Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Sunday, April 29, 2007
    Guatemala - IV

    Wednesday April 18

    "Humpday" is over. One more full day in the clinic and then a half day on Friday. We pack Friday afternoon and leave Saturday am. Today is classic internal medicine all the way with tons of back pain, gastritis, headache, and cough. Several of my patients also have GYN problems, so S. (the GYN nurse) and I swap patients a lot.

    One woman comes in with a list of minor complaints and then breaks down crying in the middle of the exam. Her son was murdered a few years ago and she's had other troubles at home; she is clearly depressed. I send her for spiritual counseling (HELPS offers this to patients). There just isn't much else we can do for her; we have no antidepressants available here and even if we did, how do I explain that they take four to six weeks to work, and where is she to go for follow-up and to get ongoing treatment? A lot of patients here also complain of being "nervous." We have no anti-anxiety meds and I wouldn't feel comfortable handing them out even if we had a supply. On the up side, I catch a case of previously undiagnosed diabetes in a woman with a blood sugar of 489. We give her a glucometer, educate her on diet and start her on medication. Also I see a man with a bad case of sciatica. After I give him a prescription for prednisone to get his pain under control he tells my translator that the local doctor had suggested amputating his leg for this problem. Words fail me.

    I tried to inject a knee today, couldn't get into the joint and had to get one of the other internists to help. I do love the camaraderie at the clinic. We're always popping into each other's rooms to point out something interesting or to ask for help. The number of internal medicine patients has slowed down a bit so we had more time. A whole busload of kids showed up today, brought from a local school, so the pediatricians were kept busy.

    A., the intern who's working with us in clinic, called me in to see a patient with a fever and cough, also symptoms of an enlarged prostate with dribbling when he tried to urinate. She said his lung exam was normal, so I thought: urinary tract infection. His urinalysis came back normal, at which point I examined him and heard faint crackles in both lung fields. I immediately diagnosed bronchitis and told her to put him on Avelox. Later I saw another patient with her, a boy with skin problems and low back pain. I diagnosed sacroiliac back pain and tinea versicolor. As I explained the diagnosis to her and the patient I suddenly realized that I had become an Attending. Suddenly I feel like a grownup.

    Last note for tonight is the insect life of Guatemala. As I mentioned earlier, we have been plagued by June bugs; tonight they were all over the bathroom. A. and I finally figured out that the lavaliere windows over the sink had been left open, so she climbed on the sink and I jumped up on the toilet to close them. The first night we were here I screamed when I saw those things. Now, my reaction is more along these lines:

    • Look up from book, see bug

    • Squash bug with nearest blunt object

    • Go back to book.

    I must add here that there was a beautiful little girl walking around in the clinic today, maybe 18 months old. Most of the children around here seem to fight somewhat shy of us, but she walks up to me. Her mother smiles and gestures to indicate that she wants to kiss me. I lean down and she plants a big kiss on my cheek.

    Thursday April 19

    Did I mention that Ronald McDonald showed up yesterday? I don't think so, but he did. Ronald McDonald House is a big sponsor of HELPS, so they sent Ron out to entertain the kids. Solola is such an isolated area that I doubt most of them knew who he was. He did show up in the mess hall at lunch, holding one of those "invisible dog" leashes and tooting a horn. The surgeons thought it was a hoot and lined up to get their pictures taken with him. I was not so thrilled and made a quick unobtrusive exit.

    Today is slightly quieter in clinic for medicine, but not for Peds; two more busloads of kids show up, again sent from local schools. We are now out of hydrocortisone cream, Lotrimin cream, acetaminophen (!), ibuprofen (!!) but we still have some aspirin. On the subject of pain relief, I successfully inject two patients' knees today. I also see a patient with a goiter who is clearly hyperthyroid, with tremor, weight loss and palpitations. We refer her to Guatemala City for treatment with radioactive iodine to ablate the thyroid. Another standout patient is an old guy with bad arthritis of the hip; he has a flexion contracture. What he really needs is a hip replacement but there's no way that's going to happen here. I explain the problem and give him aspirin.

    At the end of the day I see a bucket of plastic vaginal speculums, normally a disposable item, soaking in bleach solution. I ask S. whether she is reusing the speculums and she nods yes. It's something we'd never do in the States, but it makes sense here given our chronic shortages of equipment. Also it means less stuff to throw away at the end of the trip.




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