Medical Arms Race

Astute. These guys get extra points for doing it in the style of Dr. Seuss. There is an extra dash of irony here, considering that Dartmouth Med School just took on Dr. Seuss' name. It's just what the Dartmouth Atlas has been telling us for years: empty beds and idle OR suites don't stay that way. The more you have, the more you use, and the more everyone pays.

Thankfully Hilary, as a family practitioner, is a bit removed from the front lines of this decades-long medical arms race. It is tough to argue that there are too many general practitioners, or that they are over-consumed (over-worked, maybe, but that's different).

Wrapping Up

News from cental america:

We had our final day of medical clinic yesterday—nothing too crazy, thank goodness, but it felt better than the prior couple of days because people had more focused problems, rather than a huge long list of issues. Interestingly, very little heartburn in this village. I continue to be surprised at how I hear from all the kids and parents about headaches--not sure if this is just what American parents/kids call "stuffy" or what, but in America they'd all be getting scanned for brain tumors if they talked so much about headaches!

Later in the afternoon we got to tour the hospital. They have tons of equipment donated by various foreign governments (Spain, Mexico, Germany, and China all mentioned) and even have a 2-bed neonatal intensive care unit. And they deliver TWENTY FIVE BABIES A DAY! I would really love to come and do a rotation...

Today is a rest day. I ran with my exercise buddy this morning (she's an elementary phys ed teacher in VT), and now we are having a leisurely breakfast. In a few minutes we're going to pack up the pharmacy: meds that will expire soon will go to the local hospitals, and those that have awhile yet will be stowed away for the October Rotary team. This afternoon we are going to a local Equestrian Center for lunch and fun with the local Rotary, though apparently they don't have any horses yet.

Sunday we travel.

Clinic Day 4

Thursday's news from down south:

I can't believe we only have one day of clinic left! I am definitely ready to be heading for home.

Thursday, our medical clinic was set up at a school for orphans here in town. It was similar to the other days — mostly gripe and dolor de cabeza — though I did have a couple of alarming pediatric patients.

A grandmother brought her three grandsons, ages 5 and younger, and pointed to the five year old and said, "he has seizures."

"Is he on any medicines?" I asked through my interpreter? "No," came the answer.

"Has he only had seizures with fever? How many seizures has he had?"

"Yes, with fever. He's had two, the last one was six months ago. Well, actually, the first one he ever had, he didn't have a fever."

"Have you taken him to the doctor?"

"We took him to the hospital when it happened but the doctors were asleep so no one saw him." (!!!!)

"Does he learn and understand the way that other kids do?"

"Yes"

I'm just about to launch into a speech about how kids outgrow febrile seizures, but if he has another seizure without fever, he really needs to see a doctor, when grandma adds, "and he has diabetes."

"Diabetes????" I want to make sure I'm understanding this correctly, so I make my interpreter ask again.

"Si, diabetes."

"On medicines?? Shots???" (The only way to treat juvenile diabetes is insulin.)

"No."

It's at this point I start looking for the camera, because it has to be a joke. I make my interpreter ask again, and then grab one of the older Rotary ladies who is completely fluent, because there has to be some sort of misunderstanding.

"When did you find out he has diabetes?"

"Two days ago. They did some blood tests and said he has diabetes and to bring him back tomorrow, but I heard that you were here and brought him here instead."

The kiddo looks way too healthy to be in diabetic ketoacidosis, which is usually the way that kids are diagnosed, and there's no way that a kid in DKA would have been sent away from the hospital, they usually have to be admitted for several days. So I still don't understand the sequence of events at all. Nonetheless, I am NOT a pediatric endocrinologist and there is no way I can start insulin on this kid, and I still think there must be some sort of misunderstanding anyway. I explained several times through the interpreter that childhood diabetes is VERY dangerous, that they absolutely need to follow up at the hospital tomorrow and will probably need to see the doctor very often while they are starting treatment, and that we do not have the ability at our mini-clinic to do this!

Crazy.

Then there was the mom with the 8 month old who said he was vomiting all the time and losing weight. The child was INCREDIBLY chubby, 20 pounds on our scale! (B, for example, didn't reach 20 pounds til around her 2nd b-day). Mom insisted that he used to weigh 28 pounds. (???) I explained that babies spit up a lot, some much more than others, and that it would gradually improve over the next few months—it's only concerning if the baby is losing weight. She said he seemed skinnier to her, so I wrote her a referral to see the pediatrician at the hospital here. Who knows?

We're off for our last day of clinic now.

