A statue entitled ´Delirium Tremens´

Having a snack in a leftist coffee shop

31 October 2009

Bela and I spent last week on a quest to renew our visas. We are here in El Salvador on turist visas, and so must renew them every 90 days. El Salvador is a part of a four country agreement with Honduras, Nicaragua, and Guatemala, and so in order to receive a new visa, we needed to travel to either Mexico or Costa Rica. We chose to travel to Chiapas, Mexico, and spent three days in a city called Tapachula, on the border of Chiapas and Guatemala, drinking coffee, reading, and eating spicy enchiladas. It was a nice break, and very interesting for me to see another country.

The day after we arrived back in Estancia a meeting had been planned for us in another community called El Tablon. It is about three hours away from where we are living. In the past, there was a relationship between the NGO for whom we are volunteering and the clinic there. However, a different NGO is now in charge of the clinic in El Tablon. Ramiro, the director of our NGO, is interested in renewing the relationship, and it is possible that in the future between Bela, Neal, Juan Carlos (a recently graduated physician from Estancia who studied in Cuba), and I will be rotating one week a month each in El Tablon, living and working there.

The meeting didn´t actually happen, because the health promotor had left the site to go into town, but we did see the outside of the clinic and volunteer house. Ramiro was frustrated about the cancelation of the meeting, and decided that we should head to the nearest town for street food. When we arrived we found a spot that sold pupusas, a traditional snack, that is made of corn and cheese and fried. We had a great time sharing stories and snacks!

19 October 2009

Breakfast in the morning, and the kitchen

As I continue to struggle with the language, I try to take advantage of any free time to study Spanish. This morning I am feeling particularly ambitious and get to clinic at 5.30 a.m. Calla bought me the Rosetta Stone, which I have come to love. I spent this morning studying the preterit tense as the sun rose over Estancia.

Calla ambles up to the clinic about an hour later shouting salutations to anyone who will listen. Neal arrives shortly thereafter, and we begin the morning routine, i.e. cleaning the clinic. The place is clean by seven and breakfast follows. Today is my favorite, oatmeal with fried plantains.

The clinic opens at eight. My first patient is a girl that I already know. Two weeks ago she came in with an infected toe that required an incision and drainage. Today, she has a cold, but her toe looks fantastic. She leaves 30 minutes later with Tylenol, multivitamins and a toothbrush.

The next patient is a 6 month old girl with a fever. When it comes to patients, there is no one that I fear more than a newborn. They are so delicate and precious. The girl´s mother took her to another clinic 2 days ago. The doctor diagnosed her with pneumonia, gave her 2 days of amoxicillin, an antibiotic, and told her to come back in 2 days. Instead, the mother came to CAIPES because it was closer. This situation makes me uncomfortable. I had not seen the girl before, so I could not tell if she was better. I need help and decide to call Dr. Kasper, a pediatrician from Harvard. She makes herself available to the volunteers for consults. Given that the baby lacks any signs of serious respiratory disease, we decide that she does not need to go to the hospital. Since the clinic has run out of amoxicillin, Dr. Kasper recommends an appropriate alternative. I feel comfortable sending the baby home, knowing that the decision was made by an attending pediatrician and not by a medical student.

The following patient is 17 years old and 3 months pregnant. After babies, pregnant women are the second most terrifying patient population. This woman has headaches. I am nervous that she might be developing a serious disease of pregnancy called preeclampsia. Fortunately she has no other signs of the disease and her physical exam was normal. Nonetheless, I am not feel comfortable sending her home solely based on my opinion. I call Dr. Tresler, a family physician from Texas. He agrees that her headaches are most likely an isolated problem and not linked to a more serious disease like preeclampsia. He recommends that she get some basic lab tests to be more certain. I write her a laboratory reference and ask her to return once she had the results.

The remainder of the day passes rather uneventfully. At 2.30, Calla and I head for Jaime´s house. He is a 6 year old boy with cerebral palsy. He lives about 30 minutes from the clinic in a sugar cane shack with a dirt floor. It is sad to see him and think about what his life could be like with adequate medical care. Instead, without speech therapy he can barely speak, without physical therapy he cannot walk, with occupational therapy he cannot even hold a pencil properly. Jaime applied to enter kindergarten last year but was denied access due to his disability. The clinic is rallying around this boy. The director of our NGO is formally petitioning the school to admit him. School starts in January, so our job is to to do all we can to get him physically ready. We spend time reading, drawing and walking. Jaime is a great kid. We will be updating the blog over the next few months with his progress.

From the Annals of Learning Spanish as a Second Language

When asking to pay for our coffee the other day I said: Yo quiero pegarle, which translates into: I want to hit you.

