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

Prolapse, pessaries and HPV

Hey everyone!

Week 2 at Loma de Luz has wrapped up. This past week we had an OB/GYN from Colorado Springs join the team, so we had a lot of GYN action. I think I fitted more women with pessaries this last week than I had my entire life. I worked closely with Dr. Lockey and she taught me really good exam tricks. Unfortunately, cervical cancer ,although preventable, is a major  cause of mortality here. Some women don't have access to health care and find out too late. There is also the case of not having reliable test results, here at Loma De Luz all the cytology samples get sent to the US. So, needless to say we saw a lot of really sad cases involving cervical cancer this week.

This upcoming week there will be a team of ENT residents joining. Im looking forward to working with them.

And to end this week of OB/GYN with a Bang! Mrs Rosalia (not her real name) is a 39yo G13P9 who presented to the hospital after 2days of laboring at home. She walked [in labor] 3hrs to get to the hospital. She was 6cm dilated on arrival. We AROM'ed her and prepared to have a quick delivery. PPH kit was in the room. Baby looked great on the monitor, but after 1hr went by and she was unchanged and then 2hrs went by we knew something was wrong. She had 1 prenatal visit and nothing more, she had all of her babies at home previously- 2 breech deliveries that ended as fetal demise. Bedside US showed an EFW 4800g, no wonder baby never came out. We decided to go to c-section. After delivery of the placenta uterus was still pretty boggy and there was brisk bleeding. As we started closing the hysterotomy we noticed what appeared to be an inferior extension of the hysterotomy into the cervix. We continued to close quickly and steadily. BP was 74/36, but the anesthesiologist believed it to be related to the spinal anesthesia. By the time the uterus was closed the bleeding seemed well controlled. Tone had improved after a pit bolus and methergine. We did a BTL and put the uterus back in the abdominal cavity. BP remained low. There was more than normal amount of bleeding but at this point it didnt seem overly concerning. As we finished closing and we started to clean up we started noticing the towels around the surgical field were soaked in blood, so was underneath the surgical drape (we dont have fancy drapes that catch the blood..). Then I noticed there was a huge puddle on the floor and more blood kept falling from the bed. Initially we thought it was just from moving the towels, but vaginal exam revealed brisk bleeding. We gave cytotec. We tried a bakri balloon. We gave 3L of NS and 1 UPRBC. We were unable to bring the blood pressure back up and by this point patient was tachycardic.  There is no blood bank in the middle of Honduras, we were going to need more blood. We put out an emergency alert to have everyone who was O+ run to the hospital to donate blood, 8 of us donated. In the middle of all of this the general surgeon arrived and she was taken for a hysterectomy. And 9 units of blood later, she is currently stable. Baby likely has some meconium aspiration and is requiring a bit of oxygen, but is also stable. Today was stressful to say the least. However, I am humbled by the response of the staff at the hospital. I am not at all surprised to have nurses and doctors donate blood for a patient, but electricians and kitchen staff also stepped in and that is incredible.

And so one more day goes by at Loma de Luz.
Until next time.
-g

Greetings from Balfate, Honduras, everyone!

I apologize for the delayed posting, it has been a CRAZY few days combined with some technical difficulties. So, to make up I will try to recap my first week at Hospital Loma de Luz to the best of my abilities.

My entire time here has been an adventure. Starting with getting off a regular Boeing 737 in Roatan and then having to board a tiny propeller plane to fly to La Ceiba on the Honduran mainland. I am terrified of flying so I prayed the entire 20minute duration of that flight. But survived, and unbeknownst to be, the taxi ride from La Ceiba to Balfate (1.5hrs) would be even more terrifying. I should be used to horrible Latin American driving standards (I learned to drive in Mexico for crying out loud!), but I guess you forget and get used to seat belts and air bags and side mirrors which aren't always necessarily available....anyways I survived and made it to Loma de Luz. The first day started being woken up at 5am by a howling monkey outside my window and running across a hanging bridge to get to the hospital. And so, it began...

My first day at Loma de Luz I shadowed Alisa, a nurse practitioner who showed me the ropes. She taught me how the EMR works. How patient flow is managed. Where to find things. Introduced me to the staff. I got a copy of the current med formulary and saw a few patients. I work in the clinic 5 days a week and am on 24hr call twice/wk, one of those days is usually a weekend. 

