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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    Tuesday, April 24, 2007
    Guatemala - II

    Monday April 16

    I have no way of knowing how many patients I saw in clinic today… maybe 25, maybe more. I also learned today that it's important here to eat even when you don't feel like eating: I was terribly depressed at lunch and cheered up as soon as I'd had something to eat.

    Every patient I see has a headache and stomach pain. I saw a 19-year-old male covered in tiny nodules; he brought a pathology report with him as he'd had a biopsy the previous year. The diagnosis was “pseudoacanthosis nigricans” and I have no idea what that actually is. I checked with a couple of other MD's and they weren't familiar with it either. (Add to next year's list: Derm manual!) I asked him if anyone else in his family had this problem; he said no. There was nothing we could do for the kid, but I asked Luis and Jorge, our two social workers, to try to get him to a dermatologist. Another boy I saw had extensive scar tissue over his groin and thighs from a burn he'd received five years before when a firework went off in his pocket. The plastic surgeons were able to help him.

    We saw lots more hernia cases today (we were told at the end of today that the OR could do no more hernia cases this week). I saw a woman with hypertension, blood and protein in her urine; we gave her samples of ramipril and tried to refer her to a nephrologist via Luis and Jorge. All the patients smell the same, a combination of body odor and wood smoke. It can get pretty overwhelming in these small rooms. (Also on next year's list: air freshener.) Their clothing is beautiful; some women and many men wear Western clothing, but most wear the indigenous outfits of blouse and skirt, made of home woven material that is heavily embroidered or patterned. The men wear jackets and pants of this same material. Neither have buttons or conventional belts. The fabric is pleated around the waist and then wrapped tightly with a strip of woven fabric that acts as a belt. The men also wear a square of material with a plaid or alternating square pattern over their pants, which is wrapped around the waist with the upper half of the material then folded over the belt. I will try to post pictures later.

    The OR is operating very late tonight because they’re trying to get as many surgeries done as possible. It’s 7 pm and they still have three or four more cases to do.

    Team meeting in the mess hall in one hour to discuss how things are going. Speaking of food, dinner was hamburger stew (ick), broccoli and cheese casserole, fruit and brownies. Lunch was sandwiches, black bean and pumpkin soup (quite good), and fruit; breakfast was homemade coffee cake and instant oatmeal. The kitchen staff is working hard (longer hours than we do) and is doing a good job considering the limitations they have to cope with, and really the food is not bad. It all tastes good when you've been working all day. I sit with the plastic surgeons, who are on a high from the cases they’ve seen. "We’re doing the nose tomorrow," one remarks, meaning an older gentleman with a large fungating skin cancer on his left nostril. I saw him in the clinic hallway this morning.

    "Any lymph nodes?" asks the other. The first surgeon shakes his head no. This is fortunate as it means the cancer isn’t likely to have metastasized.

    "What'd the CAT scan show?" somebody else quips. This is of course a joke as there are no diagnostic radiologic tools available except for the portable ultrasound in the OB/GYN clinic.

    "It was negative, actually," he deadpans.

    "They held a cat over him," the second surgeon comments. This is probably funnier if you're sitting in a Quonset hut at 6000 feet.




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