When I first started to see patients at the clinic and wanted to ask them about their bowel movements I said: ¿ Su bebe esta cagando normal?, which translates into: Is your baby sh#@€ing normal? Thank you to Calla for correcting this problem.

The day after Calla was stung, Bela decided to wash the clothes. It was a nice treat!

18 October 2009

I am recovering from the scorpion sting. Additionally, since being stung, I have learned quite a bit about scorpion toxins. It seems as though everyone in Estancia has been stung at least once, since they are very common creatures. My neighbors have all told me stories about various stings, with advice about prevention.

Here are a few things that I have learned, both from reading in textbooks and talking to people here:

Scorpions are hunters, and sting to get foot or when they feel threatened. They are creatures that like the dark, and so will hide under sheets, between mattresses and bedframes, in shoes, and in corners. Therefore, in order to prevent being stung, one should always shake out clothing, shoes, and sheets before using. People say that if a scorpion crawls on you, the way to avoid getting stung is to stay very still, because if you move the insect will feel threatened and attack.

Once the scorpion stings, it releases a toxin which has a half-life of twelve hours. That means that after about twenty four hours, a person still has about 25% of the toxin in their system. The toxin causes all sorts of effects, but the most striking is the numbness that occurs in the whole body, including the mouth.

Here is an excerpt from Harrison´s Principles of Internal Medicine (page 2604 of edition 16) about what happens when a person gets stung:

Patients present with restlessness, blurred vision, abnormal eye movements, profuse salivation, lacrimation, rhinorrhea, slurred speech, difficulty in handling secretions, diaphoresis, nausea, and vomiting. Muscle twitching, jerking, and shaking may be mistaken for a seizure. Complications include tachycardia, arrhythmias, hypertension, hyperthermia, rhabdomyolysis, and acidosis. Symptoms progress to maximum severity in about 5 hours and subside within a day or two, although pain and paresthesia can last for weeks.

--Harrison´s.

When a person gets stung by a scorpion, first aid includes applying cold compresses to the site. This helps prevent the toxin from being absorbed. Unfortunately, in Estancia, electricity is lacking, and, therefore, refrigeration is absent. People here are not able to use cold packs, as ice does not exist. Various people mentioned the importance of staying calm and not moving once stung to prevent the toxin traveling in the blood. One family also mentioned a traditional method for preventing the negative effects. You must find and kill the scorpion, open its body, and rub the insides on the site. The family explained that the toxin would then travel back into the body of the scorpion and out of the victim.

I am feeling much better now, as I was stung almost 48 hours ago. However, it was a horrible experience, and I think that I worried Bela quite a bit. The day after being stung, my heart was beating very fast, and Bela repeatedly took my pulse at about 100 beats per minute. I was strangely sweaty and drooly all day long, and every time I ate I bit my tongue or the insides of my cheeks, assumably from my mouth being numb. The silver lining of the story is that as we often see patients who are suffering the effects of scorpion stings, I will be better able to be empathetic about their symptoms now that I have experienced them for myself.

--Calla

This is how we de-scorpion the room. Bela works, and Calla kind of helps.

17 October 2009

Last night I was stung by a scorpion.

I woke up at around midnight because I felt a sharp sting on my leg, not dissimilar to a bee sting. Shortly thereafter, the leg went numb,and the numbness crept up my body to include my arm. I woke Bela up, but by that time my whole body, including my mouth and tongue, were like lead blocks that I couldn´t move.

Bela rolled me off of the bed and onto the floor, and Rebecca and Neal helped to search the room for the offending insect. He or she was never found.

The numbness wore off about four hours later, with a horrible pins and needles sensation in my extremities, and a feeling of vomity nausea in my tummy.

Luckily, however, I am fine today, with just a headache!! Bela and I have renewed our vow to shake out shoes-sheets-pillows-clothes before using any of them.

--Calla

14 October 2009

On Monday morning, Bela and I went up to the clinic early in the morning to wash some clothes before beginning to sweep and mop the clinic. Neal and Rebecca joined us up at the clinic shortly thereafter, and so short work was made of the morning tasks.

We sat down to a breakfast of fried plantains and coffee, but just as we were starting to eat, Ramiro pulled up in the Campesinos para el Desarrollo Humano pickup truck. A young woman was carried out of the truck and into the clinic by two men and put on one of the clinic beds. We talked with Ramiro briefly, and then the four of us (Ramiro used to work as a health promotor before becoming the director of the NGO) went in to see the patient.

She was a 19 year old girl, four months pregnant, with severe abdominal pain, vomiting, and fever. Her father and husband had thought that she had dengue fever, and so had waited for a few days before coming to the clinic. However, the night before coming in she had gotten much worse, and so had called Ramiro early in the morning. We examined the patient quickly, but decided that she might have appendicitis and would be better served in the hospital. Since Neal had just arrived, we decided that he should go to the hospital to see the process of getting a patient admitted. Bela decided that I should go as well, and that he would stay and see patients in the clinic with Etelvina.

