It’s 4:30 am in Por Venir, roughly translated, “The Future” or “Going Forward.” Mary and I are in one of two small rooms at the back of the Mayor’s house and Bette and Savannah are next door in the other. Like many families in poor areas of the world, the Mayor, has built this separate wing onto his house to accommodate visitors and add a little income. It’s not quite finished; only one of our four windows has glass, but the sturdy wooden door has a dead bolt and a twist lock, and the room is clean and has a private bath with a huge shower. Of course there are electric wires going from the overhead light to the showerhead with the live ends dangling down around where the spray emerges. We both decided to brush off the dust and pretend we were clean. At four this morning, a clock somewhere bonged the hour. It was stunningly loud; I felt like it vibrated my bed. It seems the bonging was the rooster’s alarm clock as he immediately began a call and response with several roosters across the yard. The chief rooster lives just below our window, which I would close if there were glass. There’s a curtain, but alas, it’s not soundproof. Amazingly, Mary seems to be sleeping through this raucous serenade; either that or she’s putting on a good show.
We left Sibinal around 7:30 yesterday evening after managing to see most of the patients. Luis had to set a time limit so that the drive back to San Marcos wouldn’t be in total darkness. Before we left, the mayor gave an impassioned speech about how grateful they were that we had come, but then went on to describe how many people were still waiting to have their health needs addressed. Luis then announced that he will be bringing a team of doctors and nurses from San Marcos in a few weeks to carry out another mission, and a general cheer went up.
Having Mary along opened my eyes to another huge medical issue, that of the lack of care for the middle aged and elderly adults. I have always known, intellectually, that adults have many more issues, but seeing Mary in action with the adults here has been a real education for me. As in the US, children here are generally “healthy,” and I see them for acute problems layered on chronic malnutrition. There are always a few with serious, untreated conditions, but they are in the minority. The patients Mary is seeing, like the adults in her practice in Albany, have multiple chronic problems in addition to the acute infection or injury that may have initiated the visit. There are two big differences between her patients at home and those here. In Albany, she knows her patients and manages their chronic illnesses, monitoring medications and giving ongoing care. Her patients usually don’t’ stop their medications for lack of ability to pay for them. Here, the patients have had these same chronic illnesses, sometimes for decades, and though they may have seen a doctor at one time in the past, most have not been able to afford return visits. Any medications they might have taken have been dropped long ago for lack of money to pay for them. Now Mary is faced with the dilemma of deciding whom to treat with what, knowing she can provide only a week’s worth of most medications. Her main is on educating the patient and any accompanying family members so they at least understand their conditions and can choose their care rationally. She also gives a lot of practical advice about lifestyle changes that won’t cost anything. I’m once again so grateful I chose pediatrics!
We drove back to San Marcos last night, arriving around 9 pm. We were all too tired to go out to dinner, so we made do with ramen noodles and cheese crackers. I tried to load some photos, but the WIFI was so slow that I gave up after 5 and went to bed. We left San Marcos at 7:00 yesterday morning and drove down to the jungle region for our final two days of clinics. As we drove, the temperature rose and the vegetation changed to a lush green from the dry mountain pines of Sibinal. For the first time since our arrival, we were all shedding our jackets and sweaters and rolling down the windows to let in the tropical air. We arrived at the Mayor’s house in Por Venir at 8:00 am and were served eggs, beans and tortillas for breakfast in his kitchen. The clinic was held in a large room attached to his home. Two years ago Bette and Luis and I were here and I held a clinic in a woodshed. Since then, the waiting area has been improved and two exam rooms have been partitioned off with curtains at the end. A real bathroom with toilet paper, a sink and a toilet complete with seat had been installed. Having a clean workable toilet available changes the entire clinic day. In San Antonio, the only available bathroom is the one used by the school kids. It’s a long walk down a steep outside staircase with no railing, across a courtyard to a small, dank cubbyhole with an inch of (?) water on the floor, no seat, no paper and a bucket to flush. I generally avoid drinking all day when I go to San Antonio.
It was lovely being side by side with only a curtain separating us. I ended up consulting Mary twice and when I needed Bette to interpret a couple of times, she could step over quickly and then return to Mary with little disruption. There were only two minor issues with the setup. The first was the noise from the waiting room. Take eighty kids waiting, sometimes for hours, plus an equal number of adults, many elderly with poor hearing, add in a few dogs, and the noise level is comparable to a rock concert. The second issue was privacy. The kids, waiting and bored, not only peaked around the edges of the curtains but frequently walked right in and stood in the middle of the someone else’s exam, scratching at bug bites and taking in the scene.
