Monday, August 27, 2012

Molly Journal #1

I had my eyes peeled, not knowing what to expect. Israel and I walked single file along the road through Coxen Hole. We made it to the hospital finally. I stepped through the doorway and saw patients sitting on wooden benches lining the hallways. Israel showed me the ropes and for the most part I watched him triage the patients. I knew I could do exactly what he was doing but I was so nervous because I respected the patients so much and didn't know the best way to earn their respect.

Every day patients and their family come to the hospital early in the morning, around six or so. I don't get to the clinic until 7:30 a.m. and the doctor until  almost a couple hours later. We finish up with patients anywhere from 12-1 p.m. So patients could be waiting for up to six hours! The patience the families have makes me respect them. Many of the parents have to miss work to bring in their kids. They have many other things they have to do and many times are torn between waiting for care and leaving early without being seen by the doctor. At the clinic we try and do everything to make things work out for the patients.

I learned that I'm at the pediatric clinic to do a job that many people can do, but I don't want to just do what anyone else can do. I want to do more. I try to get there early and get started as soon as I can. Everyday I fill my backpack with donations of toothbrushes, toothpaste, latex gloves, breathing masks and emergence response kits I brought with me to Roatán. I brought a large suitcase of donations and still haven't unloaded it all. These donations serve more than just their normal function. The colorful toothbrushes come in handy when the younger kids start crying because I have to weigh them, measure their height, or take their temperature. The girls love the bright pink and yellow ones and the boys the red or blue ones. I love to see every once in a while, an excited kid who comes in the door and runs straight to the small table in the corner, opens the crayon box and starts to color. I usually let them be until I have to torches them by taking their temperature etc.

Some of the kids and newborns come to the clinic just for a routine checkup, but not all of them. It's hard for them to be happy and smiling when they are uncomfortable. When they come into the clinic I just can't wait for the kids to get out the door because I know they will get their medications soon, which means they will feel better even sooner. All of the kids that come in are precious and I love to see them healthy and smile.

The people in Roatán are all incredibly welcoming and kind. I thoroughly enjoy giving back to the community in any way I can.

Monday, August 13, 2012

Israel Journal #4

Week 4: El Porvenir Es Del Pueblo

Despite the tumultuous weather this week, I at least started the week off well. I went to Clinica Esperanza to get my ear checked out and fortunately all that was wrong with it was from otitis media. The amoxicillin I have been taking is making improvements and I no longer have a runny nose. At the time I was getting my ear checked, Dr. Janice took advantage of the opportunity to teach my fellow volunteers what the inside of a normal ear is supposed to look like. My left ear was red on the inside and a little convoluted whereas it is normally a white color. During my time here in Roatan, my perspective has always been of the observer and to get a chance of being the one observed was enjoyable despite the circumstances because it provided an educational experience for me and the other volunteers.

On Tuesday, Hurricane Ernesto passed by north of the island and we ended up getting a few tails. It’s been a while since I’ve been through a hurricane so I was a little anxious at first that I had to ride into Coxen Hole and not know whether the roads would be flooded afterward. I also expected a short day at the hospital but oddly, it was actually much busier than normal. The pre-clinica area was a lot less crowded but other than that everything else was business as usual. We received about 23 expedientes and unfortunately could not start attending them early enough because the attendings had to cover in the pediatric ward. By the time they arrived, the people outside were getting quite impatient. It’s quite understandable however because the people here face a lot of pressure having to take time off of work to go to the clinica and on top of that, they will likely be spending money on medications afterward—not to mention that on this day there was a hurricane outside. One can see that in an area that has low resources like Roatan, there is a severe need for medical providers even when the people would risk getting a consult in a hurricane. Sometimes I wish I could fast forward already to my residency so that I can start helping people myself, but really I have an important task as well to reinforce what the attendings do. When you speak to people coming in for a consult in a respectful tone and show that you are there for them through your body language, they really receive this in a positive manner. This makes an otherwise distressful encounter that less stressful and encourages the patient to follow through on their half of the work including adherence and arranging follow-up care.

But sometimes even then there are the few occasional cases of neglect. One patient was brought in this week because a bone mass has been growing from his mandible. The patient’s mother said that the child was under the care of his father for the past year and a half and he did not want to bring him to get checked. The attendings were sure from the size of the bone mass that it was probably more than a year and a half that the mass has been growing. Fortunately, despite being late to bring the child in, there was a surgical brigade from Massachusetts in the hospital and the next day he would be taken in to get a biopsy. So despite the late timing, the child was able to get some help to begin his treatment process.

