Wednesday (Feb 13) was all about transportation. When Erin and I finally got back to Santa Cruz from La Paz, we packed and piled into Oswaldo's taxi (Oswaldo is a taxi driver who is often hired to drive us to the airport, clinic, etc.). It was hard enough to get off the plane into Santa Cruz's scorching sun after being in La Paz's moderate/cool climate, but it added insult to injury when I approached Oswaldo's taxi and felt heat radiating from the dark seats. No air conditioning, of course, and obviously no seat belts. Who needs seat belts on a 3 hour drive when drivers in Bolivia have a death wish?
But anyway, we finally made it to clinic in enough time to finish up seeing the remaining patients. Most patients needed medication refills for their diabetes or high blood pressure. I saw a little 18-month old girl with a strange-looking rash on her behind (technical terms do not apply here). It looked a lot like Cutaneous Larva Migrans, which I can now say I've seen before and have some basis for comparison, but my attendings weren't convinced. I treated her for a fungal infection according to my superiors' opinions, but deep down I'm pretty sure she'll be back needing treatment for Cutaneous larva migrans. Thankfully, the patients in clinic have a pretty good return rate (almost too good, and I'll get to that), so we can generally find them if they need to return to clinic. Most of the clinic groups, organized by one group leader (who doesn't get paid for their work but reaps benefits like seeing the doctor whenever they want), have a scheduled clinic day once every 2 weeks. If a Wednesday patient needs medication refills, follow-up on labs or tests, etc., we can see them again in two Wednesdays. This is really nice since most of the volunteer doctors working in the clinic are here for at least 3 weeks, so there is often the potential for some continuity of care.
The rest of Wednesday was fairly uneventful. Matt saw a patient in clinic who was deemed pretty ill on the basis of his blood pressure, recent syncopal events, and heart rate. When a patient looks more sick than we're comfortable dealing with in the clinic, we talk to our clinic coordinator (usually Rachel, who was out of commission with Dengue fever) and set up appointments for our patients in Santa Cruz. This particular patient was sent to Santa Cruz for free to have an echocardiogram and figure out if he was passing out because of Chagas cardiomyopathy causing heartblock. We found out on Thursday that he got to the Santa Cruz cardiologist and subsequently decided that he'd rather see the doctors in Palacios (at our clinic) and went home. Nevermind that we specifically sent him away since we don't even have a working EKG machine, he really wanted to see the American doctors. I've noticed that a lot of patients make comments about preferring to see the American doctors (even if it's a med student!) over a Bolivian-trained attending. I haven't figured out the basis for this phenomenon, but part of it might be the 'art' of physician-patient interactions that we're taught in med school. Every med student takes a 'warm-fuzzy medicine' class (ours is called Patient-Centered Medicine) teaching you how to talk to patients, convey empathy, learn physical diagnosis skills, etc. The part about learning how to talk to people- which unfortunately some really do need to learn in a classroom because they didn't quite pick it up in their first 25 years of life- may be appealling to patients who aren't used to this. We introduce themselves, ask how they're doing, explain what we're doing when we're looking in their throat, examining their abdomen, pounding on their back. When we figure out their diagnosis and treatment, we explain it to them. I suppose most of us take these things for granted when we're at the doctor, but it truly is quite different when you see some Bolivian-trained doctors. Most of them get through patient encounters in about 5 or 10 minutes because they ask a few questions, decide on a diagnosis, and treat them. Cut to the chase (and jump to conclusions?) and don't dig too deep. That's the general impression of some of the doctors I've seen, but of course like anything there are incredible exceptions (like Dr. Douglas Villareal, the Endocrinologist who runs the clinic with Dr. Hou and Dr. Molitch). I worked with a Bolivian gynecologist who had a good bedside manner, but who unfortuantely ordered pelvic ultrasounds on almost every patient without doing a bimanual exam (this is an absolutely atrocious behavior- foregoing an easy physical exam step that can catch an ovarian mass and simply jumping to an expensive test!)
