Back out of the black hole…

Second presentation done!!! Sorry, it was a bit of a time suck, so didn’t get to update the blog this week, and then was on call last night.
Lots to tell:
Went to Roatan last weekend, to go diving and hang out some. Overall a nice weekend (hard not to be…), but as Sanjeev commented (a UCSF peds resident who spent 4 weeks in Jan at a clinc there), not a very “Honduran” experience—lots of tourists, and lots of English. The interesting part about the English is that it is spoken not because of tourism, but because many of the Islanders are descendants from Carribbean pirates. The English is heavily accented, with its own grammatical syntax, so that when youfirst hear it, it sounds like another language… I had some nice chats with people there, particularly with a guy my last night there who hangs out and does odd jobs on the island, but just got married to an American Anthropologist in January, and told me a lot about growing up in Roatan, particularly his relationship with his father, which was not so good… People there were friendly, but less fun to hang out with than the people I’ve met on the mainland. A hilarious amount of shock and surprise that I was traveling alone—the men seemed psyched but confused, and the women a little hostile. One waitress at the end of a dinner came over to my table to get me my check and verified that I was the woman eating alone, and that I had had the grilled tunaJ There is a lot of trust on the Island, at least in West End, where I stayed—I walked out of my first morning dive without paying since I was going to come back in the afternoon, and when I wetn back to pay, they made sure I paid in cash so that I wouldn’t have to pay the 16% tariff on the credit card, and told me I could come back in the next few days to pay if I didn’t have the cash with me.
The diving was better than Hawaii but not as incredible as Fiji. Amazing visibility, and some beautiful moments above coral beds, with gorgeous schools of fish, and a large grouper, etc, only the coral was not as vivid as the soft coral in Fiji. No majorly exciting sightings either, but overall really nice to dive again. The other good news is that I finally was not cold while diving—used a 5mm suit, very warm water, and two hats. The male divemasters thought I was crazy, and all the women divemasters told me what a great idea it was to have two hats. Also, for those of you thinking of going there, a bit about the shops I used—Ocean Connections and Coconut Tree divers. Ocean connections—pros: they got back to me fast, and you can pay with PayPal. Cons: very old wetsuit, the divemaster did not know I was coming, so planned an advanced dive and then made a big deal about changing it, though was great after he had adjusted to the change. I ended up leaving to go to Coconut Tree partly because of the wetsuit, and because they do two tank dives in the AM, which Ocean Connectiosn does not (you can go out further on a two tank dive in general). Coconut Tree inspired a lot more confidence and was fun to go out with. They also have you take care of your own gear, which was a first for me since we learned and was fun to do again.
One other bit of wisdom from the local guy I hung out with my last night there—all the shops in West End have ex-pats divemasters. Only Anthony’s Key, a resort down the road from West End, uses local guys. Anthony’s key also takes out more divers than anyone else on the Island each week, and is pricier than anyone else on the Island, but apparently has very new and nice equipment and he seemed to think was really a great place to dive. Not sure if it would be worth paying the extra money, but I did notice that my divemaster the second day at Coconut Tree did not seem to know his way around the reef very well and a local person might have been a better divemaster. Lastly, I got a nice compliment from the divemaster and some of the other divers on my second day, who were all surprised to hear that it had been only my 21st dive. The divemaster said that in terms of air usage and buoyancy control, I looked more like someone with 100 dives down than 20. I would say Jonathan can share the compliment…
Back in Tela, I worked on my presentation on Asthma all day Monday since I missed AM rounds coming back (I warned them ahead of time that I’d be gone..). I went to Arizona, one of the nearby villages, on Tuesday, in order to do home visits with one of the doctors there. Unfortunately, she was in an accident last week, and though we had arranged to meet on Tuesday AM, she was not there that morning, so I observed in the clinic and chatted with some of the nurses there, watching them give vaccinations—they give oral polio here, and mix the two month shot all in one syringe, delivered in one shot. Most moms were pretty relaxed and the babies stayed in their arms for the shot. Child development is the same here and the US—all the four year olds cried hysterically before getting the shot—luckily I had some stickers with me and managed to surprise them into forgetting the shot with some nice sparkly starsJ
I had some ice cream on my way back home from a little ice cream jingly cart—not great ice cream, but it is HOT here now, so fun to have a sweet cold creamy snack.
Wed was a regular work day—AM rounds and Afternoon ED work. The unfortunate news is that the mother of the Pediatric attending who is on for this week died on Monday or Tuesday and he went to Tegucigalpa. Everyone else is on vacation or on bedrest, so I rounded in the mornings with one of the young Family practice doctors. She was nice but assessed all the patients and made all the decisions this week, and had me do discharge paperwork. A little odd, but I think she was nervous and doesn’t know me, so I helped in the ward, and then had more independence in the ED. Saw some pretty bad asthma flares and a kid with rickettsial disease had come into the ward over the weekend. I also discharged Gloria, the girl with Kwashiokor (severe malnutrition), who looked a lot better—smiling everyday, with almost no abdominal distention. She is going back to her family, but there is going to be follow-up by the agency that is the CPS equivalent. In an ideal world, she would have stayed longer in the hospital to get a little more reserve (her Hgb at d/c was still 7.6—low), but that decision was not mine, and may not have even been the other doctor’s completely (d/c planners were involved…).
