Sunday, September 28, 2008

Alex Journal 3

I can’t believe my third week in Roatan is coming to a close! When I first arrived a month felt like such a long time, but I now realize that a month isn’t nearly long enough to really make any lasting improvements in the quality of life of the people on the island.
This past week was a little more hectic in the clinic with the arrival of the two new pediatric residents, Dr. Sydney Leibel and Dr. Sandra Lawrynowicz. Given that I spent much of Tuesday and Wednesday orienting the residents to the workings of the clinic, showing them around Coxen Hole, and doing quite a lot of interpreting, I really saw how important the intern’s job is in preserving the quality and continuity of care for patients that visit our clinic.

While there were numerous interesting patients in the clinic this week, one in particular stands out to me because it shows how difficult it can be for people on the island to get the healthcare they need. This patient was a spunky young boy of about 4 years old who more than anything wanted me to take a picture of him J. He had been diagnosed with a seizure disorder several years earlier and had been sent to La Ceiba to see a neurologist who after several tests prescribed the boy Phenobarbital. Unfortunately, in August of this year the mother ran out of the medication and had visited the Global Healing clinic to refill the prescription. Doctora Prado gave the mother a month’s supply of Phenobarbital as well as a referral to see the neurologist in Ceiba to properly manage the boy’s seizure condition throughout childhood and adolescence.

However, as is often the case with many of our patients, the mother was back in the clinic a month later asking again for another refill prescription. Now, if you are at all familiar with anti-epileptics you know that these medications are pretty nasty, and few physicians other than neurologists feel comfortable prescribing them, particularly third year pediatric residents. Therefore, I sat down with the mother and asked her why she had not gone to La Ceiba to see the neurologist as Doctora Prado had instructed? She told me that she had gone to see the neurologist and they had already done all the tests. At this, I was confused, which is when I realized that the mother was referring to the original appointment the boy had with the neurologist over a year ago. The poor woman had not understood that the referral was for a follow-up. I gently explained to the mother that her sons seizure disorder was complex in that just as he might outgrow his clothes, it is also possible that he can outgrow his medication dose, or the type of medication he would need to take. I explained that he would probably need yearly follow-ups with his neurologist until the problem was resolved. It might even be the case that he wouldn’t need to take the medication at all!

At this news, the mother became quiet and worried. This was probably the first time anyone had really explained to her the reality of her son’s problem, and the importance of properly managing his anti-epileptics. After all was said and done, we asked the women if she was going to be able to take her son to La Ceiba, to which she shrugged her shoulders. As is the case with many of our patients at the clinic, she could not afford a trip to La Ceiba but was too ashamed and proud to admit it. Thankfully, we were able to offer the women and her son free transport to and from La Ceiba. The mother and her son left the clinic completely grateful for all the education and help we had offered them. “Que Dios le bendiga” she said, which means “May God bless you”.

My interactions with this family showed me the importance of patient education. It is so important to make sure that your patient understands their problems, why they have them, how to avoid them, and how to treat them. All this mother knew was that the Phenobarbital helped her son, but she hadn’t the slightest idea that poorly managed seizure disorders could result in developmental delay, or how anti-epileptics affect cognition. While all this information may have surprised her, and even scared her a little, I am confident she left our clinic with an increased understanding of her son’s problem, and perhaps with increased confidence in her ability to help him.

