A Travellerspoint blog

February 2012

Money

sunny 80 °F

Yesterday I was on call again, naturally, when a little girl came into the ER. I was already in the room taking care of a different patient, but when I heard the girl sobbing I went over to her bed to see what was going on. Pulling back the curtain, it was clear what was wrong with her: the girl's right leg, from thigh to foot, was covered in burns and blisters. Big, floppy blisters hung from the back of her calf and heel, leaking purulent fluid onto the sheet beneath her. The nurse handed me her chart. Temperature: 104.

I came closer to the crying girl and saw her mother standing by.

"Que paso?" I asked, "What happened?"

The mother explained that the girl had been burned when she bumped into and spilled a pot full of tajadas frying in lard.

"Cuando?"

"Viernes," replied Mom. Wait, really? This happened on Friday and she's just now bringing her daughter in on Tuesday? After confirming that yes, it was viernes and yes, viernes definitely does mean Friday, I was still a little shocked.

I asked the obvious question: Why did she wait so long to bring her daughter in?

The mother lowered her eyes and said quietly, "Falta de dinero." Not enough money. At this point, I chattered on for quite some time about this hospital being different, not turning away people who didn't have money. Unlike other hospitals, this one isn't here to make profits so we can help patients who don't have enough money and we'd never turn a patient away who couldn't pay. She nodded and mostly just kept looking at the floor.

I went on evaluating her daughter, glad that she had at least come in today and not tomorrow. Later, I was talking with some of the other American docs about this patient. We were all pretty horrified that it had taken 5 days for them to get to the hospital, but once other people started telling stories of what goes on in the public and private hospitals on a regular basis I could see that her story was not only not unique but was based on logic.

The largest regional center is Hospital Atlantida, the public hospital in La Ceiba. Despite being public, it is not by any means free. In fact, patients have to prove that they can pay before they are treated. I've heard stories of children showing up with visibly broken arms who are turned away because their parents have no money. Many families use all of their money just getting to the hospital, and when they arrive will sit outside the doors for days waiting for family members to bring money.

Some kids with broken bones end up with worse fates than a whole lot of pain and possible infection, though. As it turns out, amputation is a lot cheaper than complicated orthopedic surgeries involving plates and screws. Because of this a lot of young people end up with amputations after fractures simply because their families cannot afford the more complex surgery. This happened to a 19-year-old man here who was a local soccer star. Ironically, he broke his leg playing soccer and unfortunately the surgeon here at LdL was gone at the time. The other doctors sent him to Hospital Atlantida, thinking that he would get decent medical care (what an assumption). He came back with a below knee amputation and the entire hospital was shocked.

Because of stories like this, Loma de Luz often keeps critically ill patients and performs surgeries usually thought to be outside the scope of general surgery because the alternative is potentially lethal. We thought long and hard last week before finally sending a newborn in respiratory distress to the NICU there despite the fact that we barely have enough nurses, let alone an incubator, ventilator, or surfactant.

So after some thought, I can see where the mother was coming from. It's their first time at the hospital, so it would be fair for them to assume that this hospital would be like every other one and would ask for money up front before treating her very sick daughter. Of course, we did not. If money is an option here, we send patients to speak with someone about discounts and payment plans, or just covertly write "no charge" on their chart before they leave. Followup in clinic after hospital stays is often something that patients have trouble affording, given that they spend a good chunk of money on their hospitalization. This was the case for the family of a 5-week-old girl who I took care of in the hospital last week. When her mom told me that she couldn't come to the appointment I wanted to schedule for a few days out, I had to promise her we wouldn't charge in order to get her to agree. Luckily, she did come in (and the baby is doing fine). I'm so thankful that we have this option.

As for the little girl, her fever has come down significantly, though she is still pretty unhappy that she has to be in the hospital. We're doing daily betadine baths and using every non-adherent dressing we can find to wrap up her leg. Only time will tell if she'll need skin grafting or surgery to help her fully straighten her leg out, since the burn wraps nearly the whole way around it at the knee. Updates to come...

Posted by vagabundos 12:46 Archived in Honduras Comments (0)

Endings & Beginnings

sunny 88 °F

As I write this entry, we're starting to realize that our time here at Loma de Luz is coming to an end pretty soon. In just 2 weeks, Mariel will be in the air headed toward Chicago (and eventually Iowa City) and Ben and his brother will be starting their bro-cation together to the Copan ruins. We're looking back and reflecting on what we've learned, seen, and done here.