The talk yesterday went pretty well—I decided to focus on the model of treating asthma as a chronic disease, since the model for kids here is mostly to treat asthma attacks in the hospital or ED, since the only home medicine readily available, ie at the hospital pharmacy, where the co-pay is Lps5=25cents for all the medicines in one ED visit, is oral Salbutamol—the equivalent of albuterol liquid. Occasionally inhalers are available, but only sporadically—the next shipment is expected in May. Albutamol and steroid inhalers are available at private pahramacies, but they cost Lps135~$7.50 for salbutamol, and Lps200~$12 for beclametazone. For the presentation, I did alittle research about the morbidity and mortality of asthma in Honduras, and the local catchment, and used the recent Peds in Review article about Asthma epi to illustrate the magnitude of the problem in the US. I also described the asthma clninc at SFGH as an example of how to approach asthma preventatively. Not sure how people would react, I suggested at the end of the talk that we could act as advocates for our patients to try to get more inhalers available and to do more parental education. There wasn’t much of a reaction, but someone mentioned that another trigger for kids here is that people cook over open fires in the houses or right next to them. Education won’t help much, since that is the only way for people to cook if they can’t afford gas. Some of the residents stayed afterward chatted a bit more. One of them had been to a meeting recently about the most up to date developments in treating asthma, and explained to the other residents how to use the Peak Flow meter I had brought. It seemed like there was a range of experience and that it was generally an approach that they were interested in. Giving these talks was generally fun to do—hard work translating things, but definitely improved my Spanish, and a good challenge to figure out how to present info and ideas here—but hard to know people’s reactions since no one gives negative or constructive feedback, and the positive feedback is fairly general. It may also be that there is not a culture of discussion in general in the medical training here, so there was less discussion than here might have been if people had felt like they could react out loud to the ideas in the lecture.
My call nigh tlast night was fairly benign, though very busy in the first half. There had been an accident in the afternoon, and so the line for the less acute cases had gotten backed up and everyone was pretty antsy when I came on. At one point I had two families come into my room at the same time, about ready to come to blows, each claiming they were next in line. I got the nurse to be the bad guy, because it was beyond my Spanish ability to mediate. The woman who was asked to wait gave one of the nastiest looks I’ve seen here to the other woman as she walked out… The good news is that when I went to get the nurse, the mother of a kid at the end of the line grabbed my arm and told me her daughter was having trouble breathing—very bad asthma flare, so I got her treatment going immediately on my way back into the stand-off.
A few other stories from last week—two broken bones: the first in a 7 year old boy, who had fallen two days before, and hit his head. His mother brought him in because she had heard that if you hit a part of your body, you can get a tumor there later. I reassured her that he was not going to get a tumor—“Yes, I’ve heard other people think that, but getting hit or falling really will not cause a tumor. Which is a good thing, because think how much kids fall and hurt themselves—all the time!!” then she asked me to look at his arm, which she said also had gotten hurt. One look and it was clear that the bones were not totally aligned, but oddly, he didn’t mind any of my pushing or prodding, had full strength, and didn’t mind my flipping his hands around or moving his elbow joints, etc. When we looked at his x rays, he clearly had broken both of the bones of his forearm, but they had already started to knit back together, a sign that he had broken them at least 2-3 weeks ago. The mother had no idea when it might have happened, and he didn’t seem to know either. Unfortunatley, he had to come back the next day for them to be re-broken and re-set. I’m not sure if the boy just had a very high pain tolerance and didn’t tell his mother, or if something odd had happened—child abuse, or something the mother was embarrassed about. Given how worried she was abou the bump on the head, it seemed like child abuse or neglect was less likely, but still hard to know what to make of it.
The other story was a 21/2 year old who had been lying under a car when someone had started driving it. Miraculously, she survived with a broken right arm and hairline fracture of her left femur, and a scrape on her cheek. Her mother was so relieved that her daughter was still alive, she didn’t mind the wait to see the Orthopod.
Another case of kerosene ingestion and aspiration, and a 2nd dgree burn from hot butter in the ward convinced me that well-child checks focusing on safety might be a good idea after all. Occassionally I feel like the well-child check is not so crucial to kids health, but just anecdotally and with no evidence of etiologic connection, there seem to be less preventable accidents in SF than here.
Okay, enough philosophizing.
This will probably be my last blog posting, as I leave tomorrow morning to go back to the states but check one more time next week, as I’ll post pictures and give any other updates I might hear.
Feel free to e-mail with questions and comments!!
Take care, Naomi

