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The Honduran staff was a joy to work with…Dr. Maggie Jolly

February 15, 2015 nimDA

I slipped on a scrub top and walked down the hill to the hospital. It was one of my call days, and the nurses had given the characteristic message on the Ham radio, “Dra. Maggi, Dra. Maggi, tenemos una emergeeencia.” They always seemed to draw that last word out, making it sound more urgent than it really was. This case was simple however, a kid with a rash, and I didn’t expect it to take long. I had turned to Mackenzie as I left, just after breakfast, “You don’t think I need to change out of my shorts and flip flops do you?” “Nah,” she replied, “you won’t be gone long.”

How long did your child have this? Does it itch? I had made it about two questions into the interview of the child’s mother when I heard a bustle in the other ER bed. Glancing past the curtain, I saw them hoisting a young man with a rather large blood stain spreading down the front of his shirt. “What happened?” Calmly, “Una balla Doctora.” As I could hear the gurgling from his chest from across the room, I turned to the mother and asked her to excuse me for a minute. After two painstakingly small and difficult to place IVs, several liters of fluid, a measly shot of IM toradol, and a large bore chest tube placement, the patient was finally stabilized.

Quite a rush of adrenaline, when your trauma bay team initially consists of only two generally trained Honduran nurses, other physicians have to be called in by Ham radio, and the Xray tech has to be called in from afar on his bike (we left a voicemail message on his phone and never actually saw him that day). No tension pneumothorax, no other complications, thankfully, and he did extremely well. The trauma surgeon who came in to help me place the chest tube, a veteran of several tours in duty in Afghanistan, looked at me after all was said and done, stating, “Well will you look at that. You didn’t even get blood on your shorts!” I think that will be my first and last chest tube insertion while in flip flops, for the record.

While one of the most intense, the past three weeks have been spent full of similar intriguing learning experiences. I was lucky enough to be able to spend them working at Hospital Loma de Luz, a small but comprehensive missionary hospital approximately two hours south of La Cieba, a large city on the North Coast of Honduras. Typical days were spent in clinic, after rounding on any patients, mothers or babies you had admitted in the days prior. Clinic encounters ran the entire gamut of possibilities, from the familiar triad of HTN, Diabetes, and hyperlipidemia to more unfamiliar complaints such as “diarrhea/stroke” (that was a disconcerting chief complaint to read, and quite complicated to deal with in clinic). I noted that most patients were in the practice of not taking their medications the day of their appointment, as they knew we were to be evaluating their blood pressure and they did not want the medications to interfere with the value… I saw mothers and babies whom I delivered (recen naciedos), well child checks (one “chequeo general” turned out to be a 12 yr old with an obvious genetic syndrome and bilateral cataracts who had never been seen before), as well as numerous bouts of Giardiasis and parasitosis. I also saw a girl with Bells palsy, lots of optho complaints (and the removal of the largest cataract I have ever seen), orthopedic complaints, kidney stones, gallstones, and an abundance of ladies presenting for prenatal care.

Call days were always interesting, and as is characteristic for the visiting doctors I’m told, were usually busy. Often paired with Mackenzie, I was able to do a multitude of vaginal deliveries as well as help out with a C-section and do the baby resuscitation. The vaginal deliveries often tended to be at 4AM, after walking back and forth to check on the patient and make sure the nurse’s vaginal check was accurate (they almost always were). Monitoring was brief, but the nurses would turn it on for ten minutes prior to my arrival, as they knew I was used to at least glancing at a part of a baby’s strip. Otherwise, it was all by sound, if the mother was on the monitor at all. As I had witnessed in Guatemala previously, the mothers delivered their babies without so much as Tylenol, and all were very gracious. It always made me smile: in the warmth and humidity of the tropics, the families often dressed their new infants in tank tops rather than onesies.

I learned to cast broken bones on call days, and also sewed up lacerations from machetes. I learned that treatment of stroke is difficult without the aid of an immediate CT scan. Treatment of MI is difficult without PCI or heparin or lovenox. Treatment of cancer is often impossible, and sometimes people can get septic and die from infections that have been present much longer and progressed much more quickly than they might have in the states. Pressors don’t work as well if you can’t stop the bleeding and you don’t have ready access to blood transfusions. (Thankfully these were not all lessons learned on my own personal patients).

In general, my Spanish had improved greatly after my 9 months in Guatemala during medical school. Rather than being stuck on basic communication, the Honduran nurses spent their time improving my pronunciation and correcting inaccuracies: “Como lo veo?” I asked the ladies working in the lab. “You look very pretty today Doctora. Giggle giggle.” I had accidently asked them how I looked rather than asking how the labs looked. They appreciated the extra laughs.

The Honduran staff was a joy to work with, as was the medical missionary staff. I spent time with an ER doctor from the states, who to this day is so dedicated to teaching that whenever he staffed patients with me he inevitably made it home hours later than he normally would, solely from the extra time spent with me on the ultrasound machine or looking up new concepts. I was able to witness Mackenzie Slater use her full spectrum skills from VCMC as she delivered babies vaginally, did C-sections, worked in clinic and took care of ER patients. I was able to see how much she had gained even, adeptly carrying out obstetrical ultrasounds for dating and reducing and casting fractures in the ER. It was encouraging to see how much she uses her skills, how much her skill set has grown, and how happy she is post residency doing work that she loves.