Monday, September 22, 2008

Alex Journal 2

This past week was my first full week working at the global healing clinic and boy, was it busy! I think the reason we were so busy each day was because Monday was the Honduran Independence day and a national holiday for the whole country, so all the children had the entire week off of school. Therefore, all the mothers took advantage of the holiday to bring their school-aged children to the clinic. Whereas last week we had between 10-15 patients each day, this week we had about 20 to 25 patients a day. Since most of our pediatric patients at the clinic present with illnesses like bacterial skin infections, urinary tract infections, and parasites, all illnesses associated with poor hygiene or unsanitary food, water, and living conditions, imagine my surprise when we had a young girl come in complaining of migraines. Back at Stanford at the Pediatric Pain Management Clinic where I do clinical research, nearly every other kid we see has migraines or chronic daily headaches. Usually we take a long, detailed history of the child’s migraine history, the quality of the migraine (Ie. is the pain throbbing, stabbing, does it travel from one spot to another, etc.), their sleep hygiene, and finally all the different medications they’ve tried. We then go on to suggest a multi disciplinary approach to treat the migraines, including medication, biofeedback techniques, physical therapy and stretching routines, and finally acupuncture if the child is willing. Now, given how I was used to treating a migraine condition, imagine how utterly frustrated I felt when all we had to offer this poor girl was to take some Tylenol when she felt a migraine coming on and to avoid eating chocolate, sweets, and soda.
The harsh reality is that in a place like Roatan we don’t have the resources for properly treating many medical problems. In fact, we’re lucky if we can get patients to listen to us. Even if we had all the wonderful multi-disciplinary approach to treating chronic pain problems as we do at Stanford, we probably couldn’t get the families to invest all the time and effort needed to come to all the follow-up appointments or to take the medications as directed. This fact is one of the main reasons why I want to do an MPH in addition to my MD, because the only by learning the belief system of the community and finding effective ways to bring awareness and education can one begin to see long-term changes in the way people understand health care. I mean, educating one patient at a time is important, but is also quite futile if when they go home their grandmother, the matriarch and wisest most respected member of the family, convinces them that the gringo doctor doesn’t know what they are talking about, and that the baby needs to see the bush medicine doctor if they want to remove the curse of the evil eye that is making them sick.
Despite all my frustrations, I do still feel we are making a difference in the Global Healing Clinic. I see this in the mother’s who bring their children back for follow-up visits, who come to refill prescriptions before their child’s chronic problem becomes uncontrolled again, and who bring in a list of the medications their child is taking.
In the afternoons I continue to tutor the children in the orphanage. We’ve switched to learning spelling in Spanish, which is a lot more challenging for them since they speak primarily English. They’ve been doing well, however, and are bright kids. The challenge is mainly just to find ways to keep them focused and interested. One day I accomplished this by timing them on how fast they could say the Spanish alphabet without messing up a single letter. I used their natural competitiveness to get them focused on the task, and because they were so determined they were all able to recite it in less than a minute after only one lesson. There is nothing more rewarding than to see kids, who usually get easily frustrated and quit, learn to persevere and succeed with huge smiles on their faces.
Finally, I should probably talk about how completely beautiful Roatan is. Last weekend I completed my dive certification and one the four dives I’ve been on I’ve seen turtles, lobsters, sting rays, a green moray eel, a two-foot long barracuda, shrimp, and a huge crab that could have fed three people! There is so much to discover under the water, so anyone who comes down here should definitely take advantage of the aquatic beauty of the island. Today was also my first day going down to West Bay, a gorgeous white sand beach. I walked there from West End which took about 30 minutes, but if you aren’t in a rush it’s quite relaxing. Finally, I’ve taken up yoga again with a group that practices twice a week and on Sunday mornings. It’s a great way to start my morning and feel peaceful and centered after a long week at the clinic. Cheers!

Saturday, September 13, 2008

Alex Journal 1

My first impression of Roatán was how similar the island was to my own island home, Guam. The weather, the vegetation, and the relaxed pace of life on the island all brought back memories of my childhood, particularly the images of children running around barefoot and jumping off the docks to cool off from the afternoon heat in the clear blue ocean. My first couple days in the clinic, however, brought me back to reality making it clear that although this was a gorgeous tropical paradise the people here have real problems and very few resources to remedy these problems due to in part to poverty but also because of Roatan’s geographic isolation.
The austerity of the Global Healing clinic and the doctors working with such limited resources was a real eye-opener for me, particularly coming from my clinical research job at Stanford where our Pediatric Pain Management team is so quick to spend money on superfluous supplies like heat lamps, or where we drink our five dollar chai tea lattes daily without thinking twice about the cost. I was completely humbled by the fact that part of our job at the clinic was to wash and disinfect the ear scopes once a week because it would cost too much to simply throw them away after one use, or how I was using alcohol to disinfect the temperature probe after each use for the same reason. The reality is that in places like Roatan, a large part of success is learning how be resourceful and efficient with the resources at hand, traits I’ve realized few American doctors have. Another example of how resourcefulness is key when practicing medicine in resource poor situations is how Doctora Prado, when she was unable to find the right size face mask, was able to MacGyver (so to speak) an oversized mask, some tubing, and some medical tape to fit onto the face of a 3 year old girl receiving a nebulized medication for her asthma. I should also add that we washed and disinfected these masks as well after their use.
Despite the limited resources, however, I am confident that the Global Healing clinic is making a positive difference in the lives of our patients. I feel the difference we make is primarily through the education we provide to patients during each visit. One example of this I saw was a young mother who had recently borne a premature baby. Doctora Prado had seen the baby two days earlier, and although nothing was wrong at the time, she had told the mother to return if she noticed that anything at all, even the smallest thing was wrong since her little baby was very fragile. When I triaged this mother and asked her why she had come, she confidently told me that her baby had watery stool and that “la doctora” had told her to return if she had noticed any sign of illness. Her saying this gave me hope that our patients were listening to our advice and following up with care, a task that is often difficult for a population that is poor and uneducated. In the coming weeks I hope I can witness more instances like this.

Thursday, September 11, 2008

Stephanie Journal 4

It is my last week in Roatan! It feels like I just got here, but also like I've been here for a long time. It's strange. When you're on the island, you get into a routine. Mine was waking up at 6:40, getting to the clinic, leaving around 2 to go to the orphanage, and then working at the orphanage for a couple hours. This life compared to the life at school is so different. There's just an island feel to life here. You can study in the afternoons, be productive, or just waste it away snorkeling, kayaking, watching TV, cooking,... the list goes on. At the end of the day though, I feel good that I'm able to help people at the clinic, and also teach the kids in the afternoon. it feels like I'm actually accomplishing something!!

