calla&belasblog

Final Thoughts

2010-06-13T08:16:00.000-07:00

We left El Salvador in April, nearly two months ago. I count myself fortunate to have worked in Estancia. I count myself blessed to have gone there with Calla. I thought Calla was my Elizabeth Bennett, but I discovered she is so much more to me. I learned so much from her and am so proud of her.

I spent the first night away from Estancia crying. I cried because I was sad to leave. I cried because the people in estancia could not leave.

Now, two months later, I find myself back in Rochester and preparing for fourth year, as if I had never left. Despite the fact that my experience was the most significant and enlightening time of my life, my daily activities have a way of distancing this experience from myself.

When I think about all the different work I did, there is one common theme that saturated my whole experience. Poverty. The dehumanizing effect of poverty is like a stain that cannot be washed off, only ignored.

I was only able to spend 8 months in Estancia because I received a generous stipend. Helping others is one of the most truly satisfying and rewarding ways to spend time. It saddens me that the poor are generally excluded from this experience. When Calla and I left Estancia, we gave away the majority of our things to friends as presents.

We were also given goodbye gifts, usually a bag of beans. In addition to our gift of beans, people often apologized for how meager their gift was. I was so touched by these gifts because I knew how little our friends had to offer, but I was also saddened by the apology. Even though these people had given much more of themselves in their gifts of beans than I had with my used clothing, they were the ones who felt shame because of the stain of poverty.

I did not feel any “culture shock” as I returned to the wealth and excessiveness of America. I was struck by how successful the wealthy are at hiding poverty from every aspect of their life.

As a wealthy person living in Estancia, I was always aware that I had ten bucks in my pocket, while my neighbors made about three dollars a day for seven people. At the very least I was forced to feel uncomfortable, and it compelled me to do what I could to help them.

I went to med school to help people, but it took going to El Salvador to make me feel like I was. As a doctor, every patient is an opportunity to help someone. My lesson from Estancia is that if I am not helping the poor, then I do nothing to wash away the stink of poverty.

-- Bela

2010-06-08T09:02:00.001-07:00

Photos

1. Sunset
2. His grandfather is kicking a soccer ball to him
3. Playing race cars
4. and 5. Neighbors
6. Making protein meal for malnutrition program (Siete Semillas--Seven Seeds)
7. Neighbors
8. Town corn-grinding mill, owned by women's coop
9. Carrying cornmeal to the mill
10. I can only make baby tortillas
11. Town band
12. Etelvina

2010-06-08T08:39:00.001-07:00

Final Thoughts

Bela and I have returned back to the United States. We spent a total of eight months in Estancia, and the time flew by. Part of me cannot believe that we are already back home, and part of me feels like the time went too fast to even be real. It is almost as if we haven't even left yet.

Our last few weeks in Estancia were spent in a macroscopic version of a sign-out. Every volunteer from Doctors for Global Health becomes attached to specific patients, and these patients, over the years, have come to be known as "special patients." These patients typically have both complicated medical histories and difficult social circumstances, and it is a main job of volunteers to advocate for these patients both within the health system in El Salvador and in the local community. Leaving is particularly hard in terms of signing over the care of these patients. I think that I speak for both Bela and myself when I say that the goodbyes were emotional and difficult. Luckily, Juan Carlos and Etelvina are still tirelessly working in the clinic--seeing patients, providing psycho-social support, and accompanying patients to the hospital or to specialist appointments when they are able.

In addition to saying goodbye, many people wanted to share with us their stories from the war in El Salvador. I can only speculate about motivations for sharing with us during our departure. I imagine that it was easier for people to talk with us, knowing we were to be leaving for a period of time (although it is our promise to return to visit within the year). I also imagine that people feel a need to not be forgotten, as a story shared is a story that lives on. I also hope that Bela and I earned a level of trust over the time that we were there. We both believe that the community, after surviving the war, surviving extreme poverty, and working together to change the future, deserves a tremendous amount of respect. We tried to let people know that we respect them, respect their generosity towards us, and respect their incredible capabilities and talents.

However, the stories of the war were very difficult for me to listen to. People related incredible violence against themselves and their families. The histories were not related in a detached, emotionless way. Rather, it is apparent that the memories of the war are very clear, and very painful. Some things that were told were so awful that I had to try to calm my stomach in order not to vomit. Women endured rape. Children watched beheadings of their parents, and parents of their children. Hangings, shootings in the back of the head, torture of the elderly. War is not justice.

I had barely the amount of emotional strength needed to be able to listen to the stories. I am amazed and awed by the resiliency of the people of Estancia. To wake up every morning, to prepare food, to care for children, to farm, to endure day after day.

* * *

I also wanted to follow up on a few patients.

The man with anemia passed away two weeks ago. He was at home, comfortable according to his family, and surrounded by people who love him.

Following our trips to the hospital in December and January, he was able to be scheduled for an upper endoscopy, a procedure to look at the stomach to see if there is an ulcer or a cancer, in early February. The endoscopy was completely normal. Following the procedure I asked the gastroenterologist from San Miguel to please interview and examine the patient again, from scratch, as I was confused as to what could be his diagnosis. She spent about forty-five minutes with the patient, and then came out to speak with me, to clarify some parts of his history and share her thoughts.

She sat down to think. After awhile, she looked at me and said, “You know, I think he has kidney failure. It can look like so many other things, and would explain his severe anemia and mild congestive heart failure.” She agreed to admit him to the hospital in San Miguel to perform the necessary tests. After writing up a note and test recommendations, the physician had a long conversation with me about the clinical symptoms and signs of advanced kidney disease. As she talked, I thought about the patient, and all of things that I had assumed were not part of the main problem causing him to be so sick, and I reminded myself to read more about kidney failure.

Bela, Juan Carlos, and I spent the next month following up with tests, and accompanying the patient to outpatient appointments with the nephrologist in San Miguel. The trips were always difficult. Ramiro, the NGO director, would drive the patient and his oldest son (who was always at every appointment) up to the top of the hill and to Cacaopera, where we would catch a bus to Gotera. Once in Gotera, we would catch a bus to San Miguel, a trip of an hour and fifteen minutes. Once in San Miguel, we would take another bus from the terminal to the hospital, a trip of 20 minutes. At the end of the day we would make the trip in reverse, and the patient would be exhausted.

The nephrologist was a wonderful woman. She was very kind, and very respectful of the patient. On the day when she talked with the patient and his son about prognosis, she spent about forty minutes with us answering questions, and used simple language that the patient could understand. She explained at that visit that his options for treatment were limited to palliative care or dialysis. She encouraged the patient to have a family meeting to discuss options and goals. She made a follow-up appointment for three weeks later, and gave Bela and I her cell phone number, and told us to call if the family or we had any questions prior to that.

Before the leaving the office, the patient asked her, “Why did this happen.” The doctor pursed her lip, and said, “I’m sorry, I don’t know.” This answer did not satisfy the patient, and he repeated his question, and, after again receiving the same response, replied, “Well, you must have some ideas at least.” The doctor repeated that she didn’t know what had caused his kidney disease specifically, but she had seen a sharp increase in cases of kidney disease from the Morazán province. She explained that she was among a group of nephrologists who believe that it may have to do with the war. Morazán was heavily bombed during the war. In places like Estancia, bombs were dropped from airplanes almost daily for a number of years. A group in Mexico that studies environmental effects of war and conflict had tested some of the rivers in the area and found extraordinary levels of heavy metal contamination, and she explained that the lead levels were quite shocking. It is her concern that kidney failure might be an unrecognized long-term consequence of war. She then lowered her voice, “To me it is an injustice of the greatest magnitude.”

Following this discussion, there was a moving exchange between the patient, his son, and the nephrologist. The nephrologist displayed gratitude to the son for caring so well for his father, and to the patient for his service to the poor. The patient smiled. “I am poor. I am dirt poor. So these,” and he made a sweeping gesture in the direction of the waiting room, “are just my people. We look out for each other.”

We arrived back in Cacaopera after dark, long past the departure time of the latest bus in the evening. Ramiro came to pick us up, and we set up a time to come back and meet with the family. At the meeting, we tried to listen to everyone and answer questions. The patient seemed reluctant to attempt dialysis. His wife and son seemed to want him to try. We encouraged them to keep talking as a family. When we left, we told them that to us, whatever decision they came to as a family was the right decision. We explained that the patient had to choose what was best for him, and that it was Bela’s and my job to support that choice.

