Final Post

Better late than never...sorry for my delay with this last post!

I can’t believe my time in Honduras has come to an end. I am now sitting in the airport in Roatan, an island off the coast of Honduras, listening to a Caribbean rendition of “Achy breaky heart.” At Loma de Luz, I saw several patients who came all the way from this island via ferry and then a bumpy 1.5 hour drive to get care simply because they could not afford health care on the island itself (since it’s a tourist island, health care is here but expensive). Being here again makes me reflect on the inequities that plague our patients every day.

My last week at Loma de Luz flew by. I was on call 2 of the 4 days I worked this week. Call is a 24 hour shift and entails working clinic again the next day no matter how busy you were the night before. Most nights you can get some sleep; however, we use a walkie-talkie system and my walkie-talkie spontaneously changed channels on me, so I would wake up multiple times per night to make sure my walkie-talkie was on the right channel. My last day of call I was called at 7 am, the moment my shift started, about “a child” whose oxygen saturation was 46% on 15 L/min of a nonrebreather. I sprinted across the bridge to the hospital to find what I thought was a 12 yo boy huffing into the rebreather with blue fingers, toes, and lips. I quickly instructed the nurses to call a rapid response to get more hands on deck. The nurses looked at me with big eyes and said “Why doctor? We know this child. He always looks like this.” After getting my hands on his chart, I come to find out this is a 20 yo man with a hx of a large VSD from birth that has now developed Eisenmeger’s syndrome. His fingernails demonstrated the classic clubbing signs associated with chronic cyanosis. His prognosis was obviously poor, but right now he was acutely ill and needed our help. We empirically treated him for pneumonia and ordered labs- platelets of 41,000. Likely dengue. He held steady on the rebreather initially but then had an episode of rigors that dropped his sats to the 30s, 20, 10s…we set up to intubate and got the ventilator (there is only one in the hospital and boy, talk about old school). One the rigors stopped, his O2 came back up and we got him back up O2 sats of 60-70s, a win for today at least!

Being at Loma de Luz has challenging in so many ways, good and bad. Of course, devastating cases like that described above make me feel anger towards the world. One surgery to close this man’s VSD would have lengthened his lifespan by so many years and given him such a better quality of life. But because of where he was born, he was not granted access to services that could have helped him so much. Seeing patients suffering from curable diseases was a harsh reminder of the unfair reality of the world we live in.

Working at Loma de Luz also renewed the importance of public health for me. I saw a lot of trauma from motorcycle/motorvehicle accidents, unsafe working conditions (lots of machete and cow injuries), parasitic infections from unclean drinking water/food sources, and of course the effects of poor diet and physical inactivity in communities that are essentially “food deserts.” In a global health setting, incorporating public health in what you do is essential to really improving the community you work in (I guess that applies to the US as well).

I think the biggest lesson I have taken away is that global health is such a challenging yet rewarding experience for those who decide to take it on. The docs who work at Loma de Luz are so dedicated, basically on call 24/7 for any and everything that might be needed. They save so many lives and help so many people but at a cost to their own quality of life. Again, I can’t say enough about how hard the docs work in this setting- I think I worked harder this month than any other month of residency (actually, I take that back, OB was pretty busy…).

I am very much looking forward to coming back to the US and seeing you all, but will certainly miss all of the wonderful relationships I formed here in Honduras. I will also miss getting freshly-picked mangos as presents from patients. Hopefully I’ll be back some day, si Dios permite (if God allows…a favorite saying of the Hondurans).

See you all soon!!

Half way through!

Hi all, well I can't believe I am half-way through my time here in Honduras. The people here have been so wonderful, patients and employees alike, in embracing me during my time here. I have been invited over for dinner many nights which has saved me because I have not been able to go to the grocery store due to my schedule and have mostly been subsisting on cheese and crackers with a side of oranges for dinner!

The last week of clinic and being on call has been different from my first week. I began to feel frustration this week with some of the patients I was seeing- vague complaints of stomach pain, body aches, and foot pain (everyone here works in sandals doing manual labor, no wonder they have foot pain!). Because of my short orientation, I was not well-versed in what these complaints meant and felt frustrated as I could not pin a diagnosis on anyone given constantly changing history and vagueness of the complaints. It turns out there are several very common ailments here to explain these aches and pains that I was not aware of. Stomach pain is often a gastritis or parasitic infection, so everyone gets treatment for GERD and parasites. With these treatments (and maybe a multivitamin for good measure), most people amazingly get better! The same goes for body aches and pains- a little Tylenol or Ibuprofen goes a long way as most people have not tried or had access to either one of these medications at home. I started to become more familiar with what people wanted when they complained of "stomach pains" and the like, and with this my frustration with these complaints subsided.

The country of Honduras is on alert for Dengue at this time. However, we do not have the serology test to confirm or refute a diagnosis. There is unfortunately no cure for Dengue anyway, so we treat a lot of people supportively with close return precautions with the assumption that they have Dengue (or a similarly presenting disease such as Chikungunya or Zika). I have seen tons of kids with fevers but otherwise no focal symptoms, which is likely one of the above diseases. This is something we rarely see in the US, so it has been interesting to talk with parents about return precautions of "bleeding from the gums" instead of our usual respiratory return precautions in the US.