At the same time, we're looking forward. On Wednesday, we submitted our residency program rank list, which is now officially set in stone and unchangeable. The weight of the decision was sitting pretty heavily on our shoulders for the last few weeks (and months...) so it feels great to have it out of our hands! Now we, along with every other fourth year med student in the country, will find out where we'll be for the next 3-4 years on Friday, March 16. We're really excited, and luckily would love to end up at any of our top 5 choices so we don't anticipate being too disappointed come March 16.

But back to the now. I wanted to take this time and do a run-down, both for our sake to see it all in front of us, and to let you all know what we're up to. Here goes!

Stuff we've cut open/sewed up
Abscesses - III (one pyomyositis - deep, intramuscular abscess that you see in the tropics semi-frequently)
Skin tags - III
Anteater attack wounds (seriously)
Dog bites
Machete whacks - III (one of which cut into bone, another of which left quadriceps muscle bulging out)
Toenail removal
Laceration repair after toddler fell off a horse
Foreign body removal (from hand)
Skin biopsy
Sebaceous cyst removal
Little toe amputation (ok, this wasn't us who repaired it but it's still pretty interesting! The guy whacked the toe just about the whole way off with - you guessed it - a machete, then the doc just took it the rest of the way!)

Lumps and bumps
Thyroid nodules - IIIII+ (one confirmed cancer)
Pyogenic granuloma (large noncancerous gum mass)
Basketball-sized ovarian cancer

Interesting ER/hospital cases
Strongyloidosis
Neurocysticercosis
Meningitis
Ipecac flower ingestion - http://en.wikipedia.org/wiki/Carapichea_ipecacuanha
Enormous lung mass which suddenly the patient bled into and died
Distracted fracture of radius and ulna after falling off of hammock
Seizures in a 2 year old
Seizures disorder in a patient with appendicitis
Barb of barbed wire implanted in tibialis anterior muscle
Cholecystitis
Known leukemia patient casually coming in with a hematocrit (red blood cell level in the blood) of 12%, normal being near 40%

Patients we've done CPR on: 3, 2 unsuccessful

OB stuff
Deliveries - II (hoping for more!)
Self-induced abortion at 28 wks - (Apparently the patient took some kind of 'abortion pills' - possibly Cytotec sold out of the back door of a pharmacy, since it was in a box of omeprazole - at 7 months pregnant because she decided she didn't want her baby anymore. She was sent to La Ceiba where they have a NICU since these pills basically induce birth.)
Retained placenta after birth, which stayed in as the woman hiked 6 hours through the mountains to get to the hospital
Pre-eclampsia, and full-blown eclampsia with seizures

Clinic patients
Hypertension - a whole lot
Diabetes - another whole lot
Reactive airway disease in small kids - a surprising amount, often leading to hospitalization
Possible hypertrophic cardiomyopathy with outflow obstruction - rare cause of sudden death in young people
Congestive hepatopathy in a CHF patient
Bilateral hydroceles
Malaria (P. vivax) - III
Dengue fever - I
Cleft lip/palate - IIII
And a lot of colds, coughs, pneumonias, UTIs, muscle strains/sprains, renal stones

Whew! No wonder it feels like we've been so busy. We'll have to do another round-up like this in 2 weeks, but for now it's fun to see it all in one place. Cheers!

Posted by vagabundos 06:22 Archived in Honduras Comments (0)

A Day in the Life

sunny 85 °F

This past weekend, we took off Friday and went out to the beautiful island of Roatan to snorkel and relax. We also met up with Mariel's dad there and had a really great time. We will post some photos on Facebook once we get it together a little. But this blog entry isn't really about the weekend (though it was wonderful). I thought that instead I'd give you a synopsis of a day in the life of a med student down here.

It can be a little deceiving and seem like we're really taking it easy when we say that we have clinic only from about 8am to 2 or 3 in the afternoon most days (because all the patients try to catch the last bus back home, which runs at 3:00). We also take call every 4th or 5th day with one of the physicians here overseeing us, and jump in wherever else help is needed or something interesting is going on. So here it is, a day in the life...

Wednesday, 6:30 am - wake up, decide I'm too tired to go for a run and snooze for another 20 minutes. Eventually drag myself out of bed and get ready.

8:00 am - I get to the hospital and survey the waiting room. Lots of people today. Uh oh. Before heading to my clinic office, I go to the ward to check on the patients I'm responsible for. Today I just have one, a woman one day post-op after a hysterectomy, and she's doing well so I chat with her and then write a quick note with orders to advance her diet and encourage her to walk.