Presentation done!!

Yippee!! For thos eof you who do not know, part of the Yale program is for the residnet to give two lectures7teaching sessions at the host hospital. I gave the first of the two today--in Spanish, with overheads (prepped on my laptop with powerpoint and printed here on Isabel´s printer), and lasting about 50 minutes. The topic was febrile seizures and in general went shockingly well--no major technical flaws, and generally nice feedback. Unfortunately, my audience was mostly attending level doctors. It was thought that the audience would be a mix of attendings, residents, and nurses (ED and peds) but unfortunately the residnets are in Tegucigalpa for a seminar, and most of the nurses had to go to an administrative meeting... I had designed it to have something for all levels, which made it a bit too basic for the attendings. Fortunately, my highlighting the differences between here and the US management made for some interesting discussion and so I think even the attendings generally thought it was interesting. The best part is that it´s done!!! Now I can start working on the next one... Next week, Thursday at 8:30:)
for those residnets reading this, the lateness to conferences with guest speakers is a common problem world over and I took no offense that people dribbled in:)
Just to make my day more exciting, I was woken up at 5:30 am by a call from the hospital that they needed me to come in for an emergency C section. Why me: two nights ago, Dr. Vasquez, the peds attending, left for the day and night for a meeting in San Pedro Sula. Because they had no peds in house, they were sending all their emergent c-section to San pedro sula, to another hospital. The definition of an emergent c-section in general, however, is that it is an emergency, so the extra 1.5 hours to SPS may put mother and baby at risk. At Isabel´s suggestion, I made myself available to go to uncomplicated C-sections. I didn´t end up getting called and I thought it would be just for that night, since Dr. Vasquez came back the next day. But there was some miscommunication and so I got called this morning. My ride arrived about five minutes later, so it seemed silly to insist that they call Dr. Vasquez, so I went and helped out. The c-section indication was basically for failure to progress--the birth stalled out because the baby was too big to move through the mother´s pelvis. The baby came out without a problem, complaining loudly and reassuringly about the cold...
The other indication that I´m getting more absorbed into the fabric of the hosptial is that I got consulted today by the orthopod, who was about to do a closed reduction of a fracture for a 5 year old, and the kid had just developed a cold. He asked me to start treating it immediately so that he could try to take the kid to surgery in the AM. I refrained from pointing out to him that there aren´t any good treatments for colds that make them go away overnight. After a thorough exam, I prescribed Ibuprofen and benadryl (see if we can dry up those secretions :) and told the social worker trying to decide what to do about the kids admission that it would be up to anesthesia in the AM. It will be interesting to see what happens. It sounded like in the OR the kid had a coughing fit and made people worried, but he didn´t cough once for me (about 1/2 hour and sounded better than I do--I developed my own URI a few days ago:)
It´s nice to beging to feel like I´m part of acommunity here.
A fascinating culture tidbit from the ED yesterday--a woman brought in her child for avisit, wearing a jewish star necklace! I was so curious to ask her about the jewsih community in Tela, which I fiugred didn´t exist, and find out if she was honduran, or maybe spanish.. when I finally asked if she was Jewish at the end of the visit, she looked totally confused. I pointed at her star and explained that in the US people who are Jewsih wear stars like that. She looked less confused but reassured me several times taht she was not Jewish and that she just was wearing the necklace as anecklace, nothing more... So interesting. The added twist is that her daughter´s name was Sarah.. Not sure what to make of the whole story...
Okay, off to my call night and then to Roatan tomorrow. I´ll try to wirte from there if anything interesting comes up!!
Love, N

One more funny story...

