After a month of time establishing ourselves in Xela, Guatemala, Lauren and I have found a much happier balance with the culture, communication and medical treatments of the area. I've learned to identify the signs and symptoms of an abdominal infection requiring anti-parasitic medications, or the difference between a patient needing trimethoprim-sulfamethzole or metronidazole. Intestinal infections, lack of appetite and respiratory infections have become the typical chief complaints requiring treatment in the past two weeks. The prevalence of flu-like symptoms have been extremely high recently, which has been locally blamed on the heavy fluctuations in weather patterns and the body's ability to cope with the cold and rain. Patients seen in the mobile clinics and day care centers over the past 5 days have shattered our status quo of illnesses and treatments, bringing new challenges and learning experiences with each visit.
The end of last week and the first day of this week have been spent on the road moving from guardería to guardería (daycare centers). A camping backpack was been loaded with medications and we covered 6 different guarderías in 3 days and treated roughly 150 patients and I myself examined and treated 25 children from the ages of 2-8 years old. The first patient I saw on Thursday walked up, sat down in the seat in front of me and proceeded to remain completely mute for the first 2 minutes of our visit. I couldn't even get her to nod yes or no to my questions, she was just utterly terrified. Another volunteer stepped in and was able to discover that the child had a stomach ache, but that still wasn't exactly useful and we were left with more questions regarding the girl's health. Finally one of the teachers showed up and informed me that this girl had been having trouble moving her right arm for the past week. After an examination and discussion among the medical providers, it was decided that this girl needed to be sent to the hospital for x-rays and a possible casting. We quickly discovered shortly thereafter that this child had a cast on her arm just last week, but for some reason, someone unbeknownst to us, had removed the cast and let the girl run freely without proper traction. If we had not visited the daycare center that day, nor cared for this child, she may have continued to live day to day with a broken arm and very restricted mobility. Still, we have yet to determine if our continuity of our care will be sufficient for this girl and her arm.
Friday presented further challenges and patient encounters requiring collaboration and collegiality which resulted in our collective best treatment within the limitations of restricted resources. Upon entering the second guardería on Friday, we found a boy lying on a mat in the middle of the play area being soothed by one of the teachers. He had been thrown out of his chair not 5 minutes earlier by a tonic-clonic seizure and at the moment we entered, he was suffering the confusion and exhaustion of any post-ictal phase. We were told it was his second seizure documented and he was only 5 years old. He received the full attention of all three Guatemalan medical students while Lauren and I tended to other children and consulted on the examination and discussed possible differentials for the child victimized by a traumatic seizure. Lauren noted this boy had erythemic tympanic membranes of his ears and a fever. From these noteworthy clinical observations, the group decided on a treatment plan of Tylenol to reduce the fever, Bactrim for the ear infection and a follow up appointment on Monday were the best options we had for this child. From our education at Vanderbilt, Lauren and I knew that febrile seizures occur in about 5% of children and that they often suffer more than one seizure before growing out of this very disconcerting habit. But the limitations of my education for treating Guatemalan patients became apparent the following day after another Guatemalan practitioner discussed treating seizures here.
Neurocysticericosis is not an infection I ever encountered or read about during my 6 semesters of education in medicine, but here in Guatemala I was informed that it is a leading differential whenever there is a new onset of seizures. Spread through fecal-oral transmission and poor hygiene, neurocysticericosis is a parasitic infection that has become the leading cause of acquired seizures in the world (DeGiorgio, et al., 2004). Once merely a worry in developing countries, but now neurocysticericosis is a growing problem in the United States and it should be a recognizable risk especially among immigrant populations (DiGiorgio, et al., 2004). The larvae of the parasitic migrate to the brain, cause an immune response that leads to viable cyst formation within the cranium which can last for years. Neurocysticercosis is quoted as being responsible for 10% of emergency room visits for seizures in the southwestern region of the United States (DiGiorgio, et al.). A CT scan is the recommended diagnostic tool and albendazole is the preferred treatment over praziquantel because it is more affordable the causes less drug-to-drug interactions (Davis, L.E., 2005). I spoke with the medical director at Primeros Pasos briefly about the prevalence and presentation of neurocysticericosis in the hospitals he has worked. He has seen the infection many times and ordered multiple CT scans to rule out neurocysticericosis whenever a patient presented to the hospital with new onset of seizures. The anti-parasitic and anti-inflammatory medications help the treatment along, but neurosurgery is required to remove the cysts as well. We are all hoping here at the clinic that the child we saw was experiencing febrile seizures, but neurocysticercosis must also be ruled out.
