Wednesday, August 30, 2006

Michael Journal 1

I’ve been here for a whole week, already, and still not a single Starbucks in sight! In fact, there's no sign of corporate America, except for the occasional 21st Century Real Estate sign and a Bojangles (which I’ve never heard of anyway). I must admit that this was a bit unexpected, because after reading about how Roatan was a resort island, I expected some measure of corporate America following the American tourist. However, it is really refreshing to be here in a completely foreign land, with very few recognizable symbols of America. It’s almost as if Roatan is back to the basics, building everything themselves with little reliance on American culture.

Anyway, I’ve been here for a week, and I love it here. My week here has been everything I expected and more. The community of volunteers and health workers here is amazing and has introduced me to an entire movement and purpose to provide healthcare to developing countries. Peggy and all the other volunteers here have read Mountains Beyond Mountains, which tells Paul Farmer’s story of building clinics to provide healthcare for developing nations, and they all seem to swear by the book. It’s very encouraging and inspiring to see such devoted and proactive workers who come out here and build entire clinics from the ground up out of their own will and initiative. I’ve just begun reading the book today, and I hope to finish it soon.

I’m enjoying working in the clinic as well. Monday was a very daunting day for me as Molly tried to fill me in on everything I needed to know to run the clinic, from the location of different meds to how to take a history in Spanish to showing me around Coxen Hole. At first, I was very intimidated by the two attendings in the clinic too, Dr. Rom and Dr. Karina, and I was not very confident at all – it’s very intimidating to call a patient in front of 20 other impatient mothers. However, as the week went on, I became more confident in my ability to perform the job. Although my Spanish wasn’t as good as Molly’s, I found that it was enough to communicate easily with most patients. I learned that Karina and Rom weren’t nearly as scary as my initial impression of them. I started to get the hang of giving meds to patients. And most of all, I really enjoyed being able to help the patients – I loved the feeling of walking into the hospital every morning knowing that I was going to help the dozens of sick patients I saw sitting on the benches. I’m glad I can help in very direct and meaningful ways here, as opposed to the limited role we students are allowed legally in the United States.

I’m also enjoying my time outside of the clinic. The last few days when Molly was here were spent traversing the island with the other volunteers. On Sunday, a bunch of us went to the east end of the island by car and enjoyed the white sandy beaches there. On Monday, we went to a beautiful hidden swimming hole called the Creek by boat. On Tuesday, we went hiking through some of the poorest barrios called La Colonia, which was formed when a lot of the poorest islanders living near the coast fled up the hillside in 1998 during Hurricane Mitch and squatted on the land. The houses there are built up a nearly 30-40% grade hill, and there is little infrastructure of running water or sewage, creating a huge health risk. It was mind-boggling to see how humans were forced to live under such poor conditions.

Other than that, I’ve occupied myself with swimming, snorkeling, kayaking, cooking, and reading. I’ve had a lot of time to relax, and I think this month is going to be an excellent way to end the summer.

Tuesday, August 22, 2006

Molly Journal 4

I’m just days away from my departure from Roatan, and I can’t believe it. Somehow, this city girl managed to adapt to the island life. I spent the last few weeks happily doing the same things each day at a very relaxing pace. I am so grateful for the opportunity to have worked in the RVPC with Dr. Charles, Karina, and Rom. They really made an effort to include me as they treated patients and I learned quite a bit in the process. I’m also thankful for the relationships I was able to form with patients and their families. This is the aspect of medicine I look forward to most. Finally, I will not forget the peaceful walks home from the gym at night where nearly each night afforded a sky with an incredible display of stars and an accompanying lightning storm.

A quick summary of my last week in clinic: The patients we saw were sicker this week, and many had very interesting histories and diagnoses. Thus, although we didn’t have too many more patients, we spent a lot longer in clinic. I also learned that the nurses had been cutting us off at around 15 patients, which is absurd because we had two doctors each day. We asked them to make the default about 25 appointments per day, which will increase when Charles returns from the United States next week.
On Friday, the second baby died in the wards since I’ve been here. Although I was not there to see it happen, both Rom and Karina were really affected by what happened. Apparently Karina showed up in emergency to admit a patient from the clinic and saw a baby that was on the ward turning blue. The resident was suctioning the baby but no one was using a bag or trying to resuscitate the infant. She ran back to our clinic, got a bag, and tried to resituate the baby herself, but it was too late. Although everyone agrees that the baby should never have died, it did have signs of multi-organ failure and its prognosis was not good. Nevertheless, it seems hard to imagine that something like that could happen under the care of trained medical personnel in a hospital.