The follow-up appointment with the nephrologist occurred after Bela and I had returned to the States. We called the family the next day, and they told us that the patient had decided to not pursue dialysis. I asked to speak with the patient. I asked him how he was feeling. “Scared, but ok. I want to be at home, with my family.” I tried to validate his decision, but told him that he had the right to change his mind. “That’s funny,” he said, “The doctor said that too. She wants to see me in San Miguel every month to check up on me.”

Three weeks later, a few days before his next appointment, Victorino, the administrator of Campesinos para el Desarrollo Humano, left us a message in the afternoon. The patient had passed away in the morning. We called the family right away. Juan Carlos had arrived at the patient’s bedside in the morning, and had been very supportive of the family. The patient’s brothers had been notified and were traveling in from the coast. The son was stoic on the phone. “He knew it was going to happen. He called us together two days ago to say goodbye. He was very sleepy after that.” His wife was crying. “I miss him right now. I am so sad. But I am so glad that he is here with us, and that he didn’t die alone in a hospital.”

* * *

Following the death of the woman with congestive heart failure, Bela and I continued to visit the family. Her husband is a frail man, in his mid-eighties, and blind. He has an incredible sense of humor, and every time we visited had a new riddle or a joke for Bela.

The couple’s daughter lives in a neighborhood that is closer to Cacaopera, and, after a lot of family deliberation, it was determined that the man would go and live with them in their house.

He moved a week and a half before we left El Salvador. As we didn’t know that neighborhood very well, Abraham, the community health promoter for CDH, agreed to take us to the house. We had a wonderful visit with him and his family, and it broke my heart to say goodbye.

* * *

The woman who we took to the hospital with shortness of breath stayed there for a little over two weeks. When she was discharged, she went to stay at her daughter’s house in Cacaopera, to continue her medical treatment of antibiotic therapy for pneumonia (the tuberculosis tests that were done were negative). She returned to Estancia after that. Bela and I saw her about once a month, and ran into her grandchildren often. She is spry and funny, and very hard of hearing. Her grandchildren are very energetic and very polite, and it was always a pleasure to see them and chat.

* * *

What I learned:

Relationships matter. The relationship with Etelvina, the health promoter in charge of the clinic, was so important. I miss her terribly now that I am back in the States. She was fun to work with, and she is great mentor and teacher. She is in the community, of the community. She knows everyone, and keeps strict confidences. Seeing patients with her was enlightening and inspiring. I was able to sit with her in a visit from a woman with post-partum depression, in visits by farmers for physical therapy, do home visits with her, etc. etc. She is professional and kind, and is always trying to learn more about medicine and health care. Additionally, no patient care would be possible without the relationships. Working in such a tight-knit community made this so apparent.

Follow-up matters. I saw so many examples of this. We were lucky to be able to work closely with Abraham, the community health promoter. He was able to follow-up with many of our patients, and would report back how people were doing with medicines, or psycho-socially. If he thought someone was having a hard time with a certain treatment, or thought a certain treatment wasn’t working well, he would go with to see the patient again in their home, or bring the patient in to the clinic. Keeping in contact with the specialists in the public system was important as well, and helped our patients get the follow-up care they needed.

Palliative care matters. Over the course of our time in Estancia, three chronic patients passed away. All three patients wanted to die at home, and all three were able to do that. I believe that in two cases, the families were prepared for the deaths, and in once case, the family was less prepared. I think that Bela and I got better at having family discussions about care goals as the year went on. Etelvina is very good those conversations, and taught us a lot. Unfortunately, there is not much access to the kind of medical palliation available in the United States. I believe that better access to these treatments is necessary.

My happiness matters. Sometimes I needed a break. I love Estancia, and I love the work, but there were times when I was a little overwhelmed. I did the best work when I was happy. Our neighbors helped so much in this regard. After a long day, hanging out with them made me excited for the next day again. Swimming with them in the river on the weekends was relaxing, super fun, and helped me to not get burnt out. On particularly quiet days, Bela and I would take a break in the late afternoon to go for a walk, or to go buy freshly made semitas, a sweet cornbread, and sit and eat the bread and drink coffee while watching the sunset. I started running sometimes with a nine-year old (and extra-fast!) girl named Angelica. Sometimes her brothers or other neighborhood kids would come too, but she was always the fastest. And visiting families was always fun and a nice break from work. I think that we had a better experience because we made a little bit of time for ourselves.

Poverty matters. Poverty and illness go hand in hand. People who are poorer have less access to both curative and preventative health care. Poverty means no access to clean water, less environmental protection, less access to education, less nutritious food, more anemia, more malnutrition, more hunger (or, in the US, more obesity, but that is another story for another blog), more violence, etc. It is our duty to advocate for the poor, to change their situation. I don’t know the best way to do that, but I think all of us in medicine must try.

Coming home is harder than leaving. But this is something I learned before!

Thank you to my friends and family for supporting me during this year. Thank you to the University of Rochester and Doctors for Global Health for providing us with this opportunity. Thank you to the community of Estancia, for giving us the privilege and honor of working with you

--Calla

2010-03-17T20:01:00.000-07:00

9 March 2010

An organization called Asociacion de Mujeres Salvadoreñas, contracted by the Ministry of Health, works in Estancia to provide preventative health care for women and children. AMS holds monthly medical brigades in CAIPES to perform well-child checks, and community health promoters visit pregnant women, women who have just given birth, and neonates. Silvia, Ramiro’s wife, is one of the community health promoters.

On the day following International Women’s Day, Silvia asked me to accompany her to see two women who had just returned home from giving birth in the hospital. Both were young women in their twenties, and both had delivered via cesarean section about a week ago. I agreed to go with her, help with the initial post-delivery evaluation, and remove their stitches from the surgery.

I met Silvia at her house early in the morning, and we began the hike to the two houses. She warned me early in the walk that we would be going straight up hill, and she was right. However, as we walked, she would turn back to point out various landmarks, especially sites that had been important during the war. She showed me the top of one mountain, where a giant massacre of civilians had taken place, and as we walked we talked about how much the community had suffered, but how much the community has also overcome.

We arrived at the first house. The mom was resting on the hammock with her baby girl, and Silvia and I worked together to examine them both. Part of Silvia’s work is to make sure that babies are gaining weight and are breastfeeding, and she evaluates the feeding of every newborn. She and I checked the C-section wound, and I took out the stitches. We talked to the mom for a while about feeding, emotions after giving birth for the first time, and things to expect over the next couple of days. Silvia made an appointment with the family; she would come back to visit in three days to check up.

The second house was a little more removed. The mom had given birth before, but this was her first C-section. Once again, we set about examining the mom and her new son. Both were doing well, and the wound was closed and without signs that made us worry about infection, and we took the stitches out. Once again, we spent time talking with the parents about what to expect. Silvia also talked with this family about obtaining a birth certificate, as this process had not yet been completed.

When we finished, Silvia walked me back to the road that leads to the clinic. She continued on, as she had three pregnant women to visit before the end of the day.

--Calla

2010-02-18T07:23:00.000-08:00

14 February 2010

To culminate the fiestas of Cacaopera, the nearest town, a race was held on Sunday morning. Men were to run 10 kilometers, and the women 6, along the highway that runs to the northern part of the country. The highway cuts up and down the mountains, and cars often have difficulty making it up the last hill into town.

I decided to participate. The winner of the men and women each received $100, and the director of CDH, Ramiro, asked me to win and donate the money to buy more medicine. I explained that it was faulty logic to put his hopes on me, as I haven`t really run since arriving in the country. He said, "It doesn`t matter, just run as fast as you can!"

So on Sunday morning Bela and I woke up at 5 am, before the sun came up, and hiked 45 minutes straight up hill to get to the highway. We arrived, sweaty and tired, to wait for the start.

14 women participated; all were over a decade younger than me. It was a really hard run, straight down and straight up, alternating, the whole way. I ran with two high-school age girls, and when we arrived into town, I let them know that I would follow them in but they had to run fast. We all three finished together, which to me was an accomplishment given the terrain!

Bela was there waiting at the finish. He rode in the official race car of the mayor`s office. A girl from Estancia won, her second time in a row.

I feel really good about the race for two reasons. One, I finished, and was not too sore or tired at the end. Two, the race has been happening for many many years, but in August the government decided to allow women to participate. Therefore, this race was only the second that women have been able to run.