Another hilarious snippet about what happens in a country whose house architecture is 50 years behind some families' technological capacities (see prior mention of internet access but no hot running water..).
The house I'm living has loose boundaries between it and the outside world--ants wander in and out, the shower stall empties out into the garden at the base of the wall, etc. Isabel told me that they have owned two other computers but that they had been replaced because they had broken down. The demise of the first was actually caused by the explosion of a Gecko inside the housing for the motherboard, who happily took up residency there for a bit, fattened up on bugs inside, until he couldn't get out, and somehow died dramatically inside, incapacitating the system:) Hard to stop laughing about that one..
By the way, I stayed in a really nice and freindly BandB in Copan--Casa de Cafe.
http://www.todomundo.com/casadecafe/
Beautiful veiw and very nice people, and breakfast served outside if you want...
I also went on sunday AM to a lovely butterfly park, with an incredible number of beautiful and intersting butterflies. I got there early and so they were all asleep and I took some interesting pictures.. They eventually woke up and so I got to see them in all their frenetic and amazing flight as well.
Okay, enough for today! Thanks for reading! Hope everyone is doing well.
Take care, N
ps. Congrats to Rebecca (my sister) who underwent Lasix surgery (vision correction) last week and can actually see well since the age of about 6? without her glasses.. pretty mind boggling when you think about it..

Back in Tela

Sorry for the hiatus, had a long trip back to Tela from Copan yesterday. See entry below from an e-mail I sent on Saturday:
I had a great day today, wandering around the ruins (the Ruins of Copan are Mayan ruins from the time of the Mayan civilization in Honduras (100CE--7th or 8th century), having lunch at the little spot outside them, going to the Macaw Mountain afterwards, a bird park with an incredible number of beautiful birds in cages, all previously domesticated and donated to the park by foreign business people living in the Bay Islands (Roatan, Utila, Gunaja), who were leaving to go back home and wanted to get rid of the birds. Fun pictures--me feeding macaws and holding them on my hand (I'll post if I get a chance).
Also some fun spanish moments--couldn't find a guide at the ruins who spoke English, so hired one who guarnateed that he would speak VERY SLOWLY:) He did, and I understood almost every word. He was a great guide and really interesting stuff. Even told me some stuff that updated things in the guidebook (new archeological understandings of the ruins, etc). Everyone is so friendly--a group of herbalists from Guatemala, Honduras, and El Salvador were also at the ruins and one part of the group adopted me into their tour for a bit, chatting with me and inviting me to listen to their guide. I got my own after a while, thinking it would be good to get a slower sppeaker, and feeling a little bad about being parasitic:) I figured it was also a good Spanish lesson, which it was:) At lunch outside the ruins, a guide on his lunch break struck up conversation so I had company for lunch. He's been guiding there for 32 years, had no front teeth, and had good english and even a smattering of Japanese. There seems to be some kind of relationship between the Japanese and the ruins, as someone in Japan (a princess?) donated a tree in the park----prominent signs, etc.
At the bird park, my guide (included in admission) was from Modesto California and spoke native english. It was pretty funny to adjust back to speaking fast and fluently with him--took a while for my brain to switch, so I sounded a little stilted for hte first few minutes... it turns out he is originaly Peurto Rican and met his wife (a native Copan girl) when she was on an exchange program in the US. He was so smitten he offered to move back to Copn with her so she could finish her exchange committment (min 2 yrs). He has a new 2.5 mo old too:)
site to Macaw Mountain: www.macawmountain.com
It's truly a lovely place to visit, with great coffee as well (the hotel where I was staying gives out coupons for a free cappucino there). I bought a 1/2 pound for the house, which Isabel and I tasted today and decided it would be great for the pre-call caffeination since it is so strong..
At the hospital:
Only had two patients in the gastro room today,so inheirited the respiratory kids as well (pneumonia, asthma). Interesting to take care of a diferent class of disease, and useful since I'll be ginving a lecture on Asthma next week. Luckily brought along a bunch of asthma stuff (including the Peds in review Asthma updates..) and action plans in Spanish.
After AM rounds, we zipped off to a STAT C-section for twins with pre-eclapmsia. They both did well, and from there we zipped off to visit the new hospital. It turns out that they were doing computer training for several of the attending doctors today (they will have labs, and discharge notes on computer file, as well as pt info (demographics and diagnoses, and hosptial bed). It is a web based program, and dare I say far more user friendly than the UCSF computer systems. they will not be able to write orders, or do daily progress notes, but the program has the capacity to do so if they have the money to develop it. The computer trainers were from Spain, whose government donated the money for the hospital. It was hilarious to hear the Spanish accent, and find it easier to understand than the Honduran one:)
By the way, the guide book is very reassuring on this point--it warns that Hondurans elide words constantly and speak super fast. This means that learning spanish here is kind of like learning to drive on a MAC truck, but now that the initial pain has waned a bit, it gives me a fair amount of confidence in my abilities to understand Spanish in multiple accents:)
Illustrative of how the ellision can fool you, I was confused last week when a woman told me she had given "Cacercera" to her son for stomach pains. I finally asked one of the nurses what that was, and it turns out the unknown mystery med was none other than Alka-Seltzer:)
By the way, congratulations to Ely and Pilar, who just had a healthy and hairy little boy!!! I can't wait to meet him!