Another case that I heard about this week was of a baby with a respiratory illness in the pediatric ward. All that could be done to get the child breathing was tried and unfortunately the baby passed away. Kristen talked to me later about the case and she said that had this case been in the United States, the baby would have survived. I salute the physicians who choose to work here in Roatan so much because they are fighters. They come in knowing that they will likely not have many of the resources they need to provide for their patients. Yet despite this, they choose not to give up the good fight for their patients and they work hard at the issues they confront. This is the type of physician that I will certainly strive to be and I am so delighted that I can find this image in the physicians that I come in contact with everyday here at the hospital. For example, Kristen has learned in what cases a urine test or blood sample would provide the most benefit. She would like to order these for all patients, but sometimes the patients don’t come back to get the results and then again the process for getting something like a urine sample doesn’t provide a culture test as well so the efficacy of finding an unbiased result is questionable.

On Friday this week, Kristen, Lenia and I all made a trip down to the daycare to dispense albendazol and multivitamins, do teeth varnishes and to get height and weight measurements of the kids. Aside from my trip to Policarpo to see how the real Roatanians live, this was my most exciting experience outside of the clinic. We arrived at the daycare when the children were in their nap time. We had all just eaten a big lunch so even we were beginning to get a little drowsy ourselves. One by one the kids woke up and they moved straight across from us where they kept the pillows to lay down. As the lights were turned on, they woke up just a little more and we began our work. I took heights and weights as Kristen and Lenia attended the more serious cases. Before we began, we were hoping to put on some hand sanitizer but then noticed that there was none in the daycare. Kristen said according to the CDC, there should be copious amounts of hand sanitizer in any clinic so it has become a priority of mine to get them a sizeable container of it. The most severe case was of a little girl who had pain while urinating. Las profas mentioned that her urine would come out brown. Kristen said that the brown in her urine could possibly be from blood and so she wrote the little girl an appointment slip so she can come into the clinic next week. Right from the outset of our mission at the daycare, I was exposed to the beauty of the entire event and of all that Global Healing stands for: to provide help for those who do not have it readily disposable and whose needs are not being met. If we would not have been to the daycare that Friday, I can only imagine how long it would have taken for the little girl to get necessary aid and for the rest of the little kids to get their heights and weights checked. The other beauty of being able to provide for the daycare lies in who the help is being given to. The children of Roatan will be there to take up the reigns of this island once they are old enough and the trajectory that the island will take is ultimately up to them. While I can only guess from my own childhood that the stresses of their parents trickle down to them occasionally, because of the limited resources on the island that isn’t too wild of an assumption. What a better way to ensure that the legacy of this island is not in jeopardy than by providing the children a glimpse of altruism and love for fellow man by doing free consults at the daycare. 

Thursday, August 09, 2012

Israel Journal #3

As I reach the mid-point in my internship, I already feel a sense of belonging but also that sense of departure. But the memories that remain of my time here in Roatan will nourish me until my next trips into Latin America. This week was certainly not my best as I got very sick for the first time. I started out with a sore throat and quickly my ear became infected. Towards the end of the week the infection moved into my other ear and now I feel very fatigued. Ultimately, however, I feel oddly proud of this sickness because it is almost like a testament of what I am willing to subject myself so that I can better understand a people and their healthcare system. I haven’t been able to get some meds for my infection because the hospital has been fairly busy this past week. We have been getting about 23 patients each day and we usually finish up by the time Clinica Esperanza has closed. Hopefully on Monday I can go and not to mention before the tropical storm hits. The part I do hate about this sickness is that I was not able to even go to the daycare this entire week to start my health workshop initiative because I didn’t want to pass on what I have to the kids. I was able to get them the nebulizer mask they needed at the very least though.