I go back to back to medicine in a couple of days, then surgery service again in a month. I’m glad to continue learning, but am betting that the next time I do a chest tube, I won’t be in shorts and flip flops…

– Dr. Maggie Jolly

News, Projects

Pop Wuj Clinic & Spanish School in Quetzaltenango, Guatemala

October 20, 2014 nimDA

With the generous support of the Family Medicine Education Fund (FMED) I had the privilege to work and study at Pop Wuj, a non-profit organization in Quetzaltenango, Guatemala. Pop Wuj is a Spanish school with a medical clinic and several public health outreach programs that students participate in while learning Spanish. My medical work while at Pop Wuj was split between primary care at the clinic and public health community outreach through mobile clinics, a nutrition program and a safe stove building project.

At Pop Wuj clinic I saw a combination of the chronic diseases such as diabetes and hypertension, as well as acute illnesses such as diarrhea and parasitic infections. Much chronic disease management was similar to Ventura, but other diseases, such as some parasitic infections, I had not treated before. Many patients who visited the clinic lived in outside Mayan villages and often sought the help of a village healer or midwife before seeking a physician’s help. This added additional challenges and learning opportunities as we sought to provide culturally sensitive, but effective care.

The nutrition outreach at Pop Wuj consisted of sites in three villages where children ages 6 months through 2 years old came monthly to be weighted, examined by a physician and given nutritional supplements. Mothers of the children were given prenatal vitamins for themselves, regardless of pregnancy status, children’s vitamins for all other siblings and teaching on family planning. As part of the outreach I helped with the educational program, assisted in examining patients and helped prepare supplies for each trip. I found this an effective public health outreach due to the continuity with monthly visits and the focus on prevention. I would love to use a similar model in a developing country in the future.

Finally, the Safe Stove Project at Pop Wuj, was a project where families were taught and assisted in building stoves within their homes with a cooking surface and chimney, instead of using an open fire. This helped prevent prevalent pulmonary diseases in children and adults that are caused by fumes. Safe stoves also served to prevent burns experienced by women and children cooking or playing near an open fire. For the safe stove project I helped present the educational program to women about the health benefits of using a safe stove as well as helped build a stove in a home one morning.

Thank you so much for this opportunity to study and serve in Guatemala. I found my time at Pop Wuj enriching and I would love to return in the future to continue to study and serve. I grew in my language ability and experienced effective medical and public health outreach in a developing country. I know I will use this in future practice abroad. Furthermore, upon return I am happy to see how it has benefited my relationship with my Spanish-speaking patients in Ventura. Not only do I feel more confident and capable to converse in Spanish, but I have a better cultural context to approach our relationship.

– Dr. Alicia Parsons, PGY2

News, Projects

The Lake Clinic, Cambodia

September 29, 2014 nimDA

The Lake Clinic was started in 2008 by Jon Morgan, an American nurse with an MPH who had been the director of the Angkor Hospital for Children in Siem Reap, Cambodia for many years. The goal of The Lake Clinic is to provide healthcare to rural communities on the Tonle Sap lake. This is one of the largest lakes in SE Asia and provides one third of the protein for the people of Cambodia in the form of fish. More than 1.5 million people live on or around the lake, some in unique floating villages that drift with the rise and fall of the waters.

For the past six years, TLC has been taking medical teams by boat to eight of these villages to provide healthcare. The full-time Cambodian team consists of a doctor, dentist, midwife, registrar, cook, boat driver and clinic coordinator. Volunteer doctors are extra. They spend three days on the lake running a walk-in clinic and try to visit each village about once a month. I had the privilege of going on two trips to the lake as well as one trip to the Stung Sen river where TLC has a second team that goes every week to a remote village.

Clinic starts Monday morning just before dawn when the whole team meets at the office in Siem Reap and piles into a van with all of our gear. We drive out to the lake and then take a boat to the village. The trip takes about 4 hours, a difficult and cost-prohibitive journey for most locals. Once at the clinic (a 20×20 room built by TLC with a bathroom out back), we have lunch and then unpack. There are boxes of charts, carefully filed with histories going back more than 5 years. The dentist sets up her equipment. We lay out the pharmacy and hang curtains to create “rooms” to see patients. Clinic runs for a half day on Monday, then a full day Tuesday and another half day on Wednesday before we head back to town. We can see as few as 30 patients in a day or as many as 200 depending on the size and needs of the village.

The staff have been coming here for six years and know the patients well. There are a lot of musculoskeletal complaints as the people spend all day hunched over fishing nets in tiny boats. I saw the usual colds as well as diarrhea, likely related to poor water quality. TLC has worked hard to educate people about water safety and has even set up water filters in some villages, but it’s difficult to get people to use them and change age-old habits. Most of the kids have horrible dental disease, even as young as two years old, and the dentist stays busy doing extractions and fillings. The midwife provides prenatal care and advises women to go to the hospital for delivery, although most will deliver in their home with a local midwife due to the long journey into town. Interestingly, the government has mandated that all women deliver in a hospital with a doctor and midwives can be fined for doing deliveries. Because of the political culture it is basically illegal to provide training to rural midwives leading to persistently high maternal-infant mortality in rural areas.

On some of the slower afternoons I had the opportunity to do home visits. We saw an 80 year old woman with end-stage dementia, a 60 year old man paralyzed by polio, another 80 year old man who’d had a stroke. One afternoon we even got to visit one of the smaller villages to follow up with two patients who had recently had cataract surgery. When they can, TLC transports the locals back to town to see specialists or have surgeries. However, resources are still very limited. I saw an 8 year old girl on the river with congenital heart disease causing her to have very low oxygen levels. She’s seen the specialists at the children’s hospital and is on the list to have the life-saving surgery she needs, but the list has 2000 other children on it and it’s a long wait. In the meantime she’s already developed irreversible complications from her disease.

For information about the Lake Clinic, click here.

– Elizabeth Uno, PGY3