Off to Copan!

I'm going to the ruins of Copan in a bit. Just a quick update to say that my call night last night was pretty good. Sick kids in the ward (a 1 year old with bad pneumonia that probably needs surgical drainage, but we're throwing tons of antibiotics at it right now (Ceftriaxone, Chloramphenicol, Oxacillin, and started with Penicillin). The kid is still with ongoing fevers and breathing fast. Otherwise looks pretty well--cheerful, alert, cute. Another kid, 2mo boy, who had a cough and they parents tried to treat it with a type of animal oil (cusuca?) and he choked and breathed it into his lungs. We gave him a lot of supportive care overnight and luckily he looks better. The last interesting new case is a 7 month old with probably a Ventricular Septal Defect (basically a hole in between two of the four chambers of your heart)--loud murmur, large heart, who comes in with bilateral pneumonia, so is decompensating. The mother came up to me when I was making evening rounds and asked me if her child was going to die that night! Initially terrified I'd have to tell her he might, I was thrilled to see him playful in his bed tolerating the plastic tubing delivering Oxygen to his nose very well. She looked more relaxed the rest of the night. Not so different from any parent in America in terms of having a very basic worry about your kid, but maybe an american parent would not have asked so bluntly about prognosis. It seems like the fact that he was on Oxygen was what made her think he might die...
I saw a few kids in the ED and felt much more comfortable with discharge plans having seen the Centro de Salud, etc. Also feeling more comfortable in the ED in general. I like the nurses, have my own little office on one side, and last night felt very comfortable consulting with the two younger doctors on call overnight. They consult with eachother all the time which makes it fell very collegial.
The other interesting thought last night was that there is a tension between being a visitor and observer of another medical system here and being a doctor with a sense of responsiblity to patients. For instance, in the treatment of asthma, I have not seen people using controller meds (meds that prevent the lungs from becoming very reactive, so that when an asthma exacerbtion happens, it is not too severe). In the absence of understanding why they are not used, I have not been prescribing thme either. My project for next week is to find out how much it would cost the family to buy a controller medicine (patients pay for the meds themselves, and the added expense may be why they don't use controllers..)
Ooops, late for my bus!
More later...

