25 September 2009

On Wednesday evening I went for a short run with Rebecca, the new American volunteer in Estancia. As we returned to our house, we saw that two of the children who live next door were playing outside, and we went to their house to say hello to them and their parents.

It began to rain, fiercely, as we chatted with the kids about what they had done in school. After a few loud thunder crashes it was clear that we wouldn’t be going back outside for awhile. Doris, our wonderful neighbor and the director of a congress for indigenous persons, brought us a drink made of corn meal and a dish made of a gourd similar to pumpkin.

I was halfway through my meal when the cane door to the house opened, and a young woman who I had met a handful of times rushed in. She came over and sat down next to me. Earlier that evening, she explained, her 84 year old father had come home from working in the corn fields. He had sat down, and then suddenly his face drooped and he started slurring his words. His daughter left the house quickly at that point and walked to mine.

I had seen her father in the clinic a couple of times before, and often ran into him when he was on his way home from the fields. He had high blood pressure, and I had recently asked him to increase the dose of the blood pressure medicine that he took. I also had asked him to start taking a baby aspirin a day. Given his risk factors, and the story that his daughter had described, I feared that he was having a stroke. I decided that I should go with her back to her house. Given the rain, and the fact that it was already getting dark, Rebecca and one of the kids from next door, Cesar, a twelve year old who adores Bela, decided to come too to help me find my way and provide support. We left the house and climbed up to the clinic in the rain to get some supplies, and then started the treck to the house.

Many of the roads were flooded on the way, and by the time we left the clinic with supplies, the night was pitch black. We trecked down a long hill, and then took a small path that winds along the bank of the river. Parts of the path were completely submerged, and water had risen up and covered the tops of my shoes. Further along, a steep incline had converted itself into a rushing waterfall, and it was only with the help of the patient´s daughter and Cesar that I was able to climb down. We finally arrived at the house about a half an hour later, soaking wet.

The man´s wife had lit candles, and the patient´s brother and other family members were surrounding the bed when we walked in. I said hello and confirmed what the patient´s daughter had told me about the event on the walk with the other family members, who updated me on what had happened since his daughter left. It appeared that he had not worsened very much since that time, and after talking to him briefly I sat down on the edge of the bed to examine him. It appeared to me that he had a stroke that was affecting the right side of his brain. I made a plan, talked to the family, and then explained that I would call a phyisician in the States to confirm or make changes to the plan.

After talking with the family more it was clear that they wanted the patient to go to the hospital. Rebecca called Ramiro, the director of the NGO for whom we volunteer, Campesinos para el Desarrollo Humano, and they made a plan to pick the patient up at six fifteen in the morning, as the roads were impassible at that time with the flooding. We stayed with the family for about a half an hour after that, and then began the treck home.

We had almost made it back when a large snake slid across the top of a deep puddle that had formed in the road. Cesar spotted it first, as he was up ahead to find the best way to cross. He yelled, ¨Stop, it´s poisonous,¨ and offered to kill the snake for us, which we declined. He grumbled, but eventually the snake slithered past and we went on our way, quicker than we had walked before. Cesar walked us up to the house, and as he said goodnight he told me, ¨I´ve decided what I want to be when I grow up. I want to be a doctor.¨

--Calla

18 September 2009

News in brief:
1. The Ecuadorian government chose not to renew the ten-year contract to allow the US Military to occupy the base in the city of Manta. A small ceremony was held at the site.
2. There were three scorpions in the house last night. One was very big. Bela valiantly took care of all three.

22 September 2009

An elderly woman came into the clinic last week complaining of feeling tired and having a hard time carrying the same amount of wood that she was used to carrying. She is a long-term patient of the clinic’s; she is being followed for high blood pressure, and for the past year has taken one blood pressure pill in the morning. After talking with her about her symptoms and her health in general, I took her blood pressure and examined her. Her blood pressure reading was high.