The patient´s father and husband carried her back to the truck. Neal and I hopped in and traveled the forty five minutes to the hospital with the family. Once we arrived, the hospital guard brought us a wheelchair, and I went in to the talk with the nurses and doctor while Neal helped the family wheel the patient in. The doctor took one look at the patient and decided to see her immediately. He wheeled her to an examining room in the emergency department, talked with her and family, and then examined her. After the exam, he asked her not to eat or drink anything, told her that he was afraid she would need surgery, and sent her to get laboratory testing done. After she was admitted, Neal and I traveled back to the clinic.

We arrived at the clinic a little after noon, and ate quickly, because we had planned on presenting a workshop on tuberculosis at one of the neighborhood community meetings. Each month the neighborhoods have a meeting where families discuss community projects, community development, plan events, and occasionally have guests. Etelvina´s husband is the secretary for her community, called Colon, and so we were invited to give a talk there.

We arrived, and the meeting began with some community business. About halfway through the meeting it was our turn to present. We began with introductions and the objectives our talk, and then preceded to perform a sociodrama about a family whose mother had a prolonged talk. Etelvina played herself as the health promotor who helped the patient perform sputum samples, and visited the patient and husband later to make sure the husband performed the test and the patient received her therapy. After the sociodrama we presented the symptoms of tuberculosis using cards on which had attempted to draw examples. After our talk there were a lot of questions from the audience.

The next morning Etelvina told us that the community liked our sociodrama, and we are now making materials for a new workshop, on burn prevention and basic first aid for burns that do occur.

--Calla

A Typical House in Estancia

8 de Octubre 2009

There are now two new volunteers in Estancia with us. Neal, a fourth year medical student at Tufts, will work with Etelvina and us in the clinic, and Rebecca, his girlfriend, will work on community projects.

Yesterday Etelvina, Neal, Bela and I saw patients in the clinic in the morning. It was an interesting mix of patients for me. A couple of children came in with colds, a woman came in with diarrhea, and a woman came in for a Pap smear. Additionally I saw a woman with headaches and a child with impetigo. I was tidying up the exam room to go eat lunch when Israel, the health promotor in training, came in to talk to me.

Abraham in the community health promotor of the NGO for which we are volunteering. He is in charge of health promotion in 9 communities, and travels every day on foot visiting patients who are sick or children who are malnourished. He was visiting some families in a nearby community in the morning and heard about a very sick patient, a 40 year old man who had been ill for about a year. He went to visit the house, and decided that the man needed more medical attention. He contacted the clinic, and asked Israel to have someone come and visit the man.

Fortuitously, Israel had a meeting in the county seat, Cacaopera, a town a forty minute walk and twenty minute bus ride away. After talking to Abraham and then to Ramiro, the director of the NGO, it was decided that he would take the organization´s pickup truck to drop me off at the top of the hill below which lives the patient. I quickly packed up my stethoscope, opthalmoscope, thermometer, and blood pressure cuff and hopped in the car to go to the patient´s house.

Because it has rained so much lately, parts of the road were difficult to pass in the pickup, and took us awhile to get up to the main highway that leads to Cacaopera. Once on the highway, we drove for awhile before encountering Abraham, the health promotor, who was waiting on the side of the road. We parked the pickup and Israel continued on to Cacaopera, and Abraham and I started the descent to the patient´s house. We took a windy dirt path that led us through a forest and a cornfield on the slope of a hill above a rushing river. Interestly, we passed by the house of the woman whose Pap smear I had performed in the morning, so I stopped to say a quick hello to her before continuing on.

We finally arrived at the house, a cane shack off to the side of a bigger cane shack, where the patient´s family lives. Because he had been sick for so long, the family had decided to have him live apart, so that he would not infect his small children with whatever illness he was suffering from. We stopped and said hello to his wife and daughter, and then continued on to visit the man.

He was a forty year old man who had first become sick in December of last year. He began to lose weight, and started to feel weak, so he was taken to the hospital. He left after one day before tests were performed, because he was afraid of dying in the hospital. He came back home, and then began coughing.

He coughed for months, and continued to lose weight. However, by the end of May, he began to feel better. He started to work again, sewing hammocks, and began to regain his strength. However, by the beginning of August, when the corn harvest is in full swing, he began to cough again. He lost his appetite, and lost weight. Furthermore, he was having fevers that began to happen more and more frequently. Every once in awhile, when he coughed up flem, there was blood in it.