After the race, when the cash prize was being distributed, one of the workers in the mayors office came over to chat with me. He asked what sports women are allowed to play in the States. I explained, "All of them." He then borrowed the microphone from the mayor, who was distributing the prize, and said, "I think we have seen today that women can play sports. It is time to stop punishing our daughters if they go out to run, or play soccer, because one day they might be great athletes, like the two-time winner of the women`s race." I looked over, and the winner`s mom had a huge smile on her face.

--Calla

2010-01-30T08:32:00.000-08:00

28 January 2010

There is a patient who has been coming to the clinic for about a year with rheumatoid arthritis, a nasty painful disease requiring very toxic medications to control its progression. To properly treat this disease, the patient needs to see a rheumatologist, a specialist that can only be found in San Miguel, about a four hour journey from the clinic. The patient had last seen the rheumatologist in December. At that visit, the doctor told him to come back in a month with some lab studies and gave him medicine only for one month. The problem came when the patient tried to make the appointment with the nurse. She said the earliest he could get in with the doctor would be in July and there was nothing that could be done.

A month later when the patient was without medication and his pain was increasing he came into our clinic. Luckily we had some pills that could tide him over for the moment, but he still needed to get back in with the rheumatologist. I decided to call the rheumatologist just in case his schedule had opened up. He was super friendly and said he would make space for the patient the following Tuesday, we just had to get there by nine in the morning.

Where we live, it is impossible to arrive to San Miguel before ten in the morning. As I explained the situation to the patient, he promptly invited me to stay at his house in Cacaopera, which is closer to the hospital. It was a perfect plan.
I left the clinic the following Monday afternoon to catch the final bus to Cacaopera. We met in front of the town’s equivalent to a grocery store and walked to his house. His family was incredibly gracious and hospitable to me, and it meant a lot to me. We spent the evening eating fried fish and talking about life in El Salvador during the civil war.

A neighbor walked by while we were chatting out in front of his house. She heard there was a health care worker here and had a question. Her 7 year-old son had a painful ear that had been draining blood for about 2 months. She wondered if I could take a look at it. I happily agreed, but I couldn’t do much without my otoscope to look inside ears. I told her I would be back on Wednesday and would make sure to bring my equipment to properly assess his ear.

I recently read the book, Mountains Beyond Mountains, by Tracy Kidder. It is about Paul Farmer, a doctor that works in Haiti. He often walks miles to see a patient. In the book he remarked that when he goes to see one patient and happens to come across another, he feels like his visit was a “good cast”. For some reason I really like this fishing metaphor. It reminds of reading the New Testament in college, where Jesus called himself a fisher of men. While I have no religious inclinations, I always liked this idea. Anyway, when I saw this boy I felt like my visit had been a good cast because I had the opportunity to help two people when I had only anticipated one. I ended up coming back two days later and removed a ball of dirt about the size of a jelly bean from his ear, and I also gave him some antibiotics. I recently went back to the house. The kid was at school, but his mom told me that the ear was no longer bleeding and he was without pain. A success.

But getting back the original patient, we woke up the next morning at 4:30 to catch the 5 o’clock bus to San Miguel. The doctor was great and saw the patient with minimal delay. We were able to secure four months of medication for the patient and got him a follow-up appointment for four months as well. I got back to clinic Tuesday evening. I was exhausted but satisfied.

--Bela

2010-01-30T08:26:00.000-08:00

29 January 2010

On Wednesday, 27 January 2010, the patient with heart failure passed away. She was at home, surrounded by friends and family. She died at five in the morning, and her family prepared her body for burial, which took place on Thursday.

She died 22 days after we met. I hope that she spent her last few weeks more comfortable based on our treatment. I think that she did, as she seemed to be drowning when I met her. She spent the last week of her life saying goodbye. Her extended family all came to visit, and members of the community held numerous ad hoc church services in her home. I visited her 10 times over the 22 days, and in that time got to talk with her, her husband, and her daughter a lot. She and her husband were married for 65 years. Additionally, in the last week of her life, her oldest great-grandson got married. She was too sick to attend the wedding, but the bride and groom came to the house after the ceremony, and brought the rice that had been served to the guests. The wedding rice was the last real food that the patient ate, and her evaluation was that it was “bien buena, un arroz tan rico como nunca he comida.”

--Calla

2010-01-30T08:06:00.000-08:00

28 January 2010

Bela and I have been doing a lot of home visits. Additionally, we gave two charlas over the past month. One was about first response for burns, and the second was about hepatitis. Etelvina chose the topic of hepatitis because we identified 6 children in one neighborhood with symptoms of hepatitis A, and got them linked up with the Ministry of Health System. Here are a few photos:

--Calla

2010-01-27T07:45:00.000-08:00

25 January 2010

Last Thursday, Bela and I embarked on what seems to be a Sisyphean task: we are attempting, per the Hospital in Gotera´s medical team´s request, to get a very anemic man transfused with two to three units of O negative blood.

In early December, Juan Carlos (the recent graduate from medical school, who just last week started working full time at the clinic to fulfill his Social Year requirements to begin practice) came to find Bela and me on a Saturday morning. He explained that his mother, a local community health promoter, had been at the patient´s house earlier in the week. Juan Carlos´s mother Silvia was very concerned, and so had told the man to come in. We waited and waited, and at two-thirty in the afternoon Juan Carlos began the trip back to San Miguel, the closest big city and the site of a course for recent graduates on the administrative duties for one´s Social Year.

Two days later, Ramiro came to talk to me about the patient. He drew me a quick map to direct me to the patient´s house, but Israel, the health promoter in training, volunteered to accompany me. We talked with Etelvina, who knew a little bit about the man´s history, before we started on our way.

It was, as most visits are, a long walk uphill to get to the house. We entered, and were greeted by a jubilant but thin and tired looking man. He was pleasant, and had a slow drawn-out way of telling stories and answering questions. He had had a long history of high blood pressure and gastritis, but over the last six months had begun to feel very bad. He was tired all the time, and was short of breath walking even short distances. His appetite was very poor, and he felt uncomfortable and burped a lot after eating even a little bit. Sometimes he had dark, tarry stools, and once had vomited blood. I examined him, and was surprised by his pallor. He seemed to be working hard to talk to me, but maintained his friendly demeanor throughout.
Israel and I came back to the clinic in time for the weekly staff meeting of CDH, the NGO. Afterwards, I talked with Ramiro about the visit, who suggested that I call Dr. Garcia, the director of the nearest Ministry of Health Clinic, and a constant source of advice and support for the clinic in Estancia. Dr. Garcia and I discussed the case, and he recommended that we take the patient to the hospital for more evaluation and possible blood transfusion.

Israel, Bela, and I took the patient to the hospital the next morning. His admission hematocrit was very, very low, and he stayed in the hospital for eight days. I visited him on two separate occasions during the admission to talk with his physicians and see how he was doing. Part of the reason that he stayed so long was the lack of compatible blood in the hospital´s blood bank, and a lack of equipment at the hospital to evaluate the cause of his anemia. He was discharged, with a date in another city for an endoscopy, which is a way to take a look inside the stomach to try to figure out whether something is bleeding and therefore causing anemia, and told to look for blood donors within his family who might be of the same blood type.

He went to the endoscopy appointment on the scheduled date, after having not eaten since the night before and traveling for about three hours to get there. The endoscopy machine was broken, and a repeat appointment was made for him in May, when there was the possibility of fixing the machine. He returned to Estancia, frustrated.

However, he was determined to follow the doctor´s orders for a blood transfusion. Some members of his family live in another city, on the Pacific Coast. We arranged with Ramiro to transport the patient to the hospital, and for the patient´s brothers to leave at three in the morning on the same day to meet us. Bela and I were introduced to the family outside of the hospital gates, and we went inside en masse to begin the preliminary testing for the potential donors.

None of the three brothers, nor the patient´s son, had the same blood type. Ten other donors were present that day to donate to various inpatients, and none of them had the same type either. There was no O negative blood in storage. Desperate, I asked the hospital´s social worker and director of the medicine residency program to meet quickly with me, to try to figure out a plan. We called the Red Cross in the capital. We called the public hospitals in both San Miguel and San Salvador. We tried to admit the patient directly to the hospital in San Salvador for more evaluation, but were not able to do that as the referral site for the Gotera Hospital is San Miguel and not San Salvador. We left the hospital in the afternoon, frustrated.