This week has been GI bleed week and motorcycle accident week. We had Mr. M who presented with a complaint of convulsions. After trying to piece together the story we realized he was recently started on warfarin for A fib. His INR was too high to read. His gums and conjunctiva were white. Surprisingly we had vitamin K and he received 2 doses overnight. Several of us donated blood as he required 4U PRBCs and there is no blood bank available. He recovered and got discharged yesterday!

Mrs M presented with hematemesis and melena. She is neutropenic (still unsure why). Has a history of recurrent GI bleed and we're currently treating her with PPI, H2 blockers and NPO. I just heard today we're running low on PPIs until Friday when the new shipment arrives. She is stable from a GI bleed stand point. It is definitely weird not being able to get an EGD on site and knowing this is all we can do for her, and replace blood if needed knowing if she lived somewhere else (developed nation) she could get a life saving EGD...

I was on call Saturday with Dr. Bryan Jennings (recent NCFM graduate) and we had the craziest/busiest shift they've had in a while. In 24hours I saw 19 legitimately sick patients. Admitted 4 patients. Managed an induction and delivered a baby. I had to repair a pretty gnarly head laceration after a motorcycle accident. I learned to do a infraorbital and mental nerve blocks to repair lip lacerations after yet another motorcycle accident. And a 16yr old walked in very calmly to the ED and said he had a cut on his hand, when I asked him to take the bandage off the entire tip of his 3rd finger was missing (how was he so calm?!). For some reason he stuck his finger and it got cut on the motorcycle chain...the tip was no where to be found. We have no hand surgeons available, but we have a general surgeon who does a lot of ortho surgeries who recommended closing as best we could and follow up in a couple of days with him. 

Most of the crazy cases are obviously seen in the ED. But, I like clinic (partially because there isn't a burden of heavy documentation and time constraints, unlike in the US). I get to sit and talk to the patients. Learn their stories. It is also nice because most of the time the patients do not know what medications they're on. What happened during a hospitalization. What the diagnoses were, etc so trying to piece the story together takes longer. The patient's at LDL are so grateful for the medical help. I've had patients that drove 8 or 12 hrs to be seen at the clinic. Some leave their villages 2 days in advance and make the pilgrimage to LDL in hopes of being seen. The worse clinic cases I've seen have been botched orthopedic cases. It truly is sad. I saw an 8yo F with Blount's disease. Usually bracing will do the trick and correct a bowing tibia, but if needed a relatively simple growth plate arrest surgery would've corrected her problem. However, she is 18months out from surgery she has infected hardware, non healing ulcers and the xray revealed an eroded fibula from the chronic infection. The likelihood of her needed an amputation is high. I cant help but think that this would never happen in the US.

I could go on and on about other cases over the last week, but I've written enough. To sum up my first week at LDL

1. I am in awe of how much the full-time missionaries can do with so little

2. My sense of compassion and love for medicine has been re-ignited by the gratitude and stories from the patients I've met at LDL

3. I cannot help but feel sad by some of these patients knowing that by no fault of their own they were meant to live in a developing country were some life saving resources are just not available- but that they exist somewhere else. 

P.S I've also become very good friends with the LDL dog: Paisley. I may or may not steal her in the afternoons to soothe my puppy withdrawals....

Till next time,

g

One final reflection

My time in PNG has come to a close. I’m currently sitting in the Brisbane airport partway through my 3½ day trip home. As I think back through my time, there are a number of memories that come to the surface. To be honest, many of them are sad and difficult. I think about diagnosing a woman with twins and polyhydramnios (too much fluid) at 19 weeks and then a week later delivering the twins, too small to have any chance even if they had been born in a different setting. I remember the tiny three month old, suffering from malnutrition and likely some undiagnosed congenital syndrome who came in with respiratory distress and miraculously survived through the weekend only to die on Christmas Eve. I think about the mother with uncontrolled diabetes that we took back for a C-section due to failure to progress because her baby was 5kg. After the C-section, I went in to check on baby and he was cyanotic and had significant difficulty breathing due to his massive chest and the amount of fluid and meconium still present in his lungs. I knew in my heart that he wouldn’t survive till morning. And yet there are a lot of other memories that are more positive, although not as etched into my memory; the man slowly recovering and gaining strength following TB meningitis, the molar pregnancy I diagnosed in clinic after 20 weeks that could have been life-threatening if allowed to go much longer, the little boy with acute bacterial meningitis who slowly improved over time, the cord prolapse baby that survived, somewhat miraculously, to be born early Christmas morning, and the countless people in clinic who left with a diagnosis that could explain much of their pain and suffering.