Abraham and I talked to the man for a long time, and then I examined him. Both Abraham and I feared that he might have tuberculosis. His symptoms were troubling, and he looked thin and weak. He coughed up a thick flem frequently when talking with us. We told him of our fear.

The Ministry of Health in El Salvador has a tuberculosis control program. As many people in the area were exposed to tuberculosis during the war, and all children receive the BCG vaccine against tuberculosis, the Ministry uses sputum samples of symptomatic patients to diagnose the illness. The test is complicated—patients must perform three separate samples and deliver them to the health department clinic, which for many patients is over an hour away. Luckily, however, the test and treatment are free.

The man was surprised to hear that we thought he had a disease that could be treated. He had assumed that he was dying from an illness for which there is no cure. He decided that he would like to be tested for tuberculosis, and if positive treated. His biggest goal is to move back into his family´s house, but he did not want to harm his children.

I spent the walk back up the hill hoping that the man would be easily cured, knowing that an easy cure for a disease like tuberculosis is not a reality. Treatment is long and difficult, as patients must take many pills over the course of six to nine months. It is difficult to coordinate in a place like the United States. In a place like here, just the thought is overwhelming. However, there are people like Abraham working hard to treat and prevent illness in the community, and so there is hope that the man will one day return to live with his family.

--Calla

Dancing at the event

At the charla given by Laura, the Peace Corps Volunteer

A view of the clinic

Calla and Etelvina, the health promotor

Calla, Rebecca, the new volunteer, Vicenta, who does massage therapy, and Etelvina
Calla, Etelvina, and Israel, the new health promotor

Clinica CAIPES

29 September 2009

I have adapted to the work day routine of the Clinica CAIPES. There is a general schedule, however the quantity of patients ebbs and flows with the rain, as the rain brings more mosquito born illness, and people stay shut up in their houses, allowing illnesses to pass more easily as well.

We wake up in the morning between five thirty and six, with the sun. We have not needed to use an alarm to wake up since arriving. After waking up, each of takes a quick shower. I smear on sunscreen and insect repellent before walking up to the clinic. The walk to the clinic is short, only about five minutes long. Once there, we open the clinic and kitchen doors, and stack the chairs. We mop and sweep the entire clinic, which consists of a small entry way, two rooms in which to see general patients, a small surgery room, and a ¨women´s room¨ with a table designed for gynecologic exams. Additionally there is the pharmacy room and the bodega, where extra medicines are stored. Sweeping and mopping takes about a half an hour, after which we wipe down the exam tables and wash the dishes from the night before. After completing these morning tasks we heat water for coffee and make breakfast.

At eight we start seeing patients. Each patient gets registered in the electronic medical record. Each patient has a paper chart, where daily notes are written, but the electronic system tracks age, weight, some demographic parameters, diagnoses, medicines, and references written. We see patients alongside the health promotor. We first take a history, then take vital signs like pulse, temperature, and blood pressure, and then do a physical exam. We talk about our ideas with the patient, and then step out of the room to make a concrete plan. Making the plan usually involves a discussion, reading more in the textbooks at the clinic, or calling local or international physicians. Once a plan is made, and if we are prescribing medicine, we get the bulk bottles out of the pharmacy and pack the correct number in a baggie, and then write or draw instructions on a sheet of paper inside the bag. If we are prescribing a liquid medicine, like an antibiotic, for a child, we mix the medicine and calculate the dose before handing the patient´s parent the medicine.

We see patients all morning, and usually take a quick lunch break at around one in the afternoon. On most days there are more patients waiting to be seen in the afternoon, and we generally finish seeing the patients by four thirty. After seeing the patients, their information must be entered into the computer and their records filed away. At that point we tidy up for the day, close and lock the clinic and head back home.

Generally in the evenings we hang out with the children who live next door, or sometimes visit other people in the community. It gets dark by six thirty, so at that point we head up to the clinic again to heat up the leftovers on the gas stove from lunch for a quick dinner. We are generally in bed by eight, and will sometimes read by the light of a flashlight before going to sleep.


Special Event for People of the Third Age (Tercera Edad)

After Bela and I arrived, the clinic held an event for anyone in the community over age 65. People were invited via word of mouth and by home visits from the community health promoters.

On the day of the event, a Peace Corps volunteer from a neighboring community, three hours away, arrived and gave a charla about natural ways to relieve arthritic pain. She did a wonderful job. Her charla was interactive, and everyone in attendance participated in stretching exercises. After her charla, we moved to the lawn in the back of the clinic for music and dancing! The local band, four men who have played music together since they were young, played traditional songs. We danced and sang. The clinic chef, Niña Francisca, made sweet plantains and chocolate atol, a drink made of corn meal, for everyone. It was great fun and a great way to meet people in the community.