Last week at the clinic, a senora told me that her daughter had worms. I asked "have you seen them?" and she said "si" and started opening her bag to find something. Before I knew it, she was pulling out a jar with a long white worm squirming around in it and said that it was from her MOUTH. I almost puked. Almost. I got a good shot of that on my camera - I'll try to post it up.

The clinic actually closed a couple days last week because of the strike of the social services doctors. Apparently, there is one year when a doctor is considered 'social service" - they have to work to pay off the medical school that they have received. Currently, they are on strike because there is some unfair procedure occurring in the system. Some private school is breaking the law so all the SS doctors from all of Honduras are on strike. Because of that, part of the hospital shut down and the external clinics (including ours) shut down temporarily.

The kids at the orphanage are getting better at spelling! Their new favorite word - "animal". It has 6 letters! SIX! Compared to a couple weeks ago, when they couldn't even say "the" or spell "the" - it's an improvement. TRULY. The kids had a list of 60 words that they have to learn how to spell and I really thougt it was impossible - but the kids have proven me wrong. They have gotten good at spelling almost all the words. They do forget their vowels sometimes, which is a hard mistake to correct. I'm so glad they're actually learning!

This experience overall has been a good one. The island is beautiful and the people are relatively nice. They're a bit racist though, and haven't seen too many Asian individuals so I would say that's the only downside of coming to a place like Roatan. It is a good mix of cultures - there's the tourist groups in Westend, the local Black population, the "gringos" or expats from the US, and the Hondurans who come from the mainland. Considering that Roatan used to be a English speaking island, it's pretty surprising that everyone speaks Spanish now - mostly because of the mainlanders coming to the island in hopes of making good money. I think the mix of cultures was definitely the most distinctive part of Roatan and it was interested meeting a large range of people - from meeting a Belgian who grew up in Central America to volunteer doctors who work here 7 months out of the year. It's definitely an environment that I will miss.

Monday, September 01, 2008

Stephanie Journal 3

If the Roatans came to America and saw a hospital like Stanford Hospital or all the state-of-the-art recovery center, I think it would just blow their mind. It's the same thing with houses and shops, etc. It's just a different way of life here, and although I realized it the moment I got here and started learning about the culture, it still is extremely wondrous to me.

On that note, there have been some exciting cases. There was a kid with a huge absceso on his head, and it was humongous. When Dra Prado was puncturing the abscess with a syringe and squeezing out the bloody pus, he didn't even cry! I would be crying, to be honest. I really hate needles. I'm also learning new terms - balanitis for example is the infection of the gland near the penis. I definitely didn't know that before.

Something I have been noticing as patients come in is that they ask for medicine specifically, by name, even if they don't exactly know what the medicine do or are for. Granted, I don't know exactly what medicine does what and is for what, but mothers give acetaminophen for EVERYTHING. Everyone is overmedicated because they aren't educated. Many of the doctors in the hospital don't help with this either - they give the mothers what they want. Acetaminophen, loratadine (claritin), Broncomat/Albuterol - even if the kid doesn't need it. It's a placebo effect. Mothers see their kids getting better, but it's not because of the drugs or treatment. It's because things like flu, colds, and the cough just clear up after a while. What worries me most is giving out antibiotics when kids don't need it. This will just reinforce the resistance in the community, and no one - patients, doctors, mothers, kids - will benefit from that.

It's now the end of my 3rd week in clinic. I have about 1.5 weeks left. I am still volunteering at the orphanage and helping the kids with their reading/spelling. Unfortunately the four kids that I work with really cannot read yet - even though they are in first grade. They can barely say basic sounds: th, ch, sh, etc. I've been doing my best but the kids don't realize the importance of reading, and they are used to being rowdy, rude, and obnoxious so that is how they are. One of the kids chased me around with a tarantula spider in his hand in order to get out of studying!! Allen and I have been persevering, but it's getting very frustrating when the kids do more complaining and whining than studying during our time there. Surely but slowly, they're making progress. I just wish it was a more SURELY, than slowly.

From the experience I have had at the clinic and at the orphanage, I realize that I like working with older children or teenagers more so than babies and little kids. The little kids are adorable and cute, but I like making a connection with teenagers and young adults. During the school year, I tutor high school students on the side to make some money, and the experience is really rewarding. Realizing this is important for my future. Unlike most the interns, I am NOT pre-med! My goal is to become a nurse practitioner, and because of this experience I think I have decided on becoming a Family Nurse Practitioner. I was thinking of maybe becoming a Pediatric NP, but I think I would like to have general knowledge so that I can be someone's practitioner throughout his or her lifetime.