Despite all the difficult moments, discouragement is not the predominant impression I have in leaving. To be sure, it is difficult to swallow that so many people, particularly children, are still dying of illnesses that we have had the ability to treat or prevent for over 50 years. There were a number of nights I left the hospital with a heavy heart. The more I reflect on it, though, the predominant impression I have in leaving is not the individual clinical memories, but rather the conviction of God’s calling me to medical missions work and to caring for the poor and most needy. It was reassurance that I have not wasted the last 9.5 years of my life and that my motivation, though deeply buried, was not fully destroyed by the medical training process. It was also a reassurance that there are multiple paths after I finish and a number of ways to obtain the skills that I will need to serve in such a location. Overall, I’m leaving with a kind of hope for what the future might bring and the changes that might be possible.

Thoughts on transitioning back home

My time is swiftly coming to a close here in PNG. Already I am starting to prepare for my departure and it is predominately with sadness. Here are a few thoughts I’ve had as I wrap up my time.

As I reflect particularly upon the transition back to my work in the States it is with mixed feelings. Here in PNG the main difficulties I have had have been the want of equipment and medications and access to procedures; from desiring the proper medication for patients in the clinic (BPH meds to Lasix, which we ran out of shortly after I arrived) to the ability to obtain a CT or MRI for a patient to clarify a diagnosis to the more heart breaking need for proper respiratory and ventilator support for critically ill neonates and children. Knowing that outcomes for a patient, particularly a child, would have been different if the necessary materials were available is difficult and it is nice to be heading back to where supplies are plentiful. However, it is also with reservations that I head back. Here in PNG documentation consists of the essentials to communicate important diagnostic information and treatment plans, but does not suffer the burden of satisfying medical billers or future litigators as in the US. The main purpose is patient care with an emphasis on efficiency. I was reminded of the stark difference reading through emails from home with numerous attached documents of the particular documentation requirements of a specific population with government insurance. I do not doubt that EMRs and the current documentation requirements have helped to provide more comprehensive care, however, I believe they also contribute significantly to burnout and decreased time in direct patient care.

I have had numerous discussions with the missionary physicians here about the differences in practice here and in the States. In the US, we frequently discuss whether or not a test will inform our treatment decisions in an effort to minimize unnecessary testing. Here it is taken to a whole new level. I had thought I was thinking carefully through tests before, but here there have been numerous times I have suggested ordering something only to be challenged on whether or not that will meaningfully change my plan of care. Over the course of my time, I have learned to rely more on clinical exam, nursing reports and typical disease course than on laboratory values or imaging. Although there is theoretically universal health care here, the only way for hospitals to make ends meet is to charge patients or receive donations or both. Tests here cost money for the patients (often between $1-5), which, for many of our patients, is a significant investment. Minimizing unnecessary tests has very practical implications for our patient’s lives and makes it that much more critical. It is frustrating that this has to be true as I wonder if care were truly free if we would see patients come in earlier and thus be more likely to respond favorably to treatment. Of course it’s impossible to know for sure.

Over the course of the month, I have been thinking about a quote I stumbled upon a few weeks before departing for PNG: “Tact, sympathy, and understanding are expected of the physician, for the patient is no mere collection of symptoms, signs, disordered functions, damaged organs, and disturbed emotions. He is human, fearful, and hopeful, seeking relief, help, and reassurance. To the physician, as to the anthropologist, nothing human is strange or repulsive. The misanthrope may become a smart diagnostician of organic disease, but he can scarcely hope to succeed as a physician. The true physician has a Shakespearean breadth of interest in the wise and the foolish, the proud and the humble, the stoic hero and the whining rogue. He cares for people.” The last paragraph from Harrison’s Introduction, First Edition, Harrison’s Principles of Internal Medicine, 1950. In some ways, by removing the bureaucratic work and computers, PNG has helped me to come back to being able to see more clearly the humanity of my patients. In others, it has offered new obstacles of language and culture. I took one morning last week to do rounds with the chaplain through the Medicine Ward, which I had been working on for almost a week. By getting the chance to sit down with, listen to and pray for some of the patients, I learned a lot more about some of my patients than I had discovered on morning rounds. One of the women who had been admitted for a suicide attempt with gramoxone ingestion (a type of herbicide used frequently here as a means of suicide) informed us that she was pregnant, something that she had hitherto not shared. Another woman with undiagnosed abdominal pain told us about her unfaithful husband, her family’s refusal to let her divorce and her fear of contracting AIDs. I hope in the future, whether here or in the US or somewhere else, that I will not let the numerous obstacles that will always be present interfere with my ability to truly see, listen to and care for my patients.