The other baby that died weeks ago died because of some kind of misunderstanding between the mom and the doctors in Roatan. She was told to get to a public hospital in La Ceiba for an exchange transfusion for her baby who had Rh disease, but she went to a private doctor on the mainland who told her that her baby was fine and needed no treatment. By the time the mom brought her baby back to the hospital in Roatan, he was essentially dead. This was a tragedy because the baby’s prognosis was good and the treatment for Rh disease so standard.

These are the kinds of situations that make practicing medicine in a third world country seem so difficult. I have heard Karina and Rom express frustration about the lack of available diagnostic tools or even standard first/second/third line drugs for treatment. I can only imagine how difficult it must be for a doctor who knows exactly how to treat a patient to not be able to do so because the treatment options do not exist. It seems unfair and inequitable that in certain parts of the world prognoses vary for a similar condition merely because the standard of care is not available. To accept this is to accept that certain lives are less valuable than others. This cannot be. Although I am aware of the arguments regarding cost-efficient treatment of patients in the third world, I am unable to forfeit lives to keep costs down. This is a subject matter that my experience in Roatan has uncovered for me and one I hope to pursue in the future.

Wednesday, August 16, 2006

Molly Journal 3

I had high hopes for the number of patients we could see this week with three doctors in clinic, but with Dr. Jackie’s return to the hospital, there was a smaller patient pool for us. Things will pick up next week, however, as Charles will be gone and the Cuban pediatrician is returning to Cuba. Despite the relatively low number of patients we saw this week (range was from 8-20 each day), we did manage to see some pretty interesting cases and I was witness to my first public health miracle here on the island.

Right before I arrived in Roatan a baby was born in the Roatan Hospital with hyodrocephalus. The mother had little prenatal care and the baby was taken to the pediatric neurosurgery ward in the big hospital in Tegucigalpa days after birth. On Monday after work, one of the social services doctors (they are sort-of like residents in the US) came in with the mother who had returned to Roatan after being told her baby would need brain surgery to insert a shunt in Tegucigalpa but that she would need to find/purchase the actual shunt. We sent out e-mails to Global Healing and Karina spoke with neurosurgeons she knew from NYU to try to see if there was a way we could get a shunt donated from the US and shipped down quickly. We didn’t have to wait long, as we found out just two days later that Dr. Patrick — who spends 6 months of the year here in Roatan working with Peggy — would be coming down Saturday and had obtained a shunt for us. We will bring the shunt to the Mom on Monday (if not earlier) and she will head immediately for Tegucigalpa. The surgery is currently scheduled for Tuesday. It was incredible to be part of a team that was able to act so fast and effectively to help this woman and her baby out.

Another interesting case involved a 10 year old who Karina admitted on Friday to rule out septic arthritis. The girl had severe pain in her hip, accompanied by a positive urine test and a high temperature. She was unhappy about being admitted but the potential consequences of septic arthritis (i.e. losing hip function) necessitated the admit. I’m sure we will hear more about her case when we return to work on Monday.

This week I will also be following up with two patients who I am trying to get to Choluteca in October for free plastic surgery. One is in need of a cleft palate surgery and another needs external ear reconstruction. It will be quite an enterprise organizing this as Choluteca is two days away from Roatan and the organization providing the surgeries requires photos and HIV and TB tests from each potential patient, nonetheless, as Peggy said, it’s much easier than paying for a surgery (which these patients are unable to do) or traveling all the way to the United States to have a surgery done.

What else have I been up to? Rom, Karina, Suzanne, and I dove on Tuesday. I’m officially certified! We also discovered the licuados place across from HB Warren. The banana is amazing. I don’t recommend the Italian restaurant in West End, Karina and I ate there last night and are both feeling sick today.
In office news, after the new desk Charles purchased arrived on Monday we re-arranged the clinic and now there is a ton more room for intake. This means I no longer have to scribble notes on files on top of the printer or computer. Additionally, the air conditioner seems to have been fixed in the hospital. Apparently this is a huge issue for Global Healing and something they have been trying to make a priority for some time, although it seems to me to be less important than the fact that we don’t have running water in the clinic/some necessary meds. It is hard to be concerned about fixing the AC when you are looking for a shunt that may save a baby’s life.

