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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    Wednesday, April 25, 2007
    Guatemala - III

    Tuesday April 17

    I wake with a horrible headache at two am, probably due to the altitude. I finally get up early and go outside as I am getting nauseated, but I find the path to the overlook and walk it. I've been told to check out the overlook ever since we got here, and it certainly is a fantastic view down the mountain to Lake Atitlan, with a volcano in the background (not sure which one). For a small country, Guatemala is amply supplied with volcanoes; it has three, two of which are active. It turns out that the university campus is perched at the edge of a deep gorge, which explains the cement wall topped with barbed wire I see on my walk. Of course I didn't bring my camera along, but I decide to return tomorrow to take pictures.

    Clinic is better today; we have found our footing and everything goes much more smoothly. I stop by the hospital this morning to beg some steroid and lidocaine for joint injections (another entry on next year's list: Kenalog!) Now that the surgical schedule has more or less been set we're seeing more internal medicine patients rather than preops. We see a lot of TBA (total body aches), gastritis, headache and "nervousness." I realize today that internal medicine is the same no matter where you are. These patients' complaints are exactly the same as the patients I see at home. This is familiar, and thus reassuring, ground.

    One woman I see today does not fit this pattern. She comes in complaining of a rectal lesion which is bleeding and which she's had for over a year. I look at her and realize she's lost weight (these people don't have money to buy new clothing, and hers is clearly too big for her). Her face shows evidence of weight loss as well. I ask her, via Maria as translator, if she has lost weight and she confirms it. This does not bode well. Knowing she will likely need to see the surgeons, I decide to do the full preop exam; when I check her rectal exam she has a large bleeding external mass. It's clearly malignant. I send her to the surgeons, hoping for the best, but Maria tells me later that they could do nothing for her. She would have required a colostomy and we are not set up to do that. She is sent to Luis and Jorge in the hope that they can refer her to someone in Guatemala City.

    Another patient (not seen by me, but by one of the other MD's in clinic) has a large necrotic ulcer on her leg near the ankle. It has rolled edges, which indicates a basal cell carcinoma. Later in the week we hear that the surgeons found maggots in it during the operation. This isn't quite as vile as it sounds, as the maggots did a nice job of debriding the dead tissue in the ulcer and preventing it from becoming infected. The surgeons resected the ulcer and placed a skin graft, taking healthy skin from her abdomen: "She got a tummy tuck for free."

    I learn how to inject knees and shoulders today. Most every patient with joint pain wants an injection, as it gives instant relief that lasts for months (if you're lucky). Rheumatology and Orthopedics has always been one of my weak points, but I am game to try and hope to do some more while I'm here.

    An evening's entertainment around here is to go over to the hospital and watch the surgeons in the OR. There really isn't much else to do, and we internists are invested in these patients' outcome, having seen them in clinic the same day or the day before. Internists and surgeons traditionally get along about as well as cats and dogs, but in Guatemala we are all working very closely together and the barriers between us seem to have broken down. To be perfectly honest, under these conditions with no follow-up or continuity of care the surgeons can do much more good than we can. It's humbling to have to admit this, but it's true.

    The hospital is boiling with life. Both the stairs leading up to the building and the lobby are packed with relatives waiting to hear news; in Guatemala it is understood that your relative or someone from your village will come with you, stay with you in the hospital and help care for you while you're there. I meet up with B., another partner from the Firm who is an OB-GYN; he's come on these trips for years. He takes me on a tour of the OR. There are four operating rooms, currently booked with one septoplasty, two hernias and one room being cleaned where a case has just finished. The general surgeons get two rooms, OB/GYN gets one and Plastics and ENT split one. Compared to the stringent restrictions on surgical areas in the States, it's remarkably lax. Anyone can stroll in and watch (if you're with the HELPS group) and even scrub in if you want to. One of the other internists, an older man, brought his high-school aged grandson along; he has assisted on a hernia case already and is having a blast.

    I gave my heart to internal medicine early in my training and I've never been particularly interested in surgery per se. C. and I watch for a bit and she comments: "This is like watching grass grow." I heartily agree and head off to the computer lab to try my luck with logging on. (Last night the computers were down; service here is spotty.) As I arrive, someone asks: "Did you hear about the shooting in Virginia?"

    "What shooting?"

    "Some guy shot up a college in Virginia yesterday. It's on Yahoo!, they're calling it the worst massacre on a campus in U.S. history."

    I don't think I need to go further on this, but suddenly I am very glad that we've been cut off from the news as much as we have been. Once signed in I concentrate on email and avoid the headlines as much as possible.




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