Clinic Day 3

The latest from down south:

Third day of clinic today was at a village just outside town, near the city dump. We were set up, as usual, in a school complex. Today was a bit different in that we were relying mainly on teenagers from a local bilingual high school for interpretation. They were enthusiastic, and goodness knows their English was much better than my Spanish (tenses! they had tenses!), but they didn't have much in the way of medical terminology. However, we muddled through quite well. I had a run of fairly complicated patients, including a VERY prolonged discussion with a young woman who came asking for a pill so that she could get pregnant, because she had had seizures in her last pregnancy. It took about 20 minutes of questioning to try to figure out whether she had an underlying seizure disorder that worsened in pregnancy, versus eclampsia (which is seizures along with high blood pressure during pregnancy)--both very serious but approached completely differently. I think it was the former, but gave her a referral to see the OB-GYN here in town to discuss the matter prior to attempting pregnancy.

Tonight a group of us walked into town and had dinner at a Mexican restaurant. Very tasty, though somewhat tempered by our reluctance to eat fresh veggies (like salsa) or drink things with ice in them due to concerns about water purity. Then it was off to the local Rotary meeting. This trip is sponsored by the Bow Rotary and they've been coming here for many years, so it's a big reunion. I was dreading a long meeting in Spanish, but instead it was short, bilingual, and ended with, "so we will close our short meeting so we can drink and talk to each other." Now that's my kind of meeting.

We have three more days of medical clinics left. Saturday we are spending the day at someone's ranch/estate for relaxation, and Sunday will be mostly traveling. The construction team is working incredibly hard on the school, and our water/sanitation team had a wildly successful day today, installing two latrines in a village that did not have any previously. They will build two more tomorrow, and then install about 40 water filters on Thursday and Friday.

Las Roblas

Update from Honduras:

Today was clinic day 2, held in Las Roblas, where our construction team is building another school building. Our clinic was held in the two-room school that the Rotary built several years ago. All six medical providers were set up in one big room, with clusters of table and chairs around each of us, and our pharmacy (suitcases full of drugs) was set up on desks in the other room. I saw forty patients today in about five hours, mostly clusters of moms and kids. I did have one gentleman who told me he'd had two heart attacks. I'd been wondering who I was going to give our cholesterol medicine to, since we have no way to do blood tests, but he definitely qualified! Lots of "gripe," which they translate as flu but to me seems more like a cold or other viral upper respiratory infection. Lots of ringworm. No more icky lice and no huge wounds, though I did treat one skin infection AND got to drain a ganglion cyst, which was awesome.

We had some rotating interpreters, and I did a lot more on my own today and then would grab one of them if people started talking a lot, or talking fast—I found that I was usually able to get the basic questions across, and understand simple answers. I now know the words for rash ("erupcion") and for lungs ("pulmonas"). As long as I can stay in the present tense, everything is fine. I'm vaguely aware when I should be using the subjunctive, but usually don't quite manage it. People seem to understand anyway.

Our team finished early, just after 2:00, and we came back to the hotel. Some of the providers went to a nearby detox place to do some primary care, but I needed a little down time so did not join them. I did go for a walk with Cynthia (my attending) and one of the veteran Rotarians to the beautiful new huge grocery store, where we stocked up on plaintain chips (yum!!!), water, and I also discovered that the Skittles here have no gelatin, so now I have some Skittles too.

This evening a big chunk of our group—about 20 people—went to a steakhouse. It was quite fancy, and ironically, I was able to get some decent veggie-friendly food. It was lovely to eat a real salad (we'd been told by the Rotarians that it was safe to eat salad at this place because they wash things in purified water), and once I told them that I was vegetarian, they modified one of their platters for me. I ended up having beans, a fried egg, and avocado, but passed on the funny salty cheese that is everywhere here.

My little running club has taken off, they went without me this morning because our medical team was supposed to have a meeting at 6:30, which never really materialized. We're planning to run again tomorrow. It's a nice way to get to chat with people who are on the other teams (construction and water/sanitation) because we don't see them during the day.

Things are generally going well. After talking with some of the other people who had done this trip, I was concerned that I'd spend a lot of time bemoaning the lack of big-picture public health focus, but I've mostly tried to focus on the people we are really making a difference for (like heart attack guy--I convinced the pharmacy to give him 6 months of meds, til our next team comes down), or who we can reassure (several people have thought they've had cancer for various reasons and they almost certainly don't). Plus, it's just flat-out interesting to get to be in a part of the world where I've never been. Tomorrow is going to be even crazier—we are going to a village right by the town dump which is apparently much much poorer than any of the places we've been so far. Possibly also going to visit a nursing home.

This is really making me want to get my Spanish back into shape. Not sure how to work this into the rest of my life, though!