The last patient I saw, on Friday of last week was an 8 year old boy who presented as a completely healthy, vibrant and playful child. I was about to send him back out the front door of the guarderia with the typical fun bag of an anti-parasitic medication, a toothbrush and bar of soap until his teacher informed me that this child was having chest pain multiple times a week, especially during exercise. He had not told me anything about this ailment through 3-4 minutes of my persistent questioning regarding his body, health, illnesses or current medical needs. After thorough questioning, his history dictated that he may in fact have a cardiac abnormality and further testing was certainly warranted. We gave him a prescription to report to the clinic in three days for an EKG and hopefully an appointment to receive a Holter monitor and eventually an echocardiogram. Despite these measures, we have very little idea whether the continuity of care will be established or even if this child and his family will pursue medical care. We are often confronted with resistance to Western medicine, but hopefully we made enough of an impact with this child convince him and his family to seek the appropriate follow-up care under the discretion of a specialist.
After pondering the possibility of a parasitic infection causing seizures, the orthopedic ramifications of a young bone healing without a cast and an atypical presentation of chest pain and tachycardia, our medical team had one more serious diagnosis the following Monday afternoon in the 6th guarderia on our 3rd day on the road. The child walked into the poorly lit room and was going to be in the diligent and exacting care of Lauren, but as soon as Lauren touched her stethoscope to this child's chest, she realized this was going to be a patient cared for by the entire medical team. The 5 year old girl had a grade 5 heart murmur audible in all areas of her precardium with a palpable thrill radiating across her chest. Her feet were cold from poor circulation and she had fainted on multiple occasions due to her weakened heart. An immediate EKG, echocardiogram shortly thereafter and a pediatric cardiology consult were needed as soon as possible. Since this encounter, Lauren and I have been exploring the possibilities of Rheumatic heart disease in hopes that it will be an infectious process that can be controlled with medications, but from the sound this child's heart is emitting, the history and examination, it certainly appears that she has a structural defect of her heart requiring expertise far beyond our scope of practice.
The constant ebb and flow of patients usually seen and easily managed on a daily basis is occasionally disrupted with scenarios such as the four patients just mentioned who presented with conditions well beyond our scope of practice and available resources. Another obstacle for reliable care is our inability to ensure continuity of care and follow-up appointments. There is resistance to western medicine in many of the areas we provide treatments. We cannot ensure that the broken arm will be mended because it is likely that a family member removed the cast initially and would thus be resistant to returning to the hospital to have another one fitted and placed. The boy with tachycardia and chest pain was resistant to even confessing his illness to me because their exists a stoic nature in the culture of many patients' approach to health and illness. The child with seizures needs thorough follow-up testing and care to rule out neurocysticercosis, but the imaging is expensive and the child has had a seizure before and we aren't sure care will be pursued this time around. Lastly, it was rumored that the girl with a grade 5 murmur had been diagnosed with the issue months previously, and apparently her mother refused to take her to the doctor for treatment. We do not understand the level of neglect some children experience or whether it is voluntary, cultural or circumstantial, but the ability to encourage follow-up, continuity and complete care is a daily challenge we attempt to overcome with education, compassion and strong encouragement.
Davis, LE. “Neurocysticercosis” Emerging Neurological Infections edited by Power, C and Johnson RT. Taylor & Francis Group, 2005. 261-287.
DeGiorgio, C. M., Medina, M. T., Durón, R., Zee, C., Escueta, S. P., (2004). Neurocysticercosis. American Epilepsy Society: Epilepsy Currently, 4 (3): 107-111.