The public system is fraught with a dearth of resources, both in terms of medicines and machinery. Additionally, the people who work within the public system are seen by many as an addition to the problems that the poor suffer. However, in this case I saw many dedicated staff members, in the laboratory, the social work office, the resident room, and in the emergency room, trying to do their best. They are working in difficult circumstances. I believe that more attention on a macro-level is needed to resolve the resource problems within the public system.

--Calla

We use the big grey thing to sterilize equipment.

2010-01-16T08:20:00.000-08:00

13 January 2010

Last Tuesday, a woman came to the clinic to talk about another woman, homebound, who was short of breath. Etelvina knew the patient, an 85 year old with a history of chronic respiratory infections. Etelvina asked me to accompany her up the mountain to see the patient.

After forty minutes of hiking uphill, we arrived. The woman had had a few days of fever and cough. The fever was gone, but she was still coughing. She was breathing fast, but did not want to go anywhere—not to the clinic, not to the hospital, and stated that she would take any medicine just so long as she could take it at home. Her blood pressure and pulse were ok, but her lungs sounded bad. Three other people in the house had coughs and colds, and so we decided to treat her for pneumonia and visit her again.

The next morning, another family member came to the clinic. “She has bad diarrhea,” the woman explained, “and we would like you to give her this medicine.” She pulled out a scrap of paper on which the word METRONIDAZOLE was printed in neat capitol letters. “We have heard that it is a good medicine for diarrhea.”

I was confused. The patient had explained to us the day before that she had had a few loose stools when she had the fever, but that it had gone away. I was also surprised that the family would be so concerned about diarrhea, when I had found her difficulty breathing much for troubling. I decided that my confusion would be better allayed with a visit to her home than by giving out a medicine I did not think would help or that might even be harmful. I sent the woman back to the house, and told her I would meet her there in one hour.

I went to get Etelvina. She was seeing a child with diarrhea. Additionally, another child who she had sent to the hospital a week before would be coming in for follow-up of a bad burn. She therefore asked Bela to go with me.

As we hiked up the mountain, I told Bela the story and my confusion in the morning. I was afraid that I had missed something. For modesty’s sake, as she lived in a one-room cane house that had been filled with people, I had not performed a thorough physical exam. The last part of the hike is rocky and steep, and as we ascended I told myself I would do better.

We walked in to the house, and it was clear that things had changed from the day before. The house was again filled with people, but there was a tension and anxiety that had not been present. The patient was sitting in the hammock, like the prior afternoon, but this time was being supported by four woman. She was breathing fast, but additionally made a course grunting noise with each breath. She seemed to be in severe distress.

I looked at Bela, and it was clear that he agreed—the woman needed to go the hospital. I explained our concerns, and the desire for her to let us take her. “No, I will not go,” she responded between grunts. “This is my home; this is my family. If I am to die tonight, then let it be here.”

I looked pleadingly at the family. “I am very concerned that she might die if we do not get help.”

“She has always told us that she would not want to go to the hospital. You may treat her here, but please respect her decision,” I was told firmly by her daughter, whom I had met the day before.

Her husband, a kind man who is completely blind, was sitting in a hammock behind me. He reached out for my shoulder. “We are always together. Please do not separate us.”

I was sitting in front of the patient, watching her watching me. Finally, she forcefully grunted, “I will not go.”

Bela put his hand on my shoulder. I told the family, “If this is your decision, then we have to respect it. We will do whatever we can here.”

“Thank you,” stated the patient.

We set about examining her. I was more thorough and deliberate than I had been the day before. And yes, I had missed something. Her legs were swollen and edematous. “And the diarrhea?” I asked.

“No, I don’t really have that,” replied the patient.

“She had one soft stool last night,” explained the woman who had come to the clinic.

Bela turned to me, “I think she is in heart failure.”

“Yes, I think you are right.”

I told the family that we needed to get some help, by calling doctors that could help guide her treatment. The family agreed, and I called my father. I presented the patient and we talked about a plan. We decided that a medicine called a diuretic, a type of medicine that can help get rid of extra water, could help her be more comfortable and help her breath better. Part of what happens in heart failure is that the lungs can fill with fluid, making a person feel as though they are drowning and cannot get enough air. Getting some of the fluid out of the body can help to relieve that.

We called the clinic and talked with Etelvina and Neal, the other medical student. Neal offered to run to the bottom of the mountain from the clinic with the medicine. Bela scrambled down to meet him, and I stayed with the patient and her family.

She was getting agitated, standing up, sitting back down. A granddaughter yelled out to me, “Please, just give her a shot of vitamins!” I explained that we did not have vitamin shots at the clinic. At my response, the patient heaved, “Get someone here who can pray for me!”

“Can you read?” another family member asked me.

“Yes, I can,” I responded.

People searched the house and the two neighboring ones for a prayer book, but could not find one. Bela arrived shortly thereafter with the medicine, and behind him came of the local pre-kindergarden teachers, book in hand. The patient took the medicine, and the family gathered around her. The group began to pray. After the prayer, all was quiet except for the sounds of the patient’s grunting breaths. All of a sudden, her husband cried out, “Oohh, my wonderful wife has died!”

“No, no, she is here.”

“Then we must sing.” He began to sing and sob, holding his hands out towards his wife. The family followed suit. I was standing at the edge of the group. I felt so helpless that tears welled up in my eyes and began to roll down my cheeks. A small great-grandchild saw me, walked over, and held onto the leg of my pants.

We stayed at the house for five hours, and as the sun began to set the patient began to urinate. I tried to be as hopeful and yet as realistic as I could. The patient was still in distress, and so I explained that I did not know if she would survive the night. I told that I would arrive in the morning.

As we crawled down the mountain, many people from the community went up. “Is she dying?” I was asked again and again.

“I don’t know,” is all I could respond.

That night I had a talk with Ramiro, the director of the local NGO and himself a health promotor. He assured me that we had done the right thing by not forcing her to go to the hospital against her wishes. I explained that I was worried and he responded that she was family, with the whole community by her side.

For the next two mornings, I woke up early and hiked the mountain to her house as the sun rose. She seemed to be unchanging, but she survived each night. I would examine her and call my dad for help with medicine dosing.

On Friday morning, she seemed ready to talk. Her daughter, exhausted from keeping vigil many nights in a row, brought over a plastic chair for me and laid down next to her mother in the hammock. The patient’s granddaughter brought us each a cup of a drink called atol, made of corn meal and flavored with cacao. We talked for a long time about the patient and her husband, about the ways that making tortillas had changed over the years, and about the community, past and present. I took leave when the sun had completely risen to return to the clinic.

As I walked out of the house, I felt overwhelmed and uncertain. Members of the community had seen a dark bird flying over the valley on Thursday, the symbol of death. No one hesitated to remind me on Thursday afternoon that the patient would not wake up on Friday morning. I had been afraid as I walked up the hill on Friday morning. I was also surprised to find the patient so conversant.

On Saturday, Bela returned to the house with me. We started a medicine that is usually used for blood pressure control, but that can also be used to protect the heart in a patient with heart failure.

On Monday, the patient was lying down in the hammock when we arrived. She was not grunting, and was breathing at a comfortable rate. Her daughter appeared more well-rested than she had been since I had met her. We examined the patient, and she seemed dryer—her lungs did not sound wet anymore and her leg swelling had disappeared. I called my dad again and interrupted a meeting between him and a few other physicians, and we able to talk about how best to proceed.

I still do not know what will happen. Her condition is delicate. However, I think that she is much more comfortable now. She has been able to talk with her family and be near her husband. I also do not know why she had heart failure to begin with. I have a few ideas, but no way to test them.

However, I feel very privileged to have been able to work with the patient and her family. I will continue to visit. They are teaching me about strength, about family, and about non-abandonment.

--Calla

2010-01-16T08:19:00.000-08:00

12 January 2010

After a two-week hiatus in the States, Calla and I returned to El Salvador. We spent two days walking around the capital before traveling home to Estancia. It was great to be back. The only inconvenience was a lack of electricity in the clinic and the house. The clinic normally runs off of batteries that are charged by solar panels. The batteries died about a week before we left in December. They typically last 5 years and ours are now 7 years old. Normally, the lack of light is no more than a mere annoyance that requires us to cook by candlelight. Our first night back was a little different.