Anyway, as usual, it’s hard to believe how time has flown by! I officially messed up my timing of filing my AMCAS so that my Inbox has been flooded with secondaries all week that I know I am not going to be able to keep up with (not exactly what I want/plan on doing my last week and a half here). Sadly, Charles left today for San Francisco for his board review conference and I won’t be here when he gets back. The turnover here is incredible. Hopefully I can make the most of the next week before Mike arrives and I pass everything I’ve learned on to him.

Friday, August 11, 2006

Molly Journal 2

I forgot to write this in my last journal but what has struck me most while working within the health care system here in Honduras is how eager these medical professionals are to help. Perhaps it’s just the Global Healing docs, but the rule seems to extend to others I’ve met through Peggy as well. For example, my first day I assumed that I would have to turn patients away after the nurses had already given out the maximum number of appointments for the day. However, I asked just to make sure about a particular patient, and Dr. Karina said, sure, just have them stick around. The same thing happened with Dr. Charles and another patient. When other doctors close their doors early, either Charles or Karina is happy to see these patients, to follow up on their lab results, or to prescribe medications. And they do this without a single complaint, they act as if this is their duty as a medical doctor, and I guess it is. It just makes me wonder about the way our health care system operates in the United States where doctors refuse patients regularly and patients go unseen who have “the wrong” medical coverage. It makes me think back to times when I’ve volunteered in the ER through SCOPE and an on-call orthopedic surgeon would be in the hospital seeing patients but would refuse to see a patient because he’s not on call for their doctor. Maybe the problem is elsewhere, with the insurance companies who make things difficult, like the patients who come to El Camino’s ER but have to be sent over for Kaiser if they are insured by them. Wherever the problem lies, it is completely absent in the Global Healing clinic. We see patients who don’t have appointments, even adults sometimes! This willingness to help anyone and everyone, to make sure that everyone is an equal recipient of care, is an attitude I hope to carry back to the States with me.

On Sunday Melissa, Suzanne (a nurse staying upstairs with Peggy through December), Kenfor, and I hiked up to the Carambola gardens. The plants were beautiful and the view from the top was incredible. We all went to dinner together in West End and came back early to rest up for a busy week in clinic.

This week in clinic was quite busy. Each day we saw over 20 patients. A particular patient that stands out in my mind is a young boy who was admitted because of lymphadenitis, a huge swelling below his chin. He was incredibly well-spirited but had been in to the clinic 3 times and had shown little to no improvement with various antibiotic treatments. Charles was concerned that he might have a potentially fatal disease called Ludwig’s Angina. I got to see him again on Friday when Karina allowed me to come on rounds with her. Other patients in the pediatric ward include three severely uncomfortable looking abscesses (one in a patient’s armpit, another on a nipple, and a third on a girl’s arm), a possible case of TB, and a baby with high fevers and eyes that were nearly swollen shut. That same day I also went to get Galaxy Ferry tickets for a mother to take her 16 year old son on a follow-up appointment with a nephrologists on the mainland. The only problem with Karina seeing this patient and making the referral is that she had not seen any of the diagnostic workups or reports done by previous physicians and so knew very little about the boy’s medical history. Discontinuity of care seems to be a very serious issue here.

Yesterday (Saturday) we picked up Dr. Rom, a new attending, at the airport. A whole vanload of us came to greet him and he seems youthful, enthusiastic, and very comfortable practicing medicine in a third-world setting. The clinic is going to be quite busy this week with three attendings, but we’re hoping that we can see every patient who comes to the hospital this coming week, and not turn anyone away. This means I will have to get to work a bit early to triage additional patients, but I think it will be very worthwhile and rewarding to see so many patients treated each day. Additionally, Charles leaves for San Francisco for a board review conference next weekend so for the remainder of my time here we will be back to just two docs in the clinic.