After I completed my exam, and talked with her some more, I stepped out of the room to read more about the blood pressure medicine that she was on, and to read more about hypertension in general and physical exam maneuvers that I should be sure to do. From the reading I learned that the blood pressure medicine that she takes works best when taken two times a day, instead of one. I decided that the best plan for her would be to add another dose of her medicine in the afternoon, so that she would take one blood pressure pill in the morning and one in the afternoon. Additionally, she had been taking a baby aspirin, so I gave her a month’s worth of that medicine as well. During our conversation she mentioned that she felt as though she was in a state of lack of vitamins, so I brought her a month’s worth of multivitamin to take once a day as well as the other pills.

I went back into the room to give her the medicines and explain how she would take them. After explaining, I asked her to repeat back what I had prescribed. It didn’t seem as though she understood completely the way in which I hoped she would take the medicine, so I described the plan again. Again I asked her to tell me how she would take them. We went back and forth for awhile, and finally she asked me to tell her exactly the times of day when she should take the medicine. I told her that she could take a blood pressure pill in the morning, with the vitamin, and another blood pressure pill with the aspirin in the evening. With that schedule it seemed that she and I both agreed on a medicine regimen. However, I was worried about her, and didn’t feel completely comfortable with our information exchange. Each bag of medicines contains written instructions with how to take pills. She cannot read. I had tried to draw a schedule for the medicines; I am no artist and schematics are born of a cultural context that she and I do not share. I asked her to return to the clinic in one week so that I could check her pressure again.
She arrived midway through the morning during the following week. She told me that she was still having the same symptoms that she had before. We talked some more about how her week had been, and her family, and then moved on to her medicines. She explained to me that she took her blood pressure pill in the morning, along with a vitamin, and then took the aspirin and the vitamin in the afternoon. I checked her blood pressure again. On this return visit it was still high, a little bit higher than the week before. We talked again about the way she was taking her medicine, and I repeated that I would like her to take two blood pressure pills a day, one in the morning and one in the afternoon. Again it seemed that I was not explaining myself well, for she did not seem to understand the way in which I was telling her to take her medicine.

At this point I excused myself, and went to talk to Etelvina, the health promoter who runs the clinic and is the primary care provider for an area of more than 2000 people. She has worked as a health promoter for over fifteen years, and is well loved and trusted by the community. I explained that I was having trouble explaining to the patient how I would like her to take the medicines, and asked if she would go in and talk with her.

Etelvina came out of the room ten minutes later with a smile on her face. We went into the pharmacy to talk, and she explained to me that she is definitely going to take two blood pressure pills from now on, one in the morning and one in the afternoon. “How could I have explained myself better?” I asked. “I really don’t think she understood what I was saying.”

Etelvina responded, “She understood you perfectly, but you didn’t leave enough room in the schedule for her vitamin. She wants to take the vitamin pill in the afternoon, and you didn’t leave a space for it.”

“Leave a space for it? I don’t understand!”

“She wants to take no more than two pills at a time, leaving room for an afternoon vitamin. To her, the vitamin is more important than the blood pressure pill, so she decided to drop the extra blood pressure pill you told her to take so that she could take the vitamin. I told her that we could allow her to take all of her medicines by moving the aspirin to the morning. From now on she will take one blood pressure pill with an aspirin in the morning, and the second blood pressure pill and the vitamin in the late afternoon.”

I went back into the room and talked with the patient some more about her medicine schedule. I repeated the schedule that she had discussed with Etelvina, and she told me that it was a much better way to take the medicine than I had told her before. I smiled and asked her to come back in four days to check on her symptoms and her blood pressure again. She returned in four days, and when I walked in to the room she announced that she was taking two blood pressure pills a day, one in the morning with the aspiring and one in the afternoon with the vitamin. Additionally, she pointed out, the vitamin had really improved her energy level and her health.

Thanks to Etelvina, the patient and I were able to align our priorities. However, I spent the evening after her second visit trying to replay in my mind the first conversation that we had had. I wonder whether I missed what she was telling me. When she first described how she felt, she told me that she believed her symptoms were from a lack of vitamins. I overlooked this statement, and pushed it even further back in my mind when I took her blood pressure. However, by overlooking what she had said I failed to realize that my treatment didn’t take into account her needs. She had done what she had thought was best and prioritized her medicines based on what she believed was causing her to feel the way she felt.