Within 30 minutes of arriving to the clinic to cook our dinner, we got a phone call. A family that lives about 20 minutes from the clinic was calling to see if they could bring their 7 year-old girl to the clinic because she had fallen and cut her face. We told them we were already at the clinic and were waiting for them. Our relaxing return home would have to wait because there was work to be done.

The girl arrived shortly. Two hours ago she had fallen and sliced her face open on a brick. She had a 7 cm laceration over her left eye. The cut was pretty deep, and I think that we were all uncomfortable. Luckily the cut did not involve her eye. If she had been in the States, a plastic surgeon would have been there to sew her up. But out here there was only us, three medical students in a clinic without electricity.

Since I have the most interest and experience in all things surgical, I was elected to fix her face. It was a surreal experience. That night I put seven stitches in this girl’s face only with the light of a single candle.

I told the girl to come back in four days to have the stitches removed. The whole week I was preoccupied with her wound. It was so deep and so close to her eye that bad things could happen. Four days later she returned to the clinic. Her wound looked fantastic! It was fully closed with minimal scarring and her eye was completely unaffected. I feel lucky that everything worked out, but it was yet another potent reminder of how tenuous our position is here as medical students working in an area without doctors.

--Bela

2009-12-20T17:20:00.000-08:00

20 December 2009

Another event was held for people of the Tercera Edad. A lot of people from the community came, and we did a charla on oral hygiene and practiced relaxation exercises!

--Calla

2009-12-13T08:00:00.000-08:00

9 December 2009

A couple months ago, Dr. Guerrero called me on a Friday afternoon. Dr. Guerrero is a general surgeon that works in the Gotera Hospital, the hospital closest to the clinic where we work. I got to know Dr. Guerrero after he admitted a few of our patients from the clinic. I told him that I wanted to be a general surgeon like him after medical school, and we immediately hit it off.

This Friday, Dr. Guerrero called to tell me that he would be performing an operation tomorrow in the capital, and I was invited to tag along. I was thrilled and told him I would be on the next bus to Gotera. Two hours later, I arrived at the Gotera hospital as he was finishing his shift in the emergency department.

Dr. Guerrero lives in San Miguel, the largest city in the eastern part of the country and an hour drive from Gotera. We drove to his house and arrived by 6. I met his family, had a glorious dinner, and we were asleep by nine. The next morning we left at six for the capital.

Dr. Guerrero has a private surgical practice and also works in the public health system. He was operating on a private patient this morning in a private clinic. We arrived to the capital around nine and pulled up to the clinic shortly thereafter. The private clinic appeared nothing like the public hospital. The most noticeable difference was the utter lack of patients. My experience thus far in the public health system is that wherever you go, there are already 20 patients waiting in front of you. This private clinic was clean and tranquil.

Shortly after arriving, I introduced myself to the patient, and we changed into our scrubs. Dr. Guerrero was going to remove the patient’s gallbladder laparoscopically, which means he was going to make 3 tiny incisions and operate by using cameras. Laparoscopic surgery is ubiquitous in the United States. The surgery was performed without incident. I was thrilled to be in the operating room again and had a great time.

I have probably seen 20 gallbladders removed in the States. It was interesting to see the same operation in a developing country. Because we were in a private clinic the operation was nearly identical to what I had seen before. The operating theatre was smaller and the equipment was older, but it was essentially the same. Like I said, it was awesome to be back in the operating room. It reminded me how much I want to be a surgeon. After the operation we went out to eat with the anesthesiologist at Biggest, the Salvadorian equivalent to McDonald’s. Three hours later we were back in San Miguel.

Once we got back to Dr. Guerrero’s house he told me that he had to work that same evening and was wondering if I wanted to tag along. I said yes, we had a quick bite to eat, and went to the hospital.

Dr. Guerreo was pulling an all night shift in a social security hospital. This is a hospital somewhere between private and public, and as such it had elements of both. While it was very crowded, the hospital, Dr. Guerrero had access to the medicines he needed and could perform the tests he needed to make a diagnosis. Within minutes of arriving, we raced to another operating room where a surgeon had already begun an operation. He was removing the gallbladder of a woman. Although this was the same surgery that he performed in the private hospital, this operation was a bit different.

The operating room was the size of a large closet with concrete walls. The sterilized instruments were wrapped in old newspaper. The gallbladder was removed through an open incision. Unlike the three small incisions required to remove a gallbladder with laparoscopes, this open procedure required a 15 centimeter incision made across this woman’s abdomen. I had never seen a gallbladder removed in this way in the United States. In fact, there is clear evidence that open removal of a gallbladder is a significantly more morbid operation than with laparoscopes. You need a very good reason to perform this procedure openly in the States. But here in San Miguel, there was no other option. As always, I was thrilled to be in the operating room, but it was difficult to think about how much pain this woman will have and how much greater her risk of infection is because she was poorer.

The lack of laparoscopic procedures in this country is a result of a lack of equipment but also a lack of surgical training. Dr. Guerrero had to go to Europe to get his laparoscopic training. One of my career goals is to practice surgery in a developing country like El Salvador. I see a great need for a well-trained surgeon in a place like this. Besides the opportunity to help a lot of patients, I would also have the opportunity to bring the benefits of laparoscopic surgery.

--Bela

2009-12-13T07:56:00.000-08:00

12 December 2009

On Thursday night, Rebecca, Neal, Bela and I returned to our house after having an early dinner of beans and tortillas up at the clinic. Bela and I quickly readied ourselves for bed, and crawled under the mosquito netting to read a bit before falling asleep. I am slowly working my way through El General en su Laberinto, by Gabriel Garcia Marquez, and Bela is devouring La Teleraña de Carlota, a book he and I both have fond memories of from our childhoods.

Minutes later, the phone rang. It was Joel, the Doctors for Global Health site director for Estancia, calling to check in with us and discuss clinic happenings over the week. We lumbered out of bed, gathered Neal and Rebecca, and put the phone on speaker. After our conversation with Joel, we stayed at the table to chat a bit more.

Suddenly, something flew by right over our heads. I startled and jumped out of my chair.

“It’s a bat!” Rebecca yelled.

“Oh cool!” Neal responded quickly, as both Rebecca and I scrunched up our faces.

Bela jumped out of his chair, and moved behind me. “You had a rabies shot, so it’d be better if it got you!”

The bat continued to fly in circles around the room, probably becoming more agitated as our voices got louder. Bela explained that in Kenya people shoed bats out of their houses with brooms, and ducked outside to grab one. Neal enthusiastically took the broom from him and ordered us, “Stand back!”

Bela hid in our bedroom, and Rebecca and I cowered in hers, as Neal went to work. He swung at the bat every time it swooshed by. It appeared that we would spend the night watching Neal swing, and the bat fly circles around his head.

Abruptly, I heard a splat, and a dark object whizzed past my head. “Run Rebecca, run!” I yelped as I darted back into the common room and into our bedroom.

“Neal, get it out!” Rebecca exclaimed as she dashed out.

Neal ran in, opened the bedroom window and tried to shove the bat out. He was unsuccessful, however, and the bat flew back into our shared space. Out he charged, more determined than ever to rid the house of the bat. He stood in the center of the room, knees slightly bent, and choked up on the broom. Again, the bat swooped by, and he wound up and swung. I heard a crash, and saw, briefly, as our one and only light bulb exploded and rained down upon Neal, the bat swoop towards the wall.
The sound of glass tinkling on the ceramic floor continued for a few seconds.

“S%$#!” Neal exclaimed, as he tiptoed to his bedroom to grab his headlamp.

“That was amazing!” Bela responded, in awe.

“The bat’s still in here!” Rebecca reminded us.

Neal diligently swept up the glass, remarked that we would all have to be careful about being sure to wear sandals in the house for a few days, and steadied himself to continue the battle against the bat.

A few more swings, and Neal batted the bat out the front door. It landed, stunned, on the front porch. “Come take a look,” Neal said, “I’m going to throw it into the corn field.”

“You didn’t have to kill it,” Rebecca responded, despondently.

“It looks like a rat, or a tipisquintle*!” I remarked upon having a closer look.

“Neal, dude, you should not touch the bat with your bare hands. Get a bag,” suggested Bela.

Neal ran back inside, and covered his hand with a plastic bag. Outside again, he approached the bat, and grabbed for its wing. The bat, obviously recovered, rolled over and flew off. Neal walked back towards us, a smile on his face, clearly the victor.