As for work outside the clinic, Charles, Karina, and I finished a rough draft of his proposal to do public health talks in local churches, high schools, day cares, and over the radio. Hopefully, we can get started on developing ideas and collecting information for these talks soon. On Thursday, we plan on going to the day care in Coxen Hole to give a short lesson on sanitation and hand washing. I also hope to finish my dive certification with Suzanne this week, as we have only 2 remaining dives.

I can’t believe another week has passed here in Roatan and that only two more remain! Life here does move slowly-island pace so to speak-but the days also seem to blend into one another, so that before you know it, it’s Sunday and another busy week in clinic is on the horizon.

Molly Journal 1

It’s hard to believe that already a week has passed since I arrived in Roatan. Last Sunday, Melissa, Karina, and Miss Peggy picked me up at the airport and drove me to Miss Peggy’s house in Sandy Bay, where I will reside for the duration of my stay here. A short while later, Karina, Melissa, and I jumped in a two-person kayak and paddled over to the resort where they took dive certification classes. They wanted to go on a last dive before Melissa left. They introduced me to the instructor, Shane, and he promised to get me started on my certification next week after I’ve settled down at the clinic.

I also met Lindsey, a second year med student, who lived upstairs with Miss Peggy and left on Tuesday to go back home. We all went down to another part of Sandy Bay for a BBQ with 9 Irish dental students who volunteer with Miss Peggy in the mornings. We baked brownies to drive over, but when showed up only four of them were even at their apartment. After a few hours they cooked up some nachos to go along with our brownies. Interesting BBQ.

On Monday I began my first day in clinic, which involved waking up very early (6:30am!). This wouldn’t be so difficult if it weren’t for the fact that it takes me forever to fall asleep here. The dogs, birds, iguanas (I had no idea that they make noise), and even the crabs that scuttle across the floor create a symphony at night that is hard to ignore. Each day this week was pretty busy in clinic, but Melissa had enough time on Monday and Tuesday to show me the ropes. It appears to me that the most difficult part of working in the clinic might be trying to read Charles’ diagnoses and treatments for data entry. I hope that I can find more time to shadow the doctors, but with all of the triaging and data entry, I find that the most I can do is pop in on Karina or Charles’ last consultation of the day. Perhaps with more practice I can find the time to listen in more, as there have been many exciting cases already in clinic.

As far as life outside the clinic goes, I helped Lindsey finish her cervical cancer survey on Monday. This involved hiking up the hills of La Colonia to ask women if they had ever had a Pap smear (most had not) or if they had ever heard of cervical cancer (many had). The survey seems a little rigged—they have changed the questions a few times to try to get the responses that they “think is correct.” One issue is that most don’t know what a cervix is. We also run into the problem that we don’t want to scare them by telling them about another form of cancer that they are not being tested for. Hopefully, when Peggy’s new clinic opens she can provide this service for the women of La Colonia.

Lindsey left Tuesday but before she left we kayaked over to Anthony’s Key to see the dolphins during their “quiet time.” I also joined a gym this week, as I found that I run out of beach after about 15 minutes and running along the twisting road with speeding taxis is a dangerous proposition. The gym was a little expensive and had only one broken treadmill, but the owners are very nice and from my hometown. I’ve been every day since.

Yesterday, Melissa left, leaving me all alone in Peggy’s downstairs apartment. Fortunately, Peggy’s home is a revolving door and I have faith that new life will enter the home within days. Before she left, we went over to Karina’s apartment in West End to cook banana chocolate chip pancakes and eggs. We also got a chance to swim in the water at Half Moon Bay which was incredibly relaxing and refreshing.

This coming week I will get started on a few public health projects. The first involves a public radio station, which first will interview Peggy, Karina, and Charles and then will air intermittent public health PSAs that we design. We are hoping that this will be a means that we can reach the population of Roatan. Additionally, Charles is in the middle of writing a proposal to Global Healing to extend his work for them into the afternoons, when he will visit local day cares, high schools, and other community centers and give talks about nutrition/sanitation/prevention of disease and such. He hopes to reach out particularly to high school students, encouraging them to practice safe sex or abstinence, as many of the moms we see in the clinic are teenagers. On Saturday, Dr. Rom will arrive. He is a water-borne diseases specialist and we will have to find a way to squish a third doctor into our tiny clinic!