8:20 - Head back over to clinic, by way of the ER to make sure there's nobody there I need to see, since I'm on call. I start seeing patients and am delighted to see that my first one is a return patient who is here to get his sutures removed. I had put them in a week or so before after he cut his hand with a machete. It healed up well, so I sent him on his way. Afterward I swing by Ben's office, where he is rechecking the woman whose leg he sutured up last week after she was clawed by an anteater that was fighting with her dog (she won the fight in the end and killed it with a machete). Looks like she's a bit infected, so he keeps her on antibiotics.

9:00 - Head back to my office to find more charts have appeared. I quickly see another return patient, a young woman I admitted a week or so prior with respiratory distress who is finally doing better. Next I see a few older patients with diabetes/hypertension/pain complaints, with a few sick kids slipped in between.

About mid morning we hear about a case going on in the OR: a one year old boy is here to have a giant Wilms tumor on his kidney removed. It's happening now because an anesthesiologist is here for the week. He clearly has some other problems, though, including developmental delay and a general floppiness. Everyone keeps this baby in mind as they continue with clinic patients.

12:00 - There's a lul in clinic as I'm waiting for labs on several patients, so I sneak off to lunch quickly and feel relieved that it's not a 3:00 lunch day, which we've been having too many of lately.

1:00 - Return from lunch ready to go again, and find plenty of patients also ready. I spend a lot of time with an older man with lots of complaints, including prostate problems, out of control hypertension, prior strokes, athletes foot, and an unsightly growth on his face (a seborrheic keratosis, for my med student friends). I deal with him and a few other people and manage to sort out all of his problems and even lop off the seb K in time to get him on the 3:00 bus.

3:00 - Now that I've finished with clinic, I stop by to say hello to my hospitalized patient again and swing by the OR to see what's going on with the baby. He is out of surgery but hasn't come out of anesthesia well and isn't breathing on his own. I settle in and start rotating in to help him breathe with a manual bag venitilator, since there is no automatic ventilator here. We start to notice that his temperature is quite high and seems to be rising. At 104 degrees we start getting ice packs to put on his little body and we feel helpless as his temp rises to a max of 106 degrees despite all of the ice packs on him. I find more and more ice to put in the wet towels we have on him and the anesthesiologist administers dantrolene, presuming malignant hyperthermia, a very rare but potentially lethal complication of anesthesia. After a few hours of this, his temp finally starts to drop.

6:00 - The baby is looking more stable and his temp is still down, but his blood pressure is acting funny. He still isn't breathing on his own and we're having a hard time keeping his CO2 level down. I continue rotating in to help him breathe. His parents come in to say goodbye for the night, kissing him and talking to him in baby Spanish.

7:00 - The nurse on call comes into the recovery room to tell me that there is a patient in the ER ready to be seen and another who just arrived. I abandon all hopes of dinner anytime soon. A young woman about 7 weeks pregnant is here complaining of abdominal pain and passing blood clots. Her vital signs are stable, so after talking with her for a while I go see what the other patient has going on. He is laying on the other side of the curtain with blood covering his lower leg. He tells me the story: he was outside working with some kind of machinery cutting something, and he accidentally cut a piece of old wire which the machine threw into his leg. Sure enough, there is an old rusty-looking wire poking out from his shin. After his tetanus shot, we clean up the area as best we can and get ready to try and pull the wire out. The labs and X-ray techs don't work at night, so we can't get an X-ray to see how long this wire is and where it is, but we figure it's best to try to get it out and hopefully send him on his way. Despite the lidocaine to numb him, the man yells out and writhes in pain as we pull with all our might on the wire, which doesn't budge. We decide he should be admitted so that we can give him pain Meds and antibiotics through the night and check an X-ray in the morning. Later that night, I add a few words to my vocabulary and discover that he'd told me he was using a weed wacker and accidentally whacked some old fencing wire, which may or may not have been barbed wire. Spoiler alert: it was definitely barbed wire, and he was lucky enough to get the barb itself embedded in his muscle.