--Calla

*A tipisquintle is a rat-like mammal that lives near the bank of the river, likes to eat guayabas and the bark of sweet trees, and has sharp enough teeth to kill a dog if it feels threatened.

2009-12-13T07:55:00.000-08:00

5 December 2009

A few weeks ago, we went for a hike up a mountain that overlooks Estancia, called El Cerro Pelon. We started early in the morning, with a large group that included Rebecca and Neal, the other volunteer couple, Miguel, in charge of all of the maintenance of the clinic, Juan Carlos, the recent graduate of medical school, and Cesar and Javier, two early adolescent boys who live in Estancia. After a breakfast of plantains, tortillas, and cuajada, a soft cheese, we headed to the bottom of the mountain. After a forty-five minute walk, we began the ascent.

* * *

The mountains around Estancia are of particular historic importance. Many people say that the civil war, which lasted from the late 1970´s until 1992, was fought mostly here. Every family was affected. Some families left under the cover of night to cross the border into Honduras, where they stayed in refugee camps until the end of the 1980´s. Others stayed, but were forced to flee into the hills almost nightly, as bombs dropped from airplanes onto houses and schools. These families took cover in the numerous caves that cut into the mountains. Still others joined the resistance army, and fought against the United States’ trained and funded Salvadorian army.

* * *

The top of the mountain is flat like a table, and, once there, we sat and enjoyed oranges, chocolate, and sweet breads with pink frosting on top called novias. We watched the birds fly below us, and chatted about how small the River Torola looked from so far away.

We descended the mountain around noon, and shortly thereafter the sky broke open and rain poured down. The road back to our house turned to slushy mud, and in parts was covered by water that rose up over our ankles. However, we made it home and dried off. The difficulty of the climb in daylight left me both in awe of and horrified by what the people of Estancia have suffered. They have lived through things that I cannot imagine in nightmares.

--Calla

2009-11-29T09:02:00.000-08:00

17 November 2009

On Monday afternoons, a meeting is held at the clinic for all of the staff of Campesinos para el Desarrollo Humano. Bela and I were getting ready to attend the meeting, when three young children arrived at the clinic in order to talk to Etelvina.

The children explained to Etelvina that their grandmother was having trouble breathing. Etelvina knew the grandmother, and asked the children more about what was happening to her. She had been having fevers, a cough, and shortness of breath. Etelvina decided that rather than sending medicine, it would be better for someone to go to her home to evaluate her. Bela and I had planned on walking to her community in the afternoon to see another patient, after the staff meeting, so we volunteered to go. I walked in to the pharmacy with Etelvina to talk about the patient before going. She sent me with some medicines and also told me a little bit more about the woman.

“She has always had a cough,” Etelvina explained, but she has gotten worse over the past few weeks. She is such a hard worker, and a very strong woman.”

Bela and I left the clinic, saying goodbye to the staff before heading out the door. The three grandchildren led the way, across a cow pasture, down a hill, across the soccer field, and finally we arrived at the river.

“You will have to cross the river on a cable,” the granddaughter smiled at me, “I hope that you won’t be afraid.”

Torola is a large river, with steep banks on either side. There is one bridge that divides the two halves of the community, but many families live far from the bridge. In the past, before the bridge, many people would swim across the river to get to their homes or to visit people who lived on the other side. Now, however, the bridge has become the central crossing point. Additionally, as a source of income, some families have built cable cars which are powered by turning a large hand-made crank. In order to cross the river on the cable, you pay a small fee, and one of the family members will crank you across. This was one of those families. The “car,” however, consisted of a metal plate hooked to a wooden plan by three metal chains. The stops on either end of the river looked rickety, as they were also constructed of wooden planks. The children had no fear of crossing, and the two smallest ones hopped on the plate together. The plate was only large enough for one to sit, and so the boy stood, holding on to the metal chains for support. I was not pleased by the arrangement.

Bela went across next. As he sat on the plate, he turned and flashed a large grin, as if to say “This is going to be really fun, and you are going to hate it.” The crank was turned, and he flew across the river.

As the plate came soaring back across the river, I tried to ready myself. I took off my glasses, adjusted the strap of my purse, and tried to remind myself that my fear of heights is something in my own head. The plate arrived, and I think that the oldest girl noticed that I was nervous. She took my hand, and helped me sit. She took one of my hands, and put it on the metal chain, and rested the other on the wooden support. “Hold on tight!” she yelled as I started to zoom above the river. The trip was like flying.

We regrouped on the other bank, and trudged up towards the house. The grandmother´s son was sitting outside, and guided us inside towards the hammock.
An elderly woman was wrapped inside, breathing quickly through pursed lips. We began to ask questions, but it was clear that she was in distress. Prior to examining her, we asked her and her family how they would feel about taking her to the hospital. They were worried about transportation, and the cost, and so called Ramiro, the director of the NGO. Ramiro is also able to drive, and so often takes patients to the hospital in the CDH pickup truck. We examined the woman, so that we would be able to present the patient to the staff in the hospital. The house was located such that the pickup could not come to the house. No road leads there, and so, in order to bring the woman to the hospital in Gotera, the nearest city, we had to get her across the river. She was weak and had difficulty breathing, but was able to get out the hammock and walk out the door.

Her son and granddaughter were able to help her to the cable car, with difficulty because she had such trouble breathing. We were all wondering how she would possibly get across, but she plopped down on the plate and yelled, “Drive me!” The son complied, and she flew across the river. Her daughter-in-law went next, in order to wait with her. Bela went across next. I took a deep breath when it was my turn to go, and again went soaring across to the opposite bank.

Slowly but surely, the woman was able to trudge across a pasture and across a small stream to an opening in the road that leads out of town and up the hill. Ramiro picked us up, us being the woman, her daughter-in-law, and me. Along the way we picked up her two other daughters who had heard that she was on the way to the hospital. We arrived, and I went in to talk with the physician on-call. He was polite and serious, and came out of the emergency room to help me bring her in. He immediately set up a nebulizer treatment for her, and readied the radiology suite. A half an hour later, based on her clinical history, physical history, and chest X-ray, she was admitted to the hospital with suspected tuberculosis. Ramiro had waited outside of the hospital for me, and so we traveled back to Estancia together.

2009-11-21T10:28:00.000-08:00

16 November 2009

My parents visited us last week. They arrived on a Friday afternoon, and as soon as they arrived in the city we started touring around in the rain. We went to the Museo del Arte Moderno, and had pizza at a little neighborhood restaurant close to the hotel where we stayed. On Saturday we woke up early and took two buses and a pickup truck to a town called Perquin on the Honduran border. We stayed there all weekend, and on Monday we traveled to Estancia.

It was so wonderful to have my parents here for a little while. They were able to meet the staff members of CDH, the NGO for whom we volunteer, and go on home visits with me. My mom toured some community members’ gardens, and my dad hung out with me in the clinic. The night before they left Estancia, Ramiro and Lucia took us all to eat pupusas in a town called Corinto. I think that it will be easier for me to go home at the end of this year after having had them here. I will be able to talk about the people that I miss, and they will know who those people are. I remember that coming home from Ecuador was so much easier than it might have been, because my family had visited me in the town where I lived. I was able to reminisce about people and places, and they understood a little bit about what I was saying in a way that wouldn’t have been possible if they had not visited.

During the morning of the following Friday we began the trip back to the capitol. Griselda, one of our neighbors, accompanied us to Cacaopera, one of the towns along the way, as she had to run some errands related to the next school year. When we arrived in the capitol we went to see the Archeology Museum, and went on some long walks. We ate a delicious dinner that night, and woke up early the next morning to walk some more before my parents left for the airport.

* * * *

As Bela and I were already in the capitol, we decided to go to an event held at the campus of the Universidad de Centro-America. Twenty years ago, during the civil war, six Jesuit priests, the cook, and the cook’s daughter were murdered at night on the campus by the army. The four priests were very active in speaking out against the conditions that led to the civil war in the first place, and were seen as a threat by the right-wing government in control.

The event was beautiful. We arrived at the campus in the afternoon. Students at the university had spent the morning creating murals to commemorate the lives of the priests, the cook, and the daughter out of colored sand. Students worked as volunteer guides at the small museum on campus dedicated to the lives of the priests killed during the war. The university choir sang. After the sun set, a candlelight march took place on the road that runs through the university.