First Clinic Day

No valentine's day in the Moose household. From our foreign correspondent:

We had quite the introduction to Honduran medical treatment yesterday. We went to a newly built hospital about half an hour away. The six people on our provider team (three physicians, two NPs, and a nurse partway through her NP training) saw upwards of 200 people and were there for about eight hours. The dental team (a dentist plus a few helpers) saw 20 patients and pulled 35 teeth.

The majority of what I saw was cough (toz) both acute and chronic, headache (dolor de cabeza)--of which I was able to identify several migraines and give Excedrin--and gastritis/reflux (dolor de estomago)--we were handing out Tums like candy. People drink lots of coffee and soda, which is NOT good for the stomach. Also many skin and nail fungal infections.

Our first patient of the day was a woman with a chronic leg ulcer that had been there for fourteen years! She was keeping it meticulously clean, but it was huge. All we could do was give her a referral to see a specialist at the hospital here in Danli, but it's hard for me to imagine what they are going to be able to do. I think we'd have her in a hyperbaric chamber in the States.

We also saw a girl with the most horrendous case of head lice—all of us were having psychosomatic itching for hours afterwards.

And I saw a woman with pelvic pain and discharge, but without the space and supplies to do a pelvic exam I wanted to treat all the possibilities, so she ended up with meds for bacterial vaginitis, yeast infection, and chlamydia (we didn't have the right antibiotic to treat gonorrhea, but we looked through our pharmacy stores this morning and now we do have something that should serve). It was a bit frustrating, because with a pelvic exam and maybe I microscope I could have narrowed my differential diagnosis a bit!

Usually, talking to patients is my very favorite thing, but it took so much effort and mental intensity to try to understand the Spanish, and then formulate a response (though I did have an interpreter to help), that it was SO lovely to just put a stethoscope on a chest and listen to heart and lungs, which is a language I feel pretty comfortable with!

We had a few patients who I knew EXACTLY what to do with, and we even had the meds to help, and it was such a relief: a teenage girl with bad menstrual cramps (high-dose ibuprofen, and then go find a clinic for birth control if that doesn't work), and the migraine folks (yay for whoever donated that Excedrin!). We're also giving out a few month's worth of blood pressure and diabetes medications when indicated.

It was overall quite exhausting. My Spanish got a bit better through the day and peaked around 2 or 3 PM, then collapsed for the last few hours as I got tired. I still can't use the subjunctive at all, and was too tired last night to do much grammar review! Thank goodness for the translators.

Today we're off to hold a clinic in Las Robles, where part of our larger Rotary team is building a school.

Honduras

Hilary is our foreign correspondent this week. She is traveling with some colleagues from the hospital and a contingent from the local Rotary to a rural town in Honduras. After staying up all night Friday to clean up loose ends with her Concord patients, she left around 3 am Saturday for an early flight out of Logan to Miami. From there, on to Tegucigalpa, the largest city and capital. Google Earth has been a wonderful tool explaining all this to Brynna, although she doesn't quite understand that the airplane on the tarmac in the picture isn't actually Hilary's.

The whole contingent loaded onto a bus for a several-hour drive through the countryside before arriving at the hotel that will be their base of operations this week. Her take:

We have arrived safely in Honduras. Our travels went very smoothly, we seem to have gotten all the giant medication-containing suitcases hauled down here just fine. The drive from Tegucigalpa gave us a beautiful view of various sorts of countryside, including many mountains, and we're now at our hotel. Where there is wireless in the lobby! Hurray!

I'm pretty exhausted due to no sleep last night, though I did manage some naps while traveling. We're going to do some organizing of our "pharmacy" and then, I hope, head to bed pretty soon. We start our medical clinics tomorrow.

Slice...Damn

Thursday night I was working on one of my many concurrent projects. At the moment, I was taking n Xacto knife to a large (2-gal) plastic bin, trying to cut the top off. While scoring along the outside, a combination of the flimsy plastic wall, the flimsy narrow blade, and my own clumsiness resulted in the blade sliding off to one side...right across my left pinky. Cursing myself stupidity, I wrapped it tight with a heavy paper towel, and completed cutting the bottle before heading upstairs to survey the damage. A long, deep cut from along the top side of the digit, starting before the last knuckle and extending alongside the nail. It was doing a fair bit of bleeding, and was clearly deep enough to need stitches. This was the other shoe I was hoping wasn't about to drop, particularly right before a race weekend.

I turned to my doctor wife, wondering if she'd do the honors and stitch me up herself to spare me a trip to the ER. Alas, no. Even though we have some old sterile sutures kicking around, they were much too heavy gauge, and we didn't have any of the other necessities (needle driver, licocaine injection, etc.) to do a proper and clean job of it. So off I went.

Thankfully, it was a relatively quiet night, and I was seen relatively quickly. The nerve block to numb my finger took a few injections and 30 minutes to fully take effect, but after that it was pretty easy to get things cleaned up and stitched.