8:00 - We ultrasound the pregnant woman and send her on her way, and I get the weed wacker man admitted to the ward. I head back to the recovery room where the baby is still being cared for. The nurses are making a schedule for the night for bagging the baby and i notice my name under the 3am to 6 am shift. My body suddenly feels more tired, and more hungry. It looks like the baby is doing about the same though his temperature has come down significantly. He fails an attempt to breathe on his own and we adjust our bagging to make up for the deficit just created by this trial. As he becomes more stable again, we go over the schedule, the 9:00 bagger arrives, and I decide to go get some dinner and sleep before my shift is up, or until someone else comes in to the ER.

9:00 - As I round the corner of the hallway out of the hospital, my radio cries out, "Code blue, code blue, recovery! We need help!" I spin on my heels and run back to the recovery room where the tube has fallen out of the baby's mouth. The anesthesiologist is quickly trying to re-intubate the baby and I help hold his tiny mouth open. The tube goes in and we relax, only to watch the tube slip out yet again. After a few more moments battling, the tube is back in place and we give him more breaths through it after sticking it down with a whole lot of tape. Once he is stable, I grab my bag and walk the half mile home in the dark to find Ben has made me a great dinner. We go to bed early, anticipating our shifts later that night. I put my radio close to my head and pray it won't wake me until 3:00.

12:30am - Knock, knock, knock! We both start awake and look around thoroughly confused. Ben opens our door and we hear the anesthesiologist's voice, "Hey, you guys don't need to come in for your shifts anymore." Oh good, I think, he's breathing now. "The little boy died." he finishes. "Oh, no," mutters Ben. The anesthesiologist turns and walks away to his room, obviously upset. Ben closes the door and comes back to bed. We sit quietly in the dark. "What the hell happened?" I ask eventually. Ben shakes his head. We lay back down but I can't turn my brain off.

1:00 - My radio goes off: "HR3HOT, Dra. Mariel me escucha?" the nurse calls. I jump and answer, "Si, adelante" expecting a patient in the ER. The nurse starts to tell me about the baby and also says we don't need to come in, and when I ask "que pasó?" Renee takes the radio and tells the story. The baby just had more and more trouble breathing and his blood pressure wouldn't stay up. The anesthesiologist thought it was probably a metabolic disturbance, a profound acidosis resulting from the malignant hyperthermia, that was to blame, but we can't do the required tests to say for sure here. They said the mother wailed for hours. I get up and read for awhile after this news before I can fall asleep.

4:55 am - "HR3HOT, Dra. Mariel me escucha?" the radio calls out. I shuffle to the next room and answer. There's a patient in the ER, a man with excruciating flank pain radiating to his testicles. Kidney stones, I think, as I get my scrubs on and walk over in the pre-dawn dark. Sure enough, his story fits well with this disease so I admit him and start pain Meds and fluids. We'll have to wait for morning to get an abdominal X-ray to confirm the diagnosis.

6:00 - I shuffle back over to our apartment, now disoriented in the light of the day. I fit in another hour or so of sleep before I can no longer ignore the alarm clock.

At 8:30, I'm back in the hospital ward talking with my three patients before a full day of clinic.

Posted by vagabundos 19:03 Archived in Honduras Comments (0)

Hospital Loma de Luz and Blackfeet Community Hospital

A comparative study

rain 75 °F

This afternoon coming home from clinic I was thinking about our past three weeks here. We've definitely seen a lot of strange things, plenty of bread and butter family med things, a few sad things, and a lot of happy things. We have had the opportunity to do lots of things, like repair a machete wound (which Ben did today), suture up kids after dog bites and falls from horses, remove nodules, first assist on major surgery, sprint from bed to help do CPR in the middle of the night, manage our own clinic patients, and learn some ultrasound.

But today what I was thinking was about the many similarities between life in and out of the hospital here and in Browning, Montana, where many of you (whoever you are) may know that we did a 4-week elective last fall. Since Indian reservations in the US have a lot of the problems that most Americans associate with so-called third world countries, like poverty, joblessness, lack of decent food, violence, and stray dogs, comparing the two reveals a lot of similarities. We encountered a lot of these problems firsthand in Montana, and definitely see a lot of the problems we've seen in places like Mali and Mexico there, do I began to compare many aspects of Loma de Luz to the Blackfeet Community Hospital and noticed some interesting stuff. So without further ado, here is the ULTIMATE BATTLE: LdL vs. BCH!