When Bela and I returned to Estancia, I talked with Etelvina, the health promotor, about the event. She explained that one of the priests, Segundo Monte, had visited the refugee camp in Honduras where she lived with her family during most of the war. He gave mass to the people living in the camp, and spoke about the injustices that the El Salvadorian people had suffered, and gave them hope that things would be better in the future. The people in the camp where she lived returned to El Salvador shortly after the murder of the priests, the cook, and the cook’s daughter. Most settled in an area close to Estancia, and as homage to the priest who had given them hope during the war, named the town Segundo Monte. Etelvina also explained that when she fled El Salvador for Honduras, her family traveled in the night, hiding in the woods during the day. They had to cross the river that divides Honduras and El Salvador at a town called Mozote. A few years before, in Mozote, over 1000 people were massacred by the El Salvadorian and Honduran armies while trying to cross the river. She told me that the river still stunk of dead bodies when she crossed, and that the smell is something that she will never forget. However, the return trip was different. After the murders at the University, the people of her camp walked on the roads, during the day, to return. She told me that there was a feeling of strength and unity in the people. The work of the priests, their words, and their violent deaths is still very present in the memory of the people. They are remembered as martyrs.

--Calla

2009-10-31T09:36:00.001-07:00

A statue entitled ´Delirium Tremens´

Having a snack in a leftist coffee shop

31 October 2009

Bela and I spent last week on a quest to renew our visas. We are here in El Salvador on turist visas, and so must renew them every 90 days. El Salvador is a part of a four country agreement with Honduras, Nicaragua, and Guatemala, and so in order to receive a new visa, we needed to travel to either Mexico or Costa Rica. We chose to travel to Chiapas, Mexico, and spent three days in a city called Tapachula, on the border of Chiapas and Guatemala, drinking coffee, reading, and eating spicy enchiladas. It was a nice break, and very interesting for me to see another country.

The day after we arrived back in Estancia a meeting had been planned for us in another community called El Tablon. It is about three hours away from where we are living. In the past, there was a relationship between the NGO for whom we are volunteering and the clinic there. However, a different NGO is now in charge of the clinic in El Tablon. Ramiro, the director of our NGO, is interested in renewing the relationship, and it is possible that in the future between Bela, Neal, Juan Carlos (a recently graduated physician from Estancia who studied in Cuba), and I will be rotating one week a month each in El Tablon, living and working there.

The meeting didn´t actually happen, because the health promotor had left the site to go into town, but we did see the outside of the clinic and volunteer house. Ramiro was frustrated about the cancelation of the meeting, and decided that we should head to the nearest town for street food. When we arrived we found a spot that sold pupusas, a traditional snack, that is made of corn and cheese and fried. We had a great time sharing stories and snacks!

19 October 2009

2009-10-28T08:49:00.000-07:00

Breakfast in the morning, and the kitchen

As I continue to struggle with the language, I try to take advantage of any free time to study Spanish. This morning I am feeling particularly ambitious and get to clinic at 5.30 a.m. Calla bought me the Rosetta Stone, which I have come to love. I spent this morning studying the preterit tense as the sun rose over Estancia.

Calla ambles up to the clinic about an hour later shouting salutations to anyone who will listen. Neal arrives shortly thereafter, and we begin the morning routine, i.e. cleaning the clinic. The place is clean by seven and breakfast follows. Today is my favorite, oatmeal with fried plantains.

The clinic opens at eight. My first patient is a girl that I already know. Two weeks ago she came in with an infected toe that required an incision and drainage. Today, she has a cold, but her toe looks fantastic. She leaves 30 minutes later with Tylenol, multivitamins and a toothbrush.

The next patient is a 6 month old girl with a fever. When it comes to patients, there is no one that I fear more than a newborn. They are so delicate and precious. The girl´s mother took her to another clinic 2 days ago. The doctor diagnosed her with pneumonia, gave her 2 days of amoxicillin, an antibiotic, and told her to come back in 2 days. Instead, the mother came to CAIPES because it was closer. This situation makes me uncomfortable. I had not seen the girl before, so I could not tell if she was better. I need help and decide to call Dr. Kasper, a pediatrician from Harvard. She makes herself available to the volunteers for consults. Given that the baby lacks any signs of serious respiratory disease, we decide that she does not need to go to the hospital. Since the clinic has run out of amoxicillin, Dr. Kasper recommends an appropriate alternative. I feel comfortable sending the baby home, knowing that the decision was made by an attending pediatrician and not by a medical student.

The following patient is 17 years old and 3 months pregnant. After babies, pregnant women are the second most terrifying patient population. This woman has headaches. I am nervous that she might be developing a serious disease of pregnancy called preeclampsia. Fortunately she has no other signs of the disease and her physical exam was normal. Nonetheless, I am not feel comfortable sending her home solely based on my opinion. I call Dr. Tresler, a family physician from Texas. He agrees that her headaches are most likely an isolated problem and not linked to a more serious disease like preeclampsia. He recommends that she get some basic lab tests to be more certain. I write her a laboratory reference and ask her to return once she had the results.

The remainder of the day passes rather uneventfully. At 2.30, Calla and I head for Jaime´s house. He is a 6 year old boy with cerebral palsy. He lives about 30 minutes from the clinic in a sugar cane shack with a dirt floor. It is sad to see him and think about what his life could be like with adequate medical care. Instead, without speech therapy he can barely speak, without physical therapy he cannot walk, with occupational therapy he cannot even hold a pencil properly. Jaime applied to enter kindergarten last year but was denied access due to his disability. The clinic is rallying around this boy. The director of our NGO is formally petitioning the school to admit him. School starts in January, so our job is to to do all we can to get him physically ready. We spend time reading, drawing and walking. Jaime is a great kid. We will be updating the blog over the next few months with his progress.

From the Annals of Learning Spanish as a Second Language

When asking to pay for our coffee the other day I said: Yo quiero pegarle, which translates into: I want to hit you.

When I first started to see patients at the clinic and wanted to ask them about their bowel movements I said: ¿ Su bebe esta cagando normal?, which translates into: Is your baby sh#@€ing normal? Thank you to Calla for correcting this problem.

2009-10-21T16:41:00.000-07:00

2009-10-21T16:20:00.000-07:00

The day after Calla was stung, Bela decided to wash the clothes. It was a nice treat!

18 October 2009

I am recovering from the scorpion sting. Additionally, since being stung, I have learned quite a bit about scorpion toxins. It seems as though everyone in Estancia has been stung at least once, since they are very common creatures. My neighbors have all told me stories about various stings, with advice about prevention.

Here are a few things that I have learned, both from reading in textbooks and talking to people here:

Scorpions are hunters, and sting to get foot or when they feel threatened. They are creatures that like the dark, and so will hide under sheets, between mattresses and bedframes, in shoes, and in corners. Therefore, in order to prevent being stung, one should always shake out clothing, shoes, and sheets before using. People say that if a scorpion crawls on you, the way to avoid getting stung is to stay very still, because if you move the insect will feel threatened and attack.

Once the scorpion stings, it releases a toxin which has a half-life of twelve hours. That means that after about twenty four hours, a person still has about 25% of the toxin in their system. The toxin causes all sorts of effects, but the most striking is the numbness that occurs in the whole body, including the mouth.

Here is an excerpt from Harrison´s Principles of Internal Medicine (page 2604 of edition 16) about what happens when a person gets stung:

Patients present with restlessness, blurred vision, abnormal eye movements, profuse salivation, lacrimation, rhinorrhea, slurred speech, difficulty in handling secretions, diaphoresis, nausea, and vomiting. Muscle twitching, jerking, and shaking may be mistaken for a seizure. Complications include tachycardia, arrhythmias, hypertension, hyperthermia, rhabdomyolysis, and acidosis. Symptoms progress to maximum severity in about 5 hours and subside within a day or two, although pain and paresthesia can last for weeks.

--Harrison´s.

When a person gets stung by a scorpion, first aid includes applying cold compresses to the site. This helps prevent the toxin from being absorbed. Unfortunately, in Estancia, electricity is lacking, and, therefore, refrigeration is absent. People here are not able to use cold packs, as ice does not exist. Various people mentioned the importance of staying calm and not moving once stung to prevent the toxin traveling in the blood. One family also mentioned a traditional method for preventing the negative effects. You must find and kill the scorpion, open its body, and rub the insides on the site. The family explained that the toxin would then travel back into the body of the scorpion and out of the victim.