Some good, some bad

Some of the medical stuff today is sad, so feel free to skip if you´re not up for it...
Life:
I have been staying at home alone the last few nights as Isabel had shifts form 3pm-7am the next day on Monday and Tuesday, poor woman. She leaves me some food to fix for myslef before she leaves and last night I had a very yummy combo of fresh fine cut vegetable salad (a la Israeli salads) with fine cut pan fried chicken and salty cheese, all wrapped in small corn tortillas, with fresh pineapple for dessert. She´s a fantastic hostess and lets me help with the dishes. the only danger to that is that the faucet on the kitchen sink (which enters into the house through the kitchen window) has a tendency to explode off when there are changes in water pressure, and soak the kitchen completely. The past two nights I have been making as few dishes dirty as possible in order to try and avoid an explosion. It´s hilarious when it happens, but you need two people to stop it--one to hold the faucet in place (that one usually gets soaked), and one to walk outside to turn off the presssure..
Medical:
Not the sad part:
Today I got a bigger picture of what the health care system looks like in Tela. I was supposed to go visit some of the local villages and make house calls with one of the doctors here, but she was in a car accident on Sunday, so was not going out. Instead, I explored the hospital and the Tela Centro de Salud (outpatient clinic--delivers vaccinations, infant-maternal health, as well as urgent care for the entire population who cannot afford private clinics). In the hospital, I went to the laboratory, to observe what happens when I send someone there to get a test done. I learned that, actually, I am supposed to give the patient the urine collection bag (whoops!) and that kids (even older ones--8 years old) can get a finger prick blood test for a full CBC with diferential (in SF, we rarely do this, even for younger kids, unless they are neonates). By the way, also interesting is that the urinary tract infections we diagnose here are based only the microscopy of bagged specimens (they ran out of Urine analysis strips at the hospital). The complicating factor is that most kids who have white cells in their pee (the diagnostic criteria for UTI) from the bag also have diarrhea, so it´s hard to feel confident that the white cells represent UTIs and not white cells from inflammation that is part of the diarrhea..
I also watched one the lab techs look for parasites in feces (lots of feces there...). Unfortunately none came up positive while I was there, but maybe I´ll go back tomorrow to see what ascaris looks like live under a microscope. Not to worry, I´m not planning on eating those worms:)
The sad part about my day (skip if you aren´t up for the sadness):
Two of my kids on the wards. One came in yesterday with severe malnutrition--swollen belly, extrememly thin arms, 8 years old and weighing 40 pounds when she came in, and promptly losing 4 pounds overnight when we gave her medicine to take off the extra fluid in her belly. She is a beautiful girl and it made me so sad to examine her. She had no family members by her bed, so the rest of the parents in the room were trying to take care of her--take her to the bathroom, get her a blanket when she said she was cold, etc. She started crying a few minutes after I examined her, so I went over to ask her what was wrong. When she didn´t answer, I just sat and patted her until she calmed down and fell asleep. The saddest part is that even though she is in the hosptial and we will treat her, she got to this state secondray to neglect, and my doctoring abilities fall short of curing that. I´ll find out about the possibility of foster care, but I think it has to be initiated by the parents, without a state agency similar to the american Child Protective Services which could take her out of the care of her parents.
The other kid, 6mo girl, also came in with malnutrition, with severe anemia (Hgb 3.8), and parasites. She is going home today, but I also don´t have much hope that she is going to go back to a healthy life. Her mother is very attentive, but thin herself (unlikely that anyone in the family is eating well) and doesn´t sem to take great care of her daughter in terms of hygiene. Not clear if it because of a lack of money, or education, or both, or something else. I was crying a little while I was writing my notes, feeling so sad. I spoke with Isabel about it after I came home since no one else in the Ped ward seemed to be as affected as I was since they see this all the time. I spoke with Isabel about it after I came home, as she knew about the girl who had gotten admitted yesterday (have I mentioned that the hospital tends towards the gossipy side?). i consulted her on how to counsel parents when they leave about hygiene and nutritition (first find out if they have a latrine or no. If no, get a socail service perosn to try ot get one to their neighborhood. If yes, tell them to keep it covered to prevent flies from getting into the latrine and then landing on food, tell them to clean it well once a week, and also tell them to keep their food covered). She said that the families are unlikel to be able to afford meat, but that they could maybe afford eggs, and could raise chickens in their backyard...
The last sad, mind-boggling, and not-for-the-queasy story (ie, really don´t read if you get grossed out by medical stuff) from today is that a 10 yr old girl admitted on Monday from the emregency room for parasites, severe anemia (hgb 2), and malnutrition, had died overnight that night from the ascaris (parasitic worm) in her body. Sometimes, when the ascaris burden is so high, they can block the intestines. If it as complete obstruction, they may need an operation to remove the worms. She had an obstruction, and so they planned to operate, but the worms came up out of her esophagus, and into her trachea and out of her large intestine onto the OR table, and she died ( aknown possible complication with anesthesia). See the follwing site for more info on Ascaris: http://www.emedicine.com/ped/topic145.htm
The funny spanish momnet in my day happened right after I heard about the above case. The woman who told me about the girl moved on to a new subject after she told me, but I was so distracted by the story that I didn´t catch the change of subject and all of a suddne she was talking about breakfast, and eating. It turns out she was telling me that she was going to go eat breakfast and wanted to know if I was going ot stay or go but for a moment I thought that she was telling me not to eat breakfast since I had been working in the peds department and maybe I would also catch ascaris if I wasn´t careful.
Enough for now. Sorry for the downer entry. I think it is the nature of the experience, but hopefully I´ll learn enough to help in some way. By the way, started seeing patients by myself in the ED yesterday. Interesting similarities and differences between here and SF ED.
Love, N