I continue to be impressed with the diagnostic acuity and "art of medicine" practiced by the docs down here. I realize how spoiled we are to have a CT scanner at our fingertips to differentiate between diverticulutis vs pyelo vs ovarian pathology when a woman comes in with LLQ pain (had this exact scenario and still have no idea what the patient's final diagnosis was!). CT scans are available here but the family has to travel 1.5 hours away on bumpy roads to a town called La Ceiba and pay 5000 lempiras (equivalent to $200) up front to have this done which is no small feat here.We really reserve CT scans for dire cases or chronic cases we cannot find the answer to. For example, a couple days before I came there was a 22 year old student who had acutely become anuric with lower back pain. His creatinine was rising quickly and no urine was accumulating in his bladder by ultrasound. He was going to need dialysis unless he miraculously had bilateral obstructing kidney stones on CT (impossible right?). Dialysis is basically a death sentence here as it is quite expensive and once you can't pay, you are basically done for. One of the docs here felt he couldn't let this young man die without a CT scan- he sent him to La Ceiba and turns out...he had bilateral obstructing renal stones (it CAN happen). They immediately did surgery and the patient went home several days later with an improving Cr. Again, the providers here do so much within the means they have and are so astute to think outside the box when they are called upon to do so.

This week has been filled with some interesting diagnoses- new HIV diagnosis, a stinky diabetic foot ulcer with gallons of underlying pus (treated with several days of IV antibiotics and Dakin's washes only), likely inflammatory bowel disease (and get this, they came to ME for a second opinion from a gastroenterologist). Mostly just lots of "Honduran" primary care work. I am very grateful for the chance to be here and fill in where I can (there are only 3 FP doctors down here now when 2 months ago there were 6).

On a fun note, I went to my first restaurant (Arena's) in the small town of Balfate nearby (the food was not good in case you are ever in Balfate and wondering where you should eat). I hung out at the gas station and ate ice cream (the gas station is the hip part of town), tried a guanabana (soursop- best fruit EVER), and went swimming in the local watering hole (Rio Coco). Life is slower here which has been a nice change of pace from residency.

That's all for now, miss you all!

First Days!

Hi from Honduras!
I was just re-reading Georgina's posts about her time in Honduras- lots to look forward to and be prepared for. I am only on my 3rd day here, but it has already been a whirlwind of an experience. Arriving here as Georgina laid out was quit a feat- 3 plane rides and a bumpy car ride through the jungle. Luckily, the nurses and nurse mid-wife as well as Anne Hotz, one of the family physicians here, were in La Ceiba (a small coastal town of 200,000) to accompany me to Loma de Luz. I got to sit next to Carolina, a nurse midwife from the Netherlands, on the car ride to the hospital- she was a wealth of knowledge and so excited to share about her experiences so far in Honduras. She loved telling me about a patient with TRAP sequence...look it up if you want to be entertained.

On my first day, I had about a 5 minute orientation on how to function in the system. I got a 5 minute tour. Then I was off seeing patients (with many questions along the way, of course). My first patient was a 30 yo pt coming in for a routine prenatal visit--except not routine at all. She thought she was about 6 months along- this was her first prenatal visit. She explained that this was her second baby- and the first delivery was normal, no complications. As we discussed further, I realized that she had a blood transfusion in the middle of her last pregnancy for severe anemia- no complications?!?!? I quickly ordered prenatal labs (here they do a CBC, RPR, HIV, and blood type for prenatal labs- I think they choose to do labs only on the infections or disease they can do something about). She also needed a dating ultrasound and lived far away- so had to get that done during her appt. She then shared she had never had a Pap Smear done and since we were doing a pelvic exam, we decided to do a Pap too. Again, thought it would be no big deal, but turns out as Georgina outlined, we have to prepare our own slides for Pap, fix the cells with hair spray (yes, really) and send them to the US hoping we prepared a good sample. This patient exposed me to what a routine prenatal visit is at Loma de Luz-now I was ready for anything (or so I thought).

On my second day, I was on call. I saw several kiddos with fevers- thought about my usual diagnoses but also had to think about malaria, dengue, and helminthic infections in these kids given they are endemic in this region. Thank goodness I don't think any of these kiddos had anything serious. I went to the OR for a closed reduction of a boy who came from Roatan (a 1.5 hr ferry ride and 1.5 hr car ride to the hospital) with a double forearm fracture (radius and ulna) and had a patient with a mid-shaft humerus fracture all within an hour. Speaking with the docs down here, there are a lot more patients with trauma and fractures down here, mostly due to moto accidents and kiddos climbing in trees and falling without supervision. A lot of injuries from animals as well. Anyway, had another pt with a TIA and syncope, RLQ pain (likely appendicitis), and an asthma exacerbation with likely HHS (all conditions we frequently see in the US).

I have so much respect for the doctors and nurses who work here. Even with these common conditions that are fairly straightforward to work up in the US, here you have to decide what to do based not only on what is medically indicated but also what resources you have and what resources the patients have. I also have so much respect for the patients. Patients have to pay for everything out of pocket and sometimes admitting them to the hospital is going to put a serious financial strain on their family. It's a delicate balancing act for both providers and patients and seeing patients having to make decisions between their finances and their health in such extreme circumstances is heartbreaking. I wish I could pay for everyone's admission myself...

I want to say tons more, but I don't want to tell you everything before I get back, and I have several weeks more of time here to write about. The howler Monkeys are awesome (here's what they sound like in the middle of the night- https://www.youtube.com/watch?v=-vxlnZ8BihI). It's so beautiful but hot as heck here (worse than Colorado in July I think). Miss you all and can't wait to tell you more about my time at Loma de Luz!

<3 Abigail