For just one day in such a small place, I saw several kids with serious medical problems. The first was a nine month old girl, the first born to a twenty year old mother. The baby had been born at term and seemed vigorous and healthy for the first two months. The mother then began to notice that her daughter was not developing like her friend’s babies and became worried. She took her daughter to the government hospital when she was four months old and was told told that she was fine, but with continued lack of development, she was became increasingly worried and therefore brought her to our clinic. The baby was obviously severely brain damaged with spasticity (abnormal muscle tone,) signs of hydrocephalus (water on the brain,) and apparent blindness. She did not vocalize, couldn’t roll over, hold her head up or make purposeful movements. I explained to the mom that the baby needed an evaluation with a specialist to determine the cause of her condition in order to be able to determine the future, but that the baby’s muscles were weak and that her vision was quite poor. I didn’t want to take away all of her hope at once, but the truth is that this baby has some devastating neurological problem and is unlikely to ever develop beyond her current state.
Next I saw a delightful three year old girl who walked in with the classic gait of a child with untreated bilateral hip dislocation. The mother’s concern was not the hips though she did comment that her daughter walked with a little “jump in her steps.” Mom brought her because she was shorter that her classmates. An exam confirmed the hip dislocations and I discussed the implications with Mom. Luis will see about setting up an evaluation and I will search the internet to see if I can find one of the orthopedic groups that travel to Central America on volunteer missions. After several more patients, another three year old girl was brought in this time for lower abdominal pain. I asked if the child had been complaining of pain on urination, and while the mother was saying no, the little girl was nodding, yes. So I asked the child directly, and she began to nod again, but when her mother denied the symptom again, her little head went from nodding yes to shaking no. After a few more questions, the mother remembered that the child had been born with a kidney infection and was in the hospital for two weeks. She subsequntly has had two more infections, with high fever and hospitalization for IV antibiotics, the most recent being in November of last year. This whole scenario is not unusual here. The patient’s records stay with the doctor and it’s very difficult for patients to access them. They are not given much information about their conditions or treatment and have little understanding of how their bodies work or are affected by illness.
Just to lighten the tone of this report, I saw a family of three little boys, six, three and nine months. The three year old was a little rascal, dancing around, picking up my instruments and bottles of medicine, crawling under the table and generally creating chaos. While I was examining the 9 month old on his mother’s lap, the three year old sidled up and gave his brother a big pinch on the cheek. The mother didn’t react at all to the baby’s sudden shriek, so I pulled the boy’s hand off and told him not to pinch his brother. He danced away, grabbed a sharp stick from the six year old and handed it to the baby who promptly put it in his mouth. I removed the stick and the three year old pinched the baby’s leg while the six year old snatched back his stick. The final event of this Three Stooges circus was the six year old handing the baby a piece of wire with a computer chip on one end and a small light bulb on the other. The baby tried to stuff the whole thing in his mouth, and the mother finally noticed and casually pulled it out and handed it to the three year old. It will be a miracle if these boys survive to adulthood.
The final “interesting patient” was a four year old girl who limped in, partially supported by her mother. She had an ace wrap around her left knee and looked pale and tired. The story was that she had fallen while playing outside with other children the day before. No adult had been present to witness the fall, but the child had come home crying and the mother had cleaned a small puncture wound on her knee and wrapped it up. She had passed a restless night and then come in. On examination, the child had a hot, red swollen knee, but the infection did not appear to involve the joint. The main area of tenderness was actually higher, at the lower end of the femur. I asked Mary to come over to confirm what I had concluded, that the child likely had a fracture of her lower femur along with her cellulitis. I carefully explained the situation to the mother, that the child likely had a small fracture in the bone and she needed an x-ray to confirm it. I gave her antibiotics, and the Mayor volunteered to drive her to the government hospital in Malacatán in the morning. I stressed the importance of not letting her walk as she could fall and have a worse fracture. The mother appeared to understand, but when I turned away to prepare the antibiotic, she lifted the child down from the table and set her on her feet. I stopped and again told her the child should be carried, but she seemed bewildered, saying the child had walked in. We had another long discussion and she did leave carrying the child. I can only hope she will go for the x-ray.
I have one last patient story that is actually from Sibinal. A mother brought in her six year old son and stated that his compañero was climbing. I asked her to please repeat, and she did, but luckily for me began undoing the child’s belt and pointing in the general direction of his genitals. With his pants down, I could see that he had an inguinal hernia, and his “compañero” had indeed climbed up into his groin where it didn’t belong. I started explaining about hernias to the mother using the word “testículo,” but she looked so puzzled that I switched to compañero, a great word.
So we’re on our way to Malacatán, and the last clinic day. I have one observation about a difference between kids at home and kids here. None of the kids here object to having me look in their ears. It’s often a big deal in the US, babies and toddlers hate having their ears checked and often have to be muscled through the exam. Kids here often cry and some try to twist away from the stethoscope, but when it comes time for the otoscopic exam, they all sit right up and cooperate. Very Weird!
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