Taking call and going down river...

Back again after a weekend awayto rest my poor Spanish besotted brain and explore the rivers and jungles of Honduras (well one anyway)...
Call night:
Easier than I expected, as I ended up not being primarily responsible for any patients that night. Arrived at the ER with baleadas in hand from Isabel (snack food for the evening) and was introduced around. There were two doctors on call, though not the lovely lady who was supposed to be there. I think she´ll be back next week. AS it was busy, and neither doctor was up for doing an orientation, I observed for the night until about 2am. It also felt much more comfortable for me, as the combined challenge of understanding patients, writing notes and orders efficiently as well as arranging follow-up was too big for me to take on that night without feeling like I was giving bad patient care. At the end of the night I felt like I had a better handle on things, however, and a good back up plan for how to feel comfortable in the ED--ask one of the MDs to read all my orders before I send the pt out (they go and buy meds at the hospital pharmacy, then come bring them ot the ED nurses to have them administered, then return for re-eval), and árrange ahead of time to pass on any unintelligble patient to one of the other doctors. I´ll be working there during the day this week, so will adjust better before my next call night.
Interesting cases--a woman who had fallen and broken her hip and could have been in SF as easily as Honduras. Also a guy brought in form jail for STD evaluation--also could have easily been at SFGH, from the handcuffs and guard to the social worker who came in to explain what was needed, to the guy embarassed that the young resident evaluating him was a female. She was very professional and normalized it for him.
Also interesting--ultrasounds are not so easy to get overnight in an American hospital, but at least they´re in house during the day. The nearset ultrasound is one town over, so referrals are to the next town and then the patient is supposed to bring the report back to the Centro de Salud for evaluation. Most bizarre is the poor folow-up system. For example, the 11 year old girl who came in for evaluation for a midline swelling on her neck in the front. To my exam and the MD I was following, she did not seem to have any thyroid masses and the mother reported a history of a cold and then one day of the neck appearing swollen to her (thought not to us).
One option in this situation is to give reassurance and follow-up to see how things evolved, and consider having the PMD to the follow-up. The MD here gave a referral for an ultrasound to evaluate the mass and follow up at the Centro de Salud after. My impression is that if there was a PMD, it would be easier to have plan no 1 as a viable option and probably result in better overall health care...
The continuity in the ED is also minimal--when a patient returns from getting their medication administered, they can be evaluated by the other MD in the ED. For example, I was consulted on a 11mo girl who needed a respiratory treatment, and when she came back after the treatment, she was seen by the other MD. Since I was in the room, I did a second check of here breathing and could give a before and after assessment.
I´m looking forward to getting back to the hospital tomorrow, finding out the updates.
More later.
Rafting on the Rio Congrejal
Spectacularly beautiful and VERY exciting river. Class 3-4. A few exciting momnets from Sat: Running one of the class four rapids (basically a six foot waterfall, with some nasty rocks at eh bottom, but incredibly beautiful), we flipped at the bottom (the whole boat dumped, luckily towards the upstream side, so everyone got flushed downriver). Scary momentarily, but everyone had a totally fine swim and the two other passengers in teh boat had already fallen out above in prior rapids, so happily took it in stride.
Teh second moment was jumping off a twenty foot cliff into the water below--clear, green, gorgeous water, (and a very safe jump, for those worriers among you. I promise I will not do anything that puts me at greater risk than crossing the street in NYC:) I balked right before I jumped in the first time around, but after talking someone else into doing it, I decided to ignore the natural instinct that was telling me not do jump, and had a lovely plunge into the water below..
I loved the rafting so much I decided to do it again today, but went with an entirely different gorup of passnegers. Sat I went with two Australians who had been traveling for 1.5 years, and very happy to raft and play in the water. Today was a gropu of 11 middle aged American tourists, more monied. Two were New Yorkers, one of whom was a Barnard alum. There was also afamily practitioner from Vermont, who liked hearing about the medicine I was seeing here. Much less adventurous group, so much so that we skipped the higher class rapids compeltely (including the prior flip site:), but went for a hike to a waterfall and had a picnic lunch instead.
the hike was notable for the termite nest we came upon, which our Venezuelan guide told us was an excellent source of food in the jungle, not to mention a good mosquito repellant: `smear it on your skin or burn it under your hammock and the mosquitoes will stay far away´ and then he proceeded to show us how to eat them as well--stick your finger on the nest and ther termites climb right on... Then lick the termites off your finger!
Needless to say, I eventually had a termite snack. They take on the flavor of the tree they´ve eaten, so tasted somewhat like Eucalyptus to me:) I also ended up clambering up a vine called a monkey tree, beautifully curved, ala Andrew Goldsworthy for those who know his work, but naturally occurring.
It was intersting to be among English speakers again. A nice relief for my broken brain, but I´m glad to be back in Tela, speaking in Spanish and watching Spanish TV again.
Hasta pronto! N