I am feeling much better now, as I was stung almost 48 hours ago. However, it was a horrible experience, and I think that I worried Bela quite a bit. The day after being stung, my heart was beating very fast, and Bela repeatedly took my pulse at about 100 beats per minute. I was strangely sweaty and drooly all day long, and every time I ate I bit my tongue or the insides of my cheeks, assumably from my mouth being numb. The silver lining of the story is that as we often see patients who are suffering the effects of scorpion stings, I will be better able to be empathetic about their symptoms now that I have experienced them for myself.

--Calla

2009-10-17T11:56:00.000-07:00

This is how we de-scorpion the room. Bela works, and Calla kind of helps.

17 October 2009

Last night I was stung by a scorpion.

I woke up at around midnight because I felt a sharp sting on my leg, not dissimilar to a bee sting. Shortly thereafter, the leg went numb,and the numbness crept up my body to include my arm. I woke Bela up, but by that time my whole body, including my mouth and tongue, were like lead blocks that I couldn´t move.

Bela rolled me off of the bed and onto the floor, and Rebecca and Neal helped to search the room for the offending insect. He or she was never found.

The numbness wore off about four hours later, with a horrible pins and needles sensation in my extremities, and a feeling of vomity nausea in my tummy.

Luckily, however, I am fine today, with just a headache!! Bela and I have renewed our vow to shake out shoes-sheets-pillows-clothes before using any of them.

--Calla

2009-10-17T11:41:00.001-07:00

14 October 2009

On Monday morning, Bela and I went up to the clinic early in the morning to wash some clothes before beginning to sweep and mop the clinic. Neal and Rebecca joined us up at the clinic shortly thereafter, and so short work was made of the morning tasks.

We sat down to a breakfast of fried plantains and coffee, but just as we were starting to eat, Ramiro pulled up in the Campesinos para el Desarrollo Humano pickup truck. A young woman was carried out of the truck and into the clinic by two men and put on one of the clinic beds. We talked with Ramiro briefly, and then the four of us (Ramiro used to work as a health promotor before becoming the director of the NGO) went in to see the patient.

She was a 19 year old girl, four months pregnant, with severe abdominal pain, vomiting, and fever. Her father and husband had thought that she had dengue fever, and so had waited for a few days before coming to the clinic. However, the night before coming in she had gotten much worse, and so had called Ramiro early in the morning. We examined the patient quickly, but decided that she might have appendicitis and would be better served in the hospital. Since Neal had just arrived, we decided that he should go to the hospital to see the process of getting a patient admitted. Bela decided that I should go as well, and that he would stay and see patients in the clinic with Etelvina.

The patient´s father and husband carried her back to the truck. Neal and I hopped in and traveled the forty five minutes to the hospital with the family. Once we arrived, the hospital guard brought us a wheelchair, and I went in to the talk with the nurses and doctor while Neal helped the family wheel the patient in. The doctor took one look at the patient and decided to see her immediately. He wheeled her to an examining room in the emergency department, talked with her and family, and then examined her. After the exam, he asked her not to eat or drink anything, told her that he was afraid she would need surgery, and sent her to get laboratory testing done. After she was admitted, Neal and I traveled back to the clinic.

We arrived at the clinic a little after noon, and ate quickly, because we had planned on presenting a workshop on tuberculosis at one of the neighborhood community meetings. Each month the neighborhoods have a meeting where families discuss community projects, community development, plan events, and occasionally have guests. Etelvina´s husband is the secretary for her community, called Colon, and so we were invited to give a talk there.

We arrived, and the meeting began with some community business. About halfway through the meeting it was our turn to present. We began with introductions and the objectives our talk, and then preceded to perform a sociodrama about a family whose mother had a prolonged talk. Etelvina played herself as the health promotor who helped the patient perform sputum samples, and visited the patient and husband later to make sure the husband performed the test and the patient received her therapy. After the sociodrama we presented the symptoms of tuberculosis using cards on which had attempted to draw examples. After our talk there were a lot of questions from the audience.

The next morning Etelvina told us that the community liked our sociodrama, and we are now making materials for a new workshop, on burn prevention and basic first aid for burns that do occur.

--Calla

2009-10-11T11:56:00.000-07:00

A Typical House in Estancia

8 de Octubre 2009

There are now two new volunteers in Estancia with us. Neal, a fourth year medical student at Tufts, will work with Etelvina and us in the clinic, and Rebecca, his girlfriend, will work on community projects.

Yesterday Etelvina, Neal, Bela and I saw patients in the clinic in the morning. It was an interesting mix of patients for me. A couple of children came in with colds, a woman came in with diarrhea, and a woman came in for a Pap smear. Additionally I saw a woman with headaches and a child with impetigo. I was tidying up the exam room to go eat lunch when Israel, the health promotor in training, came in to talk to me.

Abraham in the community health promotor of the NGO for which we are volunteering. He is in charge of health promotion in 9 communities, and travels every day on foot visiting patients who are sick or children who are malnourished. He was visiting some families in a nearby community in the morning and heard about a very sick patient, a 40 year old man who had been ill for about a year. He went to visit the house, and decided that the man needed more medical attention. He contacted the clinic, and asked Israel to have someone come and visit the man.

Fortuitously, Israel had a meeting in the county seat, Cacaopera, a town a forty minute walk and twenty minute bus ride away. After talking to Abraham and then to Ramiro, the director of the NGO, it was decided that he would take the organization´s pickup truck to drop me off at the top of the hill below which lives the patient. I quickly packed up my stethoscope, opthalmoscope, thermometer, and blood pressure cuff and hopped in the car to go to the patient´s house.

Because it has rained so much lately, parts of the road were difficult to pass in the pickup, and took us awhile to get up to the main highway that leads to Cacaopera. Once on the highway, we drove for awhile before encountering Abraham, the health promotor, who was waiting on the side of the road. We parked the pickup and Israel continued on to Cacaopera, and Abraham and I started the descent to the patient´s house. We took a windy dirt path that led us through a forest and a cornfield on the slope of a hill above a rushing river. Interestly, we passed by the house of the woman whose Pap smear I had performed in the morning, so I stopped to say a quick hello to her before continuing on.

We finally arrived at the house, a cane shack off to the side of a bigger cane shack, where the patient´s family lives. Because he had been sick for so long, the family had decided to have him live apart, so that he would not infect his small children with whatever illness he was suffering from. We stopped and said hello to his wife and daughter, and then continued on to visit the man.

He was a forty year old man who had first become sick in December of last year. He began to lose weight, and started to feel weak, so he was taken to the hospital. He left after one day before tests were performed, because he was afraid of dying in the hospital. He came back home, and then began coughing.

He coughed for months, and continued to lose weight. However, by the end of May, he began to feel better. He started to work again, sewing hammocks, and began to regain his strength. However, by the beginning of August, when the corn harvest is in full swing, he began to cough again. He lost his appetite, and lost weight. Furthermore, he was having fevers that began to happen more and more frequently. Every once in awhile, when he coughed up flem, there was blood in it.

Abraham and I talked to the man for a long time, and then I examined him. Both Abraham and I feared that he might have tuberculosis. His symptoms were troubling, and he looked thin and weak. He coughed up a thick flem frequently when talking with us. We told him of our fear.

The Ministry of Health in El Salvador has a tuberculosis control program. As many people in the area were exposed to tuberculosis during the war, and all children receive the BCG vaccine against tuberculosis, the Ministry uses sputum samples of symptomatic patients to diagnose the illness. The test is complicated—patients must perform three separate samples and deliver them to the health department clinic, which for many patients is over an hour away. Luckily, however, the test and treatment are free.

The man was surprised to hear that we thought he had a disease that could be treated. He had assumed that he was dying from an illness for which there is no cure. He decided that he would like to be tested for tuberculosis, and if positive treated. His biggest goal is to move back into his family´s house, but he did not want to harm his children.

I spent the walk back up the hill hoping that the man would be easily cured, knowing that an easy cure for a disease like tuberculosis is not a reality. Treatment is long and difficult, as patients must take many pills over the course of six to nine months. It is difficult to coordinate in a place like the United States. In a place like here, just the thought is overwhelming. However, there are people like Abraham working hard to treat and prevent illness in the community, and so there is hope that the man will one day return to live with his family.

--Calla

2009-10-03T08:25:00.000-07:00

Dancing at the event

At the charla given by Laura, the Peace Corps Volunteer

A view of the clinic