to understand better. However, it quickly became clear that this was not the service that this woman needed. She simply needed an ear to listen to her story and so that is what I decided to give her. I turned off my agenda and just sat and talked with her for the better part of an hour about whatever thing popped into her head. And in a way, I felt afterwards like I had done more for her than anyone else I had talked with that day. Near the end of the day, Mark called Andee and I into the room he was in, saying “you guys gotta see this,” a type of foreshadowing that I had come to expect meant something interesting was about to happen when he said it. The man in the room had been in a severe motorcycle accident a number of years earlier in which he had suffered a complete compound fracture through both his tibia and fibula and had never received treatment. I hope that someone took a picture because this leg was more mangled than I can possible describe. A few inches above his ankle, the leg was bent inward at a full 90 degree angle from the leg above it. Amazingly, he was able to sort of walk on it with the aid of a cane and was not there complaining about the mangled leg, but rather a large gooey abscess that had developed on the side of it. Of course to correct the actual fracture at this point would have probably been out of the question even in the US with our nearly limitless skills and resources so of course that option was not even on the table for this gentleman. Rather, we gave him an antibiotic ointment and wound-care instructions and sent him on his way with a smile on his face. Incidentally, the motorcycle situation in this country is completely absurd. We frequently would see motos with very small children either riding between the parent’s legs or still strapped to the mother’s back in those blankets that they all use to carry their infants. We had all gasped at how dangerous that must be but it didn’t really hit home until I was doing data entry one night and came across an 18 month old we had seen who already had a past medical history of motorcycle accident. My very last patient of the day was one that Nicki had wanted me to talk to about a few different health issues, particularly the fact that she had just had a miscarriage a few weeks earlier. However, upon starting the conversation, it became immediately clear that she was extremely depressed over the loss of her pregnancy and scared about the implications of this for her health and her potential for future pregnancies. I could tell that her depression was quite severe, especially when I came to the suicidal ideation part of the assessment and she endorsed that she was indeed having this type of thought. I wanted to keep her there to more fully assess her potential for acting on these thoughts, but she was becoming very anxious because all of her fellow villagers were already loaded into the trufi and waiting for her. So, although I was reluctant to let her leave without having more information, I was at least able to find Nicki, who got her a prescription for an SSRI which she could start taking and we asked her to come back in a week. Nicki also pointed out afterward that even if I had not been comfortable letting her leave due to the extent of her suicidal ideation, there was really no other option, as psychiatric services and counseling are non-existent and the hospitals do not apparently take psychiatric patients either. So I at least had the feeling that we had done for her whatever we could.
The next day was to be our last day in clinic and I was scheduled to be with Nicki and Dr. Fitz. We expected it to be another crazy one like the previous Saturday had been (due to the specialists and the dentist being back again), but it really wasn’t too bad. The first patients I saw waiting for us that day were the girl with the frozen shoulder and the rest of her family, including her sister (who was the 12 year old who was so confused about her abdominal pain that I had sent home to log her symptoms the week earlier). The frozen shoulder girl had her new xrays with her, along with a BEAUTIFUL pencil drawing of a grass-hut village surrounded by palm trees that she had made for Nicki and a sweet little thank you note on it. We took her back right away to discuss her results with Dr. Sterling. She had had a consult with an orthopaedist since we last saw her at the hospital with the neurologist and he apparently prescribed a regimen of physical therapy before considering surgery. Nicki figured out how the clinic could arrange to manage this (since the girl could not afford the nearly-daily PT she needed). The clinic would pay for her first session and would send one of the coordinators to it with her to learn the exercises. The girl would then come to the clinic after school 3 days per week and the coordinator would do the exercises with her. We all knew that, given the extent of her condition, this would be a very painful process for her and would be very unlikely to get her back anywhere near full use of her arm without the addition of surgery eventually. However, the fact that she now had a plan seemed SO important to this girl. She had been living with this injury for three years, not knowing what it was or what to do about it. After we discussed the plans for PT and the like, Dr. Stirling asked her “so, how are you feeling about doing this?” The girl just burst into tears of gratitude and proceeded to just pour out her heart to us, explaining how grateful she was for our help and for the other help that we connected her with. It was probably the most moving moment of the entire trip, almost as if it had been planted there on our last day to say to us “hey guys, what you did here mattered.” I went through the rest of the day seeing patients with Dr. Fitz without too much excitement other than typical adult internal medicine complaints. I had noticed earlier that Sarah had been signing her name as “MS2” on her notes and prescriptions and decided on that last patient that it was time for me to do the same. I suppose the end of that day was a graduation of sorts for me.