Clinic meals/sleep
Once we're done seeing patients we clean up our exam rooms and head over to the clinic's attached house to rest and start getting our dinner ready. Mid-day lunches are cooked by Mumi, and dinners are always a joint effort amongst all of the people staying atthe clinic. Mumi is a great cook, but once again I was jaded by my strong ability to find nasty things in my food (somehow I am always the one at restaurants who finds hair in my food or a bug nest in my broccoli). She cooked a chicken and vegetable soup last Thursday, and as I was eating my potato, enjoying the cold coke (which is heaven-sent on those hot clinic days), and chatting about the patients I had seen that day, I came upon a frightening scene. There on my spoon, amongst the carrots, broth, and potato, was a brain. I'm not kidding, not exaggerating, not trying to make an okay story great. This was a brain, with gyri, sulci, and a million little neurons (which probably aren't very functional given it's a chicken, and lord knows those are stupid animals). Unable to hide my disgust, but unwilling to offend Mumi, I quietly packed up the brain into a napkin and stored it next to my plate. I couldn't shake the feeling that gray and white matter were spilling into my broth, and when Mumi left the room I dumped the soup and opted to go hungry for the day. Having gotten over the memory of that frightful experience, I'll go back to talking about dinner at the clinic. We go grocery shopping on the Tuesday before clinic, planning ahead for the week's meals, and then every night we chop veggies, drink some cerveza, and cook some food (always with the lights off, of course, since the night we opted for electricity we also came away with 100 bug bites each). Dinner is usually over by 8ish, and everyone starts getting ready for bed around 9 or 10(latest) since the days are really draining and exhausting. It's also nice to get to bed early so you can fall asleep in ignorant bliss, only imagining but not seeing the little black bed bugs climbing through your sheets. Last Friday was an exceptionally fun night in clinic. It was Ginda's birthday, and we wanted to do something special to celebrate her dedication to the clinic. She works tirelessly organizing the patient groups from each different community, and it's a pretty thankless job. We bought her a vase, flowers, and Sumi&Amanda made her a cake, and Friday night after a dinner of bean stew courtesy of San Francisco Matt, we turned up the merengue music and had a dance party. It was quite a sight, with Mike being peeled from his seat to invite Ginda to dance, and then Matt teaching everyone how to moonwalk to Michael Jackson's Billie Jean. The 80's dance party commenced, and it was a good break from thinking about diabetes and bugs.
The sleeping arrangements are pretty humorous. There's once bedroom with 2 twin beds, a bedroom with 2 bunk beds (4 beds), a kitchen table that doubles as a bed, and 2 exam tables in clinic. We scoot together the 2 twin beds and squeeze three of us on there. The first week I volunteered to sleep on the crack between the beds (not comfortable, trust me), but we wisened up and converted to sleeping lengthwise so the crack between the beds hits the hips. Still quite bizarre and uncomfortable, but now the discomfort is evenly distributed. Our men usually take one for the team and sleep on the clinic exam tables. It's pretty gross when you think about it- we have all sorts of patients with scabies, fungal infections, and worms getting examined on those beds during the day and then the volunteers have to lay in those sheets for 8 hours. We make do, and thankfully no scabies (sarnas) or worms (bichos) yet. Let's all knock on wood and not think about it again. The shower does have hot water, which is fantastic, but sometimes in that heat you'd almost rather get doused with a freezing cold spray. I have to remind myself constantly not to swallow the water. I know the consequences for swallowing third-world water, and I'd rather have that remain a distant memory. The water is actually heated with an apparatus that resembles a torture device, and I'm under the impression that if I were to touch one of the wires above the showerhead I would undergo a lightning-fast, painful electric shock. I'll admire the wires from a distance and thank my lucky stars for hot water and no electrocution to date.