During my ample waiting time, I was already starting to conjure plans that would allow me to compete in Saturday's Timberman Sprint triathlon. The pinky finger is not generally needed for much of anything, but it's would not be a good idea to soak the wound and dressing in Lake Winnipesaukee. Gloves, tape, and creative sealing were in order.

Thriving

Brynna's 2-month well-child checkup was today. And she is very well indeed! In fact, the first thing the doctor asked me was whether she was breast or bottle-fed. When I said that I was breastfeeding, he asked how that was going for me. I said "great," and he glanced at Brynna and then her growth chart and said, "and it's certainly going great for her!"

Brynna is now just shy of 13 pounds (5.85 kg, to be exact). She is in the 80th percentile for weight and 60th percentile for height for a girl of her age. (This does not have any bearing on her eventual weight and height as a grown-up...I expect her to gradually come down on the growth curve over the years, until she hits her genetically determined "midparental height" and what will probably be quite an average weight.)

Little B is also meeting all of the developmental milestones for 2 months, and some for 3 months (what a brilliant child!). Of course, right after we described her to the nurse as a happy, smiley child, she had a total screaming meltdown in the office. This was an excellent reminder that the very limited time I spend with my patients, especially the kids, often will not give me a very good sense of what they are like in their normal home environment!

B was awake and chipper in the waiting room, smiling over my shoulder at the other patients and then cooing happily at the nurse as we entered the examining room. She started getting a bit skeptical when we stripped her down to her gDiaper (perhaps she needs to be a bit older to gain an appreciation of naked time?) and the fussing started when we laid her down on the hard, chilly scale and then in the little measuring box. She really lost it while waiting, still undressed, for the doctor to come in. I walked her and jiggled her, Alex walked her and jiggled her, I offered the breast, she screamed louder, we tried covering her with a blanket, and Alex finally reached a tentative peace by carrying her around on her belly, a calming technique that M (B's grandfather) uses with great success. This truce lasted most of the way through the doctor's brief questioning but was broken the moment we laid her down on the examining table.

The doctor was able to listen to her heart and lungs before she really got going with the yelling, but then she rapidly descended into red-faced lobster territory. I had to pick her up and soothe her a bit before the doctor could get a good look in her eyes. This is actually a super-important part of the baby exam because the presence of a red reflex—the same thing that ruins flash photos—is a check against retinoblastoma, one of the few cancers that can present in little ones. He also checked her hips for dysplasia. He has no concerns for B at all.

Then it was time for vaccines. As I have written about earlier, I am a huge believer in vaccines as a cornerstone of preventive care. So is Alex. We intend to do the full complement of vaccines on the regular CDC schedule (Brynna will be exposed to way more antigens just by touching a surface and sticking her hand in her mouth than even the days when she gets eight vaccines, as she did today). So poor little B had one oral vaccine and five shots. She was so upset by the time this process got started that I'm not even sure she noticed the shots...her screaming certainly did not get any louder or more distressed when the poking started! I think the nurse was appreciative that neither Alex nor I got upset, and in fact were fairly useful in holding Brynna still for this unfortunate event.

The vaccines today were for:
Rotavirus (oral drops), which causes severe diarrhea. This very rarely is fatal, but causes a lot of hospitalizations for dehydration. Almost all kids get rota by age 5 if not vaccinated, so we're hoping to spare B some misery with this one.

Streptococcus pneumoniae (shot), which is the #1 cause of bacterial meningitis, which can be fatal. Strep pneumo can also cause pneumonia and ear infections.

Polio (shot). This is an inactivated polio vaccine, not the live oral polio vaccine that is really useful in higher-risk parts of the world but can, in rare cases, cause polio.

Haemophilius influenzae Type b (Hib) (shot). This bug also causes meningitis and other nasty infections like pneumonia and epiglottitis, which can be fatal. Epiglottitis, a throat swelling that can cut off breathing, has almost disappeared since the advent of this vaccine.

Hepatitis B (shot). This is a virus, usually passed through body fluids, that can cause chronic liver damage and liver cancer.

Diphtheria, Tetanus, and Pertussis (shot). These are all bacteria that can make kids very, very sick. This shot—specifically the pertussis (whooping cough) part—is one of the big culprits in the general fussiness in the couple of days following vaccination, and can in super-rare cases cause seizures or very high fevers. But the risk of getting pertussis—there are outbreaks yearly—is much higher. And the disease itself can cause seizures and brain damage in bad cases, and a lot of misery even in straightforward ones.

By the time we left the office, Brynna had settled a bit and then zonked out. She's never cried herself to exhaustion before, which was very sad. But she's perked up now and seems to be doing just fine. In fact, here she is enjoying some tummy time with her Papa: