Thursday, August 7, 2014

Go Honduras! -- Days 4, 5, 6

I am chronicling three days in a row because they all sort of run together.  Within these three days, the medical team saw 721 patients.  Donna has quite an organized way of running the clinic.  Along with the organizational system we use to get every person through the clinic and seen by eyeglass, intake, consults and pharmacy, she also has a system to control how many people we see.  For this particular site, she issued 750 tickets to the mayor of the town.  The mayor is told to distribute the tickets however he sees fit, but usually Mission Upreach gives guidelines.  The government officials are supposed to distribute the tickets to those that need to be seen most -- basically the sickest people.  Unfortunately, sometimes the tickets are sold to others, given to friends of government officials, etc.  There are some things that Mission Upreach can and can't control, and this is one of them.

People waiting in line outside the school as we are driving up

Usually, about 2/3rds of the people with tickets are seen.  So, seeing 721 people/750 tickets was a really great ratio.  On each of the three days, people were lined up back-to-back when we drove up in the army trucks around 8:45.  The front gates of the school were opened at 9:00, then we would see people non-stop until 3:00, taking shifts for a short lunch break.  I know these hours seem limited, but that is what had to be done so we could get there and back in time to meet everyone else for dinner; we had four hours of driving to do each day.  (It is not a good idea to drive in the dark.)

 Dr. Walter, who knows bacteria by smell!  I need to go back and learn more from him...

Ashley, Staff RN... she's game-planning.

Most of the people that we saw were there for general complaints such as headache, abdominal pain, diarrhea, or back pain.  These complaints usually indicated three major etiologies:
  •  Headaches were usually indicative of the need for glasses, especially if those having headaches were children.  We were able to provide reading glasses, but the only thing we could do with those who could not see from a distance was to tell them to see an eye doctor when available.  Headaches in teenage girls was also common, but then I quickly realized that most of these girls were wearing their hair in a very tight ponytail, and they were complaining of headaches around their hairline.  If it was headaches combined with fatigue, I would usually prescribe iron tablets along with the vitamins (which everyone got, no matter what diagnosis) to cover iron-deficiency anemia.  If I was unsure about the origin of a headache or other associated symptoms, I would pass them on to Tom or Walter.  For example, Tom and I discussed the complaint of one young woman who had sustained an eye injury a year ago that included a run-in with barb wire.  Her eye had seemed to heal well, but she was complaining of a headache that ran from the corner of that eye, running in a line to the back of her head.  This was probably nerve damage and resulting nerve pain.  Neurontin, which is for nerve pain, may have helped, but again, we really didn't have anything to help her.
  • Abdominal pain and diarrhea usually indicated some type of parasite.  Fortunately, Anne Reese had this covered!  We had a parasite table in between the eyeglass room and consult room, and anyone who had not had a treatment in 6 months would get a dose of albendazole, unless you were a woman who was pregnant or breastfeeding.  When they reached me and I confirmed that it was likely a parasite causing their symptoms, I would give additional medication such as Tylenol for abdominal aches and antacids/Pepcid if they had heartburn.  I would also encourage additional fluids, and to see another healthcare provider if the diarrhea had not resolved.  If they had additional symptoms that did not fit the parasite bill, such as blood in stool or persistent nausea or vomiting, then I would send them on for further evaluation.
  • Back and neck pain were also pretty easy to figure out.  If the person was male, I would soon discover that he spends the entire day out in a field, bending over and cutting things with a machete.  If the person were an older female, I would ask about where it hurt and would eventually find that it was mostly in hand, foot, and knee joints, indicating arthritic pain.  Depending on the severity of the pain, I would prescribe Tylenol and/or ibuprofen, indicating that they could take each in alternating intervals.
Those were the three major categories I could mostly handle myself and send on to pharmacy.  By the second day, I got discouraged because I had to send so many people on to Walter or Tom.  There is only so far I can go as a nurse when it comes to assessment of signs and symptoms, especially when it comes to my area of expertise.  For example, I am not used to treating those under 17 years old.  It got to the point where if I had a mother walking up to me with a 2-month old, I would just ask Shawn to have her wait to see either Tom or Walter.  I didn't stay discouraged for long, because everyone is always smiling, always appreciative and thankful.  I spent about 20 minutes talking to a lady in her 80s who spent half that time talking about how thankful she was we were here and explaining the impact we were having on her community.  The other half of the time, she just wanted to be listened to.  I sent her on with a prescription for Tylenol and "Dios le bendiga" (Go with God).  I think this was the same lady who brought us a whole bunch of bananas later.  Sometimes, active listening is the best medicine.

Pharmacy, hard at work
Donaldo, who graciously was my translator.  Someone else from our group ended up giving him a Bible because he asked for one.  He is a U.S. soldier, stationed in Santa Rosa for 2 years.
Here are some of the more serious/mysterious cases:
  • 76-year-old man comes in, and I can easily see that he is working hard to breathe.  He complains that his chest hurts, and all of the muscles in his abdomen are working to help him get air.  I look at his blood pressure reading from intake.  It is 170/100.  I walked him on to Tom, who takes one look at him and tells me later: "I thought we were going to have a dead man in 5 minutes!" Tom retakes his blood pressure, and it is 220/110.  Tom assesses him and decides to give him amlodipine, a blood pressure medication.  Tom is with him for the rest of the clinic hours, monitoring his blood pressure and symptoms.  This scenario ended up going well.  He walked out of the clinic stating that his chest pain was gone and smiling.  He left with prescriptions for blood pressure medications that he could obtain in a local pharmacy.
  • A woman comes in with her little boy, who she is bringing in because he is not sitting up at 8 months old.  Tom assesses him, but he seeks input from Cecilia, Field and me, because we all have to look up what a baby's normal range of a blood pressure should be.  Eventually we figure out that it is within normal range, but find some other things that are pretty disconcerting.  His tongue is protruding slightly out of his mouth, and his ears are lower than they should be.  There is a considerable space between his eyes, and the bridge of his nose is a little more flat than it should be.  He won't track our fingers or respond to sounds.  All of us agreed that he might have Down's Syndrome and referred the mom to Santa Rosa for a consult.
  • A woman in her seventies comes in for evaluation of her leg wound, which, I won't describe it, was pretty gruesome.  Walter and Tom see her because Walter says that he is going to need help debriding it (removing dead tissue).  Walter explains to Tom how they teach them to identify bacteria in med school.  Since he usually does door-to-door visits with no immediate access to a lab, he is able to identify bacteria by smell!  He is sure that her wound is infected with pseudomonas.  The woman will not show Walter her other leg.  After 15 minutes of coaxing and demanding to see the leg, she lets them see it.  It is even worse!  Walter and Tom clean both of her wounds, dress them, and send her off with antibiotics.
  • A man in his forties comes in with a big lump on his back, midline near the neck.  Tom decides that we should try to remove it.  Tom, with Jacob assisting, surgically removes the lump, which is completely encapsulated, indicating that it is most likely a lipoma (fatty deposit).  Jacob... you can ask him later... is probably grossed out!
  • A 7-year-old girl walks up to my consult table and sits in the chair.  After 10 minutes of figuring out what her name actually was (her grandmother's name was listed as her name), we got to her chief complaint.  "I have bumps," she says.  "Can you show me?" I say.  The grandmother starts explaining where they started and points to where I should feel them.  The little girl has hard bumps, at least 4: one on her chest, one on the inside of her thigh, one on the opposite thigh, and one under her left armpit.  I palpate the one near the armpit and she giggles.  "Ah!" I say and I shake my finger at her, and she laughs harder.  "I know what is wrong!  You are ticklish!" We continue with this banter a little longer before I explain to her and the grandmother that they are going to have to see Walter, who referred her to the city for a more extensive work-up.  Her lumps were along her lymph node tract.  It could be a number of things, not excluding cancer.
  • A 2-year old girl comes in and is seen by Cecilia.  She sustained a head injury two days ago, and her mother explains that she has a mental deficit to begin with.  Upon examination, the right side of her head is swollen, and her right eye is gazing toward her right from pressure.  Cecilia does a neurological assessment, and in the midst of it, the little girl's mental status has worsened.  Cecilia says she will die tonight if she does not go to the hospital.  Mission Upreach staff drive her and her mother in a van towards town.  Later, Donna and Steve go to look for the girl at the hospital.  Nobody knows about her, and they can't find her.
I don't really like to end with that story, because that little girl is the exception.  We did much good for many people, and probably saved many lives.  For example, we saw many people with dangerously high blood pressures that could have led to a heart attack or stroke.  Jacob and Nyla were especially helpful in these scenarios because we needed to take repeat blood pressures over certain intervals and monitor these individuals.  There were also many with high blood glucose, and were being diagnosed with diabetes for the first time.  Tom and Walter worked diligently to assure that these individuals not only got the medicine they needed but also got adequate education on what diabetes was, how to treat it, how to control blood sugars, how to modify your diet, etc.  That prevented complications for these people like neuropathy, ulcers, and delayed wound healing.  We did help lots of people.

Shawn with a cute baby who reached up for him.

There were many that we couldn't help, though, and this is where I got discouraged.  At the end of Day 5, I talked to Tom about it.  He encouraged me by telling me the truth.  "We do have the responsibility as medical professionals to provide the best care possible, but that is not what we are here for.  We are here to bring people to church, to Jesus."  When Tom helped me place my attitude in that mindset, the whole experience changed for me.  I had much more energy, and Satan had a hard time tearing me down.  The church planting team at Mission Upreach uses the medical clinics to gauge how receptive the people in these villages are to starting a church there.  They are being led to Jesus, and I am honored to be a part of that.

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