Thursday's clinic day was one of those 'fly-by-the-seat-of-your-pants' days, because an entire community failed to show up to clinic in the morning. We had a fair number of patients show up unannounced, and planned for the rest of the day to head to a distant town that never receives medical care. The village (whose name escapes me at the moment) is just far enough away that they have a very hard time getting to the Palacios clinic. I always like going to those villages, because on top of getting a better picture of their lives by seeing their homes and roads (and lack thereof), I feel that I'm doing more of a service to people who really can't otherwise get medical care. Travel clinic days are not without their challenges. First, we have to try and predict what we'll need and pack the appropriate meds in advance. This is especially hard when we often don't have the meds we need in the Palacios clinic, and we have to dig around amongst those to find the appropriate meds. Then there's the issue of clinic space. When we visit villages, they often set up the clinic in a local hotel or church. In this case it was a home, with only 2 rooms and no furniture, and a back porch with only a chair and table, and we had to divide up so that each room had 2 doctors seeing 2 different patients, examining patients on a chair, and then having one doctor outside on the back porch seeing patients. I was outside on the back porch, which was pretty interesting because immediately after seeing a child with fungal rashes all over his feet and advising his mom that he had to keep his feet clean and dry, I saw him running through the dirt barefoot past the barn with chickens, chicken poop, etc. So much of our 'medical advice' is just to make us feel better, because what are we really going to do about living conditions? It's equally frustrating and depressing. We tell patients to avoid 'bichos' by boiling their water and eradicate their scabies infection by putting their clothes in a garbage bag for two weeks and cleaning their sheets and clothes in boiling water. Too bad boiled water is a hot commodity, and most people don't have enough clothing and sheets that they can bag it all up for a few weeks while the scabies eggs die. No wonder patients leave the clinic looking a little disappointed; they typically only feel like it was a fruitful visit if they walk away with vitaminas, medicine for bichos (both of which everyone asks for, and I mean everyone). Unfortunately we have to ration our vitamins since they're in short supply, so we only give them to the patients who are obviously malnourished or anemic (based on pale conjunctiva). And we can't treat everyone for bichos, mostly because the azole meds are not without their side effects and you can't just give them out like candy.
Another barrier to travelling to see patients in their clinics is the basic fact that we have to travel. It's easier said than done. We pile all of us doctors, students, nurses, and coordinators into a car that fits an absolute maximum of 8, pack ourselves in like sardines, and then pile on meds, stethoscopes, water, tools, and whatever else has to accompany us. I have very short legs, and even I get leg cramps from squeezing into such a tight space. The back row gets the brunt of the bumps, and let me tell you there are a LOT of bumps on the way. The closest I came to a concussion on the trip was one particularly large protrusion in the dirt road where I flew from my seat and came about an inch from the ceiling. That same excursion out to clinic was particulary nauseating, as these car trips often are, and I was told by various sources in the car that my face was green and lips purple. At least it won me a spot in the front seat on the way back, but I'm realizing that I'd be perfectly content to stay in Bolivia forever were it not for the bumpy dirt roads. Call me a diva, but I like my roads paved.
Aside from those aforementioned challenges of bringing clinic to various villages, I really like the satisfaction of seeing a group of people who obviously need it. I happened to see mostly kids that day and was pretty frustrated by parents telling me that their child has a fever, nausea, vomiting, diarrhea, won't eat, and has been ill for weeks, and then seeing the kid chasing his sister around the room and giggling. I know that this problem exists in the states, where parents exaggerate about their kids' illnesses, but I understand why they do it here. The thought process goes like this (in my interpretation): 'the doctor is here today, and while my kid isn't sick at this moment, he will be in a month and I might as well stock up on meds while she's here'. It's not like they're using us, because they eventually will need the care we provide but just not right now; however, it's hard not to feel a little frustrated and used after a day of very dramatic 'ay dios, mi hijo esta enfermo, tengo hichazon, me duelen los rinones, tengo dolores de cabeza tan fuerte... necesito vitaminas, doctorita, y pastillas para los bichos...' This is a typical patient presentation, and it takes a lot of patience to explain to patients that vitamins won't heal them, we can't treat a patient who isn't at clinic and doesn't get examined ('my dad couldn't make it today, but needs such and such for this rash'), and that walking away without meds doesn't mean that we wasted their entire day. Thursday and Friday were frustrating clinic days for me, because most of my patients presented with vague complaints or no complaint at all (my favorite of all time was a mom complaining that 'my child's urine is yellow.') When I'm refilling someone's diabetic medications, doing a pap smear, evaluating an ongoing problem and checking for progress- those are all things that make me feel like I'm doing something. Their blood glucose is going down, they're taking better control of their health, they're being screened for cervical cancer- I like being a part of that. But the patients who show up with 'diarrhea about once a month,' occasional difficulty sleeping, occasional headache, I want to explain to them that this happens to everyone and they don't need to be alarmed. I suppose that part of the problem is that most of the patients we see have so little formal education (some of them stopping at 2nd grade), that they don't have enough information to know when to worry about a health problem and when to write it off. Interestingly enough, the patients on Friday were obviously a wealthier group of people, relatively well-dressed, clearly more educated, and in some ways a little less frustrating because they had a better understanding of their health. I could counsel them on their disease and they often understood completely and seemed motivated by the education. They had a different set of problems, clearly coinciding with their elevated wealth/education. Almost every one of my patients was obese, and I spent a majority of the day providing detailed weight-loss plans, healthier-eating plans, and trying to scare them into better controlling their diabetes (threatened one patient with the possibility of limb amputation and blindness because her diabetes is uncontrolled and she'll need to start Insulin at her next visit). I had to remind myself that I wasn't at a clinic in the states, because these particular patients and their issues were pretty familiar. Part of me feels uncomfortable knowing that some of these patients can afford to buy their own medications and may have access to other means to obtain healthcare, and yet still utilize the free clinic. The other side of me feels that their 'relative' wealth is still pretty minimal compared to the U.S. The clinic administrators are working out a method to figure out who really needs free care and who can afford to pay. We encounter these problems all the time at free clinics in the states, and while my bleeding heart wants to treat everyone and just hand out health care right and left, reason tells me there's a more efficient and just way.