Category 1: Medical Facilities
Loma de Luz is definitely much smaller than BCH with a lot less clinic space. The inpatient wards here consist of 4 smallish rooms with curtains between the 5 or 6 patient beds. BCH on the other hand had large, private rooms. I think there were also more than 2 working IV pumps at BCH... As far as clinic facilities, LdL and BCH both have most of the things we need to run our clinics. Clinic rooms here are private and have nice exam tables, oto and ophthalmoscopes, and halfway computerized charting. Prescriptions are computerized and there is a formal pharmacy, which is really nice. Our clinic rooms even have air conditioning, so life is good. Clinic is a bit disorganized since few of the patients have appointments, but the same fan be said for BCH. One downside here is the lack of sufficient clinic rooms which generally means that one of us has to work out of the ER, which is a big room with 3 beds and emergency equipment inside. (BCH definitely wins the ER contest since that was the busiest part of the hospital and one of the busier ERs in the state of Montana!) On the plus side for LdL: the middle of the hospital is an open-air, covered pavilion that is very pleasant to walk through. The ORs also have windows, which is really amusing to me. Still, since the OR also has functional anesthesia equipment and disposable sterile gowns, the win for facilities has to go to Blackfeet Community Hospital.

Category 2: medical problems
When you're a med student, you always want to see the stuff you learned about the first two years of med school. Diabetes is interesting in a cerebral sort of way, but really can't hold a candle to Fournier's gangrene (caution while googling that one) or a machete wound with open fibular fracture. We saw exciting and interesting things at BCH and learned well the impact of diabetes and alcohol on native peoples. Esophageal variceal bleeds and fulminant hepatitis are a lot scarier in real life. We also got to deliver some babies, comfort and collect evidence from victims of rape, assist in the OR and open a bunch of abscesses. Here at LdL we've seen some of the same brand of stuff, but also had a much broader clinic experience, with some adult chronic medicine, some routine peds visits, and a lot of followup visits on our own patients, which is incredibly valuable and usually hard to get at our stage of training. We've gotten to be a part of a lot of hospital care and been the primary decison makers there at times, and also have gotten a lot of experience in emergencies and code blue (CPR) situations. Because of that, Loma de Luz wins this category.

Category 3: living arrangements
Let's see, our government apartment in Browning had an extremely bad odor, one twin bed, and two chairs for seating in the entire place. It was dirty when we moved in and we had to sleep on an air mattress for four weeks. Here we have our own small apartment in a bigger staff housing building with a nice common space besides our non-smelly apartment. We have a hot shower, a clean and cool bed, good fans, and a full kitchen. Clearly Loma de Luz is winning here. Food availability is also an issue in both places, though, to varying degrees. In Browning, there is a grocery store, but it's small and overpriced, and anything fresh is a little sketchy. We generally made a weekly pilgrimage to Cut Bank, a town about 45 minutes from Browning, where we had a much bigger selection of groceries. The town doesn't have much besides that and a Dollar General, though, so it's pretty limited. Here, we're actually located between two small villages so there's nothing nearby except a little restaurant at the hospital's front gate that serves fried chicken for lunch (or hot dogs if you come too late). Everyone makes a weekly trek to La Ceiba, about 45 mins-1 hour away over very bumpy dirt roads. The grocery stores are pretty decent, but fresh vegetables are often a little limp looking and better bought at a farmers market. Still, the nice thing about Ceiba is that you can find most anything you might need: replacement flip flops, floaty toys for the sea, bootleg American movies, etc. The clear winner of this category is.... Loma de Luz!

Category 4: surroundings
This one will be tough. Glacier National Park, just 12 miles west of our aforementioned apartment in Browning, is full of breathtaking mountain vistas, beautiful clear, blue lakes, and amazing wildlife. We camped and hiked and biked in stunning places that always looked like calendar photos to me. We saw moose, mountain goats, pikas, and a lot of wild dogs (oh wait, that was in town). Despite all this, Glacier is up against a tough rival: the Caribbean. We walk through the jungle to get from our apartment to the hospital every morning and have a great ocean view as we do so. Lush green mountains jam-packed with trees and beautiful, fragrant flowers are everywhere. Just today we saw 2 toucans and 3 howler monkeys - from our house! The dirt road we do our morning runs on is like a movie set to me, and getting to swim in the warm sea on our own basically private beach after a five minute walk is pretty hard to beat. Loma de Luz for the win!

Definitely more than a few similarities! The truth is we love both places, despite the unique challenges of both. But still, pretty fun game. :) Next week we should have some killer photos to share since we're going to Roatan this weekend to hang out with Mariel's dad for a few days and snorkle. Hasta luego!

Posted by vagabundos 19:21 Archived in Honduras Comments (0)

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