One of the things that I find great about the hospital is that there is no strict guideline that says you are only allowed to see x amount of people and anymore would be a violation. It isn’t uncommon to have a patient ask if their other child who they bring that day to also get a consultation. A particularly sad case that we encountered this week was a little girl who had a fungal skin infection throughout her body. The child was brought in by her aunt because her mother was adamantly against bringing her in to get checked out. I can’t help but think that the little girl’s household situation is the source of her sickness. I saluted her for having the courage to intervene and actively take responsibility for the well-being of another family member, even though it is truly the responsibility of someone else. When the aunt came in, she was originally coming in for a consultation for her daughter but asked if we could see her niece as well. Kristen agreed and she was sent on her way for a prescription. Juxtapose this image of a mother’s potentially severe negligence, with another mother who came in with her newborn. She brought in her baby because she had a high fever. She said that she knew her baby had a fever because she detected it with her thermometer. I don’t even have a thermometer at home.

Continuing, one thing I admire about physicians is their tenacity especially when dealing with a patient who does not seem to be improving despite taking their medications. A little girl this came in for the 4th time since I’ve been here. Apparently her coughing hasn’t been getting better, but I admire Kristen for not feeling defeated that the previous medication regimen did not function as hoped and that she must be limited in her actions given the low resource environment that we find ourselves in. Lately I’ve been reading a copy of “How Doctors Think” and I read that this happens a lot in medicine. Plenty of cases get passed along to different specialists and sometimes it seems like there is some sort of mental issue at hand with the patient. But the physician should work toward thinking differently about the preceding diagnoses so that a better solution may be reached.

Wednesday, August 01, 2012

Israel Journal #2

Week 2: Y Ya Siento Flotar Mi Gran Raíz Libre Y Desnuda

The island has a particular quality that makes it easy for me to be contemplative, and the events from this week have provided me with much fuel for contemplation. Aside from the typical cases of otitis media or respiratory viruses, last week a baby was presented as having severe vomiting. At the time it was suspected that the baby possibly has pyloric stenosis, which is when a muscle under the stomach is enlarged and causes vomiting. The only cure for this is to get surgery and apparently the mother was quite distraught at this news and she opted to wait for another week before making any decisions. This week she brought the baby in and there was much of the same, so Jess referred her to a surgeon. I can’t even begin to imagine the stress the mother must be under. To hear that your baby needs surgery is not a light matter and one thing that I was wondering about was if the mother was more worried about the cost for this procedure. The thing about surgery is that sometimes, especially when it is life-saving, it tends to make people put a value on their health, which I believe is invaluable. If say a sick person did not have the necessary funds to pay for a procedure, needless to say that would be a very troubling situation. But imagine in Roatan where according to the locals, the average daily salary is $15; the cost of a surgery would be very intimidating. That’s why if I ever become a surgeon, I would work my best to keep financials from dictating what surgeries I can and can’t do. I certainly would not be averse to doing a surgery for free, if possible, because no patient deserves to be turned away just because they couldn’t afford a procedure, or rather just because they couldn’t afford to stay healthy. As I always say, I would be a physician even if it meant my salary was a piece of bread and a glass of water for each day.