Saturday would prove to be one of those days that shakes you, makes you re-evaluate and re-think what 'sick' means. It would end late, make me cry, nearly stop a clinic in its tracks, and leave me silent with my thoughts and questions for the two-hour drive home.
The day started like any other clinic day, with typical patient concerns, typical medication refills, counseling, histories, physicals. A 14-year old boy came in with the common complaint of headaches, and the day took an interesting turn when he actually had serious classic migraine symptoms (we get a lot of 'occasional tension headaches' just wanting some tylenol). His story was textbook, and then he had a few cranial nerve findings (deviated uvula) and nystagmus on exam. It's always interesting to get unusual physical exam findings since I'm getting used to benign physical exams. Also annoying because we didn't have enough of the meds that had been helping him, so we essentially have to move backward with him by not giving him the treatment he needs and likely re-imposing his symptoms. Then I jumped in to see one of Matt's patients, a 14-year old boy with Chorea (the physical movements you see with Huntington's Disease, but the movements can be caused by a number of diseases). He was a case of probably Rheumatic Fever, with Sydenham's Chorea being one of the Jones Criteria for diagnosis. Interesting to see this manifestation of the disease, and also really sad because the boy was getting frustrated by his symptoms. He would cover up the movements by acting like he was messing with his hair or playing with his shirt, when in fact his movements were involuntary.
My first patient after lunch turned out to be one I'll never forget. He was 54 years old, dressed in loose-fitting sweatpants and a dirty half-buttoned shirt, was missing the center top row of teeth, and wore a dark baseball cap. I called his name in the lobby, walked him into my exam room, and watched him as he struggled to find a comfortable sitting position. Without needing to dig deep to get his history, he spoke freely about an excruciatingly painful lesion on his penis. He said it started about two years ago as a tiny lesion on the glans penis, was told it was nothing to worry about, and then watched as it grew. He had been to multiple doctors, was told to get a biopsy, but always got scared and chose not to act on it. Curanderos (natural healers) gave him herbal remedies and he prayed, but at each suggestion of biopsy became too frightened about the possibility of having an operation on his penis. His pain had progressed so completely that he was unable to sleep, he could not wear underwear or anything that would rub, and had to wear loose fitting sweatpants for comfort. I had all the history I needed to seriously worry about cancer.
disclaimer: the following may be uncomfortable to read, especially if you have a penis.