On Call tonight....

On the medical side:
I discharged one of my patients today--a very sweet 5 yr old, came in with severe anemia..Hgb 4.1 (pretty much qualifying him automatically for a blood transfusion). Secondary to parasites--ascaris, hookworm, and amebiasis. He needed to get transfused twice and was only about 25 pounds when he got admitted. He was in the hospital for about a week and is still startlingly skinny. He was eating today (yesterday his appetite was not so good) and had a little more energy, but I would have felt better if I knew he was going back to a situation in which he would have easy access to clean food and water. His mother thought he was much improved, and his stools are not bloody, so I´ll take what I can get and hope he comes back for follow-up as scheduled a week from tomorrow.
After morning rounds, an admit came in from the ER--and 11 year old boy with severe anemia--Hgb of 1.3!!!! (basically close to having water for blood) but in no distress, meaning it has been dwindling slowly, but recently probably got acutely worse, maybe secondary to a heavier parasitic load. Still waiting to find out what kind of worms he has. The nurses and doctors moved fast to get him transfused, but also pointed him out to me, knowing from experience that we do not have the same problem with parasites in the US and that it would be rare for me to see someone with such severe anemia from them. One of the nurses commented with a touch of pride/enjoyment of sharing a good story that she once had a Hgb of 4...
I´ll be taking call tonight for the first time--in the emergency room. I was nervous about it, until one of the interns gave me a quick summary of what to expect: one VERY nice, and apparently quite beautiful:), internal medicine resident who would orient me to everything (whew), and a lot of very nice nurses who would also be my saving grace. Also, families who might have registered one kid, then bring in the father, the two siblings, the cat and the dog, all to get checked out as well:) He told me to draw the line and find out which one is sick, and move on. Intern aculturation clearly has some world-wide similarities:) (not sure if aculturation is a word, but it certainly could be in spanish, and definitely something I would make up nowadays in order to get my ideas across).
Orderlies in the ER start IVs and draw blood also. Should be interesting.
Unfortunately, not much of a caffeine supply available overnight, so Isabel is making me a large cup of coffee before I go to the hospital.
Other life updates:
I´m sitting next to a teen in the internet cafe and explaining to him how to use Babelfish to translate something from Spanish into English.
I´m supposed to give two lectures in Spanish to the interns and nurses, and maybe some of the residnets. First one will happen next week and I´m supposed to cover "febrile seizures" Wish me luck!! Maybe I´ll be using the Babelfish service myself:)
I had a dleicious drink, called a licuado, yesterday. Basically a milkshake but with yummy fresh fruit--banana and pineapple (peeled fruits only..not to worry). Bad for the lactose intolerant part of me, but delicious nonetheless.
Hasta Pronto!
I´m off to raft tomorrow, so may not get to update until Sat or Sunday again.