10 September 2009

Hello! A lot of time has passed since our last entry! We will do our best to explain what we are doing now, and also want to let all of our readers know that we miss you!

As you know, there was a coup in Honduras, and the country was put on the US State Department´s Travel Alert until October 20th. The University of Rochester does not fund students to go to countries on the list, and so we made other plans in the meantime. Thanks to another classmate, Jenny, we were able to apply for a position to volunteer in the community of Estancia in the Department of Morazan in El Salvador with the organization Doctors for Global Health (http://www.dghonline.org/). We were accepted by the organization to volunteer pending a commitment until the end of the December, and we accepted the position.

Bela traveled to the capitol city, San Salvador, for language school, and I met him in the capitol later. We traveled together to the community, and have been working and living here for a month. We are working under the direction of an amazing health promoter, Etelvina Umana, seeing patients alongside her and accompanying patients to specialist appointments and to the hospital. Additionally, we have been able to participate in home visits to members of the community who are too sick to walk to the clinic. It has been an intimidating and gratifying experience. It is a hard transition to go from being a medical student with lots of direction to being in charge of making decisions (albeit with a lot of support and guidance from Etelvina, doctors who we can call within El Salvador, and doctors in the US. My dad has been a wonderful resource and is on call for me twenty four hours day if I have questions about a patient). I feel as though my history taking and physical skills are improving rapidly. Furthermore, it is so wonderful to be living in the same community in which we work, as it is an opportunity to get to know the families of the patients that we see.

The clinic where we are working—Clinica CAIPES

---Calla

I am writing an addendum to Calla´s introduction. In an attempt to better illustrate our work here, I want to describe my experience with a single patient over the past two weeks. Jorge (not his real name) is a 22 year old resident of Naranjera, a part of Estancia that is a 50 minute walk from the clinic. He came to the clinic on August 27 with a chief complaint of a swollen finger. His finger was swollen to three times its normal size and was draining pus from its distal aspect. Calla and I saw him and decided that he needed to get to a hospital.
Jorge and I immediately departed for the hospital, while Calla called a surgeon and alerted him to our impending arrival. The trip to the hospital begins with a 40 minute walk, mostly uphill, to the main road. We then waited for the noon bus to pass. It was only thirty minutes late. We then took our first 20 minute bus ride to Cacaopera, then caught a second bus for another 20 minute ride to San Fransisco Gotera, the closest city and the location of the nearest hospital. Two and a half hours after our departure, we had arrived.
The general surgeon met us and saw us as soon as possible. He adeptly anesthetised Jorge´s finger and subsequently debrided and cleansed the wound. Jorge then received a radiograph of his finger, which looked suspicious for osteomyelitis. The surgeon sent us home with orders to wash his finger every day, take antibiotics and return in two weeks.
These instructions were not easy to follow because it meant 80 minutes of walking every day for Jorge to gets his finger washed in a somewhat sterile environment. Very much to his credit, he has done whatever has been asked of him and has come every day. Three days after our initial hospital visit, Jorge´s finger failed to improve. I was becoming more and more distressed by this lack of improvement. Fortunately, Calla´s father is an expert in infectious disease medicine and has bent over backwards to help us. I discussed Jorge´s case with him. He recommended changing the antibiotic. We followed his advice, and Jorge´s finger has continued to improve ever since.
Every day for 13 days Jorge has made the trip to the clinic. He and I wash his finger and pack his wound with sterile gauze. Tomorrow, we will make our return visit to the surgeon in Gotera. I believe he will be pleased with the progress, and we will continue our current course. While I had initially been worried that Jorge might loose part of his finger to infection, I am now confident that this will not happen.
I believe my experience with Jorge demonstrates our project here at the clinica CAIPES. Through consultation with doctors, both locally and in the United States, medical students are helping administer decent health care to patients in rural El Salvador, a place where there is no doctor. In addition, I am learning a tremendous amount regarding osteomyelitis and general wound care. I have also found a new friend in Jorge. I will be a better doctor because of my experience with Jorge.

--- Bela Denes