We walked to the bed (a makeshift exam table), he sat on the edge of the bed, and pulled down his sweatpants. Covering his penis was a large piece of gauze, and I watched him wince as he cautiously removed tiny pieces of gauze. The gauze was full of pus, with a hint of a fruity odor(maybe a pseudomonas infection), and as it peeled off of his penis an ugly lesion revealed itself. Hiding his penis was a fungating, erythematous, oozing chaos of masses with multiple hard nodules. It was exquisitely tender to palpation. He pointed out the hiding place of his urethra, which was buried between two gruesome nodules full of cancer and infection. I choked back tears when I caught my first glimpse of the mass. Here was a man who carried himself with dignity, hid his pain, and walked like a man who was living, who in reality hid a secret and a death sentence lying just beneath his beltline. The tears were even harder to hide as I examined his inguinal lymph nodes to find multiple, solid, non-movable nodules bilaterally. His cancer had metastasized to his lymph nodes, and without a doubt to less obvious places. I told him to sit comfortably for a moment as I excused myself to get Erin's opinion and another set of eyes. We re-examined him together, and I translated for her as she told him he has cancer. Althouth it was coming first from her mouth in English and then from mine in Spanish, it was no less difficult to say the words. I wasn't the first one to tell him, and I'm sure doctors over the past 2 years had told him about their suspicions. But from the way he looked at me, it was if he had never heard the word cancer before. He had a look of begging in his eyes, as if maybe I could show him some mercy and pretend it was something else. We did offer him a glimmer of hope by asking him back this coming Wednesday (tomorrow, feb 20) for an RPR blood test to make sure it's not a brutal Syphilis infection. From the tone of my voice, from our exam, and from our conversation, he can't deny much. He took the hope I gave him, looked forward to seeing us again on Wednesday for the blood test (and I just pray he shows up tomorrow), and dressed himself with pride. He knows that his options are few. He doesn't want a biopsy because he knows that the results will undoubtedly imply further surgery. As a male member of a culture of machismo (latino machismo runs rampant here), the idea of losing a penis would likely be on par with loss of life. I mourn for the loss of his pride and his years. He's only 54 years old, separated from his wife, and with three teenaged children. The situation is tragic, and there's nothing else to say. Squamous cell carcinoma of the penis is something we read about in textbooks but hear about as a rare cancer, and here it is in this small village of Bolivia with nothing to offer but weak pain medications. I sent him away with an NSAID to help with pain relief and vitamins for the pending malnutrition that will soon wreak havoc on his body, and I felt defeated.
As we left the room, me clutching his shoulder and wishing him well and he promising to be back on Wednesday, he peeked out of the door and said 'a man has fallen!' I turned my head to the left to find a man seizing on the hallway floor. Hovering above him were Sumi and Erin, our attending and resident, and a crowd of clinic patients had formed a spectator's ring around him. The medical staff were already in the throws of administering a benzodiazapene (unfortunately we only had relazepam which takes 30 minutes to act, when really you need a fast-acting med like Ativan), his pulse ox was being checked, and things were relatively under control. The minutes felt like hours as we waited for him to stop seizing. The patients were beginning to panic, and the situation was chaotic. As everyone began slipping back to the patients waiting for them in the exam rooms, I became the patient's personal doctor on the hallway floor. Checking pulses and blood pressures, making sure he was gaining consciousness normally (knowing that recovery from a post-tictal, or post-seizure, state can take about 15-30 minutes), I sat with him and calmed him as he looked with fear from his vantage point on the floor. Over time, I learned from the woman accompanying him that his name was Daniel, he was 38 years old, and he was epileptic since birth. His epilepsy had caused some mental deterioration, his family had essentially disowned him, and he was accompanied to clinic by the wife of a friend because no one else cares about him. He had lived with his father at one point, but even then had been responsible for obtaining his own medications and caring for himself. Living alone, with no medical assistance, he dangerously seizes at home with no one there to keep him safe. This week alone he seized 4-5 times, all without witness but only known by the patient because of the confused state he finds himself in when he gets up off the floor. It's amazing he hasn't seriously injured himself up to this point, and it worries me that one day he will. Knowing what it's like to be part of a loving family, I grieve for this man who has no love and even more for his family that doesn't know how to give unconditional love.
The patient takes Tegretol as his anti-epileptic, and has for years, but when his medication runs low he tries to ration it to make it last longer. I can't imagine the feeling- gambling with a seizure disorder by taking a half-dose of meds in hopes that it will last 2 days longer. We're going to try to get him to a neurologist in Santa Cruz for some serious medication re-adjustment. But we can't make someone care for him, and I wonder what will happen as he ages.
On a happy note, this week had some really beautiful moments. We had a brief rainfall on Thursday afternoon and subsequently an incredibly brilliant arcoiris (rainbow). It was actually a full rainbow, a complete half-circle, and it was stunning.
With us at clinic was a 21year old Bolivian guy named Humberto, who helps translate and volunteers ocassionally. He's studying English in Santa Cruz. We spoke at length about his experiences growing up in a small village (he's from Yapacani, one of the villages we serve), and especially his experience as an Autonomista in a village of Masistas. He's articulate and politically outspoken, and it was fascinating to hear the perspective of a young Bolivian on the current intensifying situation. All in all, from devastating patient encounters to flowers and rainbows (said with sarcasm but also quite literally), the clinic experience has been very complete. I head back to clinic tomorrow, so hopefully I'll get a chance soon to write about the incredible time we had in Samaipata and some updates on the clinic patients.
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