This week was bittersweet as the clinic saw a change in the attendings. Jess left on Thursday and it was sad to see her go because I was getting to know her better and she definitely seemed to enjoy her work with the children here in Roatan. She is an ambitious person (she had to be if she majored in biomedical engineering as an undergrad) and is thinking about going into pediatric oncology. At any rate, life can be like that sometimes where cherished moments are transient so we must strive to make the most out of every moment of the day. On Jess’s last day working at the clinic, she, Tami (from Clinica Esperanza), Kristen (another attending physician from Global Healing) and I went to visit a couple of Jess’s patients in Policarpo or “La Colonia” which sits right across from Sandy Bay. To get to Policarpo, you have to traverse several steep dirt roads that veer off from the paved road. What I witnessed that day was very insightful to say the least and aside from my time at el hospital publico, it has been one of my favorite Roatan experiences so far. In the states, I am familiar with poverty (which I would now consider simply as “low-income”) but the conditions in Policarpo are of a different plane. One of the young girls’ families that we visited had a small makeshift kitchen outside of their house because it was built without windows. An upstairs section of their house was recently built and this section does have windows. The oven that they were using consisted of a slab of concrete with a shoe box-sized space carved in. Yet, even though the family lived in conditions which would be considered dire in the US, the family was happy as could be. The little children would just shower you with their love that you came to visit. They were not too shy to give me a hug although they didn’t know me. This type of happiness is something I am actually quite familiar with. From my upbringing, it is my understanding that when you suffer hardships with others, whether they are family or not, but you still maintain your optimism and you celebrate the fact that you still have each other, a special bond forms. This type of bonding is what I saw here between the young children and their mother. The message this special relationship proclaims is that despite our lack of necessities, we still have love and with that we can move mountains. As we said our goodbyes to this family, we headed further up the hill to see another patient who’s name is Michelle. Once we reached the top of the hill, there was an amazing view of a neighborhood that I had previously not known was so vast across the hills. Many tin roof homes littered the hillside, a definite change from the Spanish tile roofs I saw from the plane. When we found her, she was with her brother and another friend, Jenny, who is an adorable, playful kid. We then met Michelle’s mother and she told us about how she has been helped a lot by Ms. Valerie, who runs an HIV clinic on the island. Michelle’s house was recently built and there are a few renovations being made. At the top of the hill, they have a sizable tank of water to go along with their plumbing. Their bathroom is physically outside the house, and to go to the bathroom they have to walk a narrow path around the house. Also recent is an electricity post that was put near the entrance of the house. Aside from these commodities, the kids are going to a private school on the island run by Americans. The type of outreach that just captivated me was the medical care that was being offered to Michelle’s family. Michelle had a younger sister who had a congenital heart defect and her health was deteriorating rapidly after she was born. She was in the hospital for 3 months until she was set to go to the States for a heart transplant. Unfortunately, Michelle’s sister died before she got a chance to go to the US to get a surgery. Despite this tragic event, seeing and hearing about the great things happening to this family made me extremely happy that other people would be so giving to a population essentially on the periphery of global society. There are many wonderful people like that here on Roatan, including Miss Peggy, and being around them makes me very excited because it is this exact altruism that I would like to evoke in the future as a physician. After playing around with the kids, we headed to Clinica Esperanza for the rest of the day. Reflecting on this experience, I am quite unsettled by the fact that before now I had taken so much of what I had for granted. At the time I was uncomfortable knowing that the mentality I had in the US was to work for income so that I may obtain whatever silly material possession I desired. Now my mentality is to share my wealth with my extended international families so that they may have equal footing on par with my own.

Since Jess is gone, Kristen, a physician from Washington DC who has been working with Global Healing for a while now, will be taking over her clinical duties. I was able to shadow Kristen this week and she has exceptionally great bedside manners. Children that I triaged who were quite a handful would be calm during their consultations with Kristen because she handles herself very well. The interaction that she has with parents is also great because even though some get grumpy by the wait they have to endure in the humid waiting area, they leave their consultations happy and satisfied. I cannot wait for the other cases I will be able to shadow Kristen for.

After my time at el hospital publico, I have been going to Clinica Esperanza and to tutoring at Casa Mazapan, but on Friday this week, I went to a local daycare, Roatan Daycare, to get to know the children to start my health workshop initiative. Even though the kids were quite a handful, I had a lot of fun getting to know them and the daycare workers or “las profas”. The children in the daycare vary in age from 2 to 7 and the parents have started to pay in order to keep the daycare running. Previously, the daycare was free to single mothers who had to work during the daytime and had no one to look after their children. On Friday there was a total of 29 kids staying at the daycare, which consists of a play room kitchen, a general playing mat, a nap room, a kitchen and another play area along with a shower room. When I arrived it was nap time for the children and I had the opportunity to speak with la profa about Roatan and Honduras including the food, the lifestyles, the Roatan public school system, my experiences and about Roatan politics. One of the first children to wake up was an adorable little man with some pretty big cheeks, reminiscent of my own cheeks at that age. His name is Eldon and he has a respiratory complication which requires his meds of suero and salbutamol to be administered via nebulizer. Fortunately, his medication has been effective so far and he is no longer kept awake at night by his constant severe coughing. Unfortunately however, he could probably be improving at a much faster rate if not for the fact that the daycare is in need of a nebulizer mask. Several other children in the daycare also require use of the nebulizer and apparently during the raining season in October-November, there is a greater need for the nebulizer. Rather than being projected directly to their noses via a mask, the hose administering the meds have to be held in front of the children’s faces, leaving a majority of the medicine vapors escaping to the atmosphere. From where I was three feet away, I was able to inhale some of Eldon’s medicine. I spoke to Miss Peggy about this and fortunately she was able to secure a mask for the daycare and I will be taking it to them on Monday for general use. That is it for now, blog, and I will return with further thoughts.