November 19, 2010

by Greg Schnepper, M.D.
Vanderbilt International Anesthesia
Kijabe, Kenya

shnepper kijabe

While it feels as if I just arrived, I can't believe I will be heading back home tomorrow. What a phenomenal experience this has been. This month has not only had a high impact on my education, but has been a unique, once in a lifetime experience. I say once in a lifetime, but I certainly hope this is not the case. I would love and certainly hope that I will be back to visit Kijabe in the future.

Much of our time here has been spent working with the student nurse anesthetists. My co-resident and I have helped conduct their practical exams, have provided intraoperative teaching, and have given them lectures while rotating through the icu. Their education is vitally important, as when they become nurse anesthetists many of them will be in parts of Africa where they are the sole anesthesia provider.

We have also spent a fair amount of time teaching regional anesthesia. One nurse anesthetist has shown an inordinate enthusiasm for nerve blocks, and it has been a joy teaching her. I have provided a picture of the two of us performing a nerve block using ultrasound, something that will surly help patients with postoperative pain relief.

Our experience has also included time rotating through the intensive care unit. While taking call in the ICU, I helped take care of a very sick 8 year old boy. The boy had severe respiratory failure and sepsis, requiring an emergent exploratory laparotomy operation. I helped provide anesthesia during the surgery. Sadly, the boy passed away. His death was devastating, and it is often difficult or impossible to find any silver lining in events like this. But I did take away hope by the passion shown by all those involved in taking care of the child. Our team of anesthetists, nurses, pediatric surgeons, and critical care intensivists did all we could to save this child, but sadly he was just too sick. The deep desire of the people here to help those in need is unparalleled. The passion shown for others is inspiring. Unfortunately, despite being one of the top tier hospitals in all of East Africa, the resources at Kijabe are often limited and lacking. But hopefully with such a strong base of people wanting to make a difference, this will continue to improve. My experience at Kijabe has been touching and incredible. I have been inspired, and I only hope those I've been in contact with have been too. I can't wait to come back.

by Senator Bill Frist, M.D.

As the cholera outbreak continues to ravage through Haiti, killing hundreds and inciting terror and riots throughout the country, I'm afraid I may have more bad news. It has come to my attention today that the cholera outbreak is being vastly underreported and underestimated. My sources on the ground in Haiti have estimated that the current epidemic is up to 400% worse than the official numbers reflect. Considering that the official numbers already state a toll of 1,110 dead and another 18,000 sick, the scope of this savage outbreak is shocking.

Furthermore, it seems that nearly all the organizations on the ground were caught by surprise by this sudden outbreak and are grossly undersupplied. Simply put, eradicating the cholera outbreak requires resources beyond Haiti's capacity. Ringers Lactate fluid (required for intravenous rehydration) remains incredibly scarce within the country. The UN also refuses to provide any cholera treatment supplies to any NGO, instead dedicating all its supplies to the Haitian government. Medications from the Haitian Ministry of Health are also currently not forthcoming. Certain organizations are simply waiting for the disease to strike the capital, Port-au-Prince, before acting. A group I frequently work with, Samaritan's Purse, is receiving reports of high mortality in remote areas with no assistance reaching them. The U.S. government claims that materials are in place to respond to this developing disaster, but this does not seem to be the case and I worry that false confidence may cost lives.

The spread of cholera now seems past controlling, and using Pan American Health Organization calculations (in the MOST optimistic, with an attack rate of 2% scenario) around 200,000 people will require IV fluid. As around 75% of all cases require hospitalization, each patient uses 8 liters per day for three days, the conservative estimate for IV fluid needed stands at 3.6 million units. Unfortunately, some experts believe that the attack rate will rise above 2% due to lingering sanitation and hygiene conditions caused by the devastating earthquake combined with a Haitian population with no exposure to cholera and immature resistance.

With much of the country living in squalid post-earthquake conditions, we should expect an attack rate of up to 5-8%, according to the Refugee Health Manual. At this rate, we can expect as many as 500,000 to 800,000 cases of cholera. Due to the intense overcrowding, these cases might not be spread out over six months, but rip through the population in six weeks. Roads in Haiti, already devastated by the earthquake and again recently by Hurricane Tomas, continue to keep sick people from seeking and receiving proper aid, meaning that more advanced treatments are needed to halt the disease.

Save the Children, which has been in Haiti for over 30 years and currently operates in 17 large urban camps, is desperately struggling to fight back the disease. They are scrambling to set up new treatment centers around the country as current ones, such as their facility in Port-au-Prince now operates 24 hours a day and still cannot do enough. On the preventive side, Save the Children has distributed 10,000 hygiene kits, 19,000 bars of soap, and chlorinated water to schools and camps. These actions are important and have saved thousands of lives, but in a country of 10 million people, they are simply not enough to hold back the tide.

Similarly my friends at Samaritan's Purse, who remain a major national player in Haiti, report that even with their huge public awareness WASH program, 400 treatment beds, and over 300 staff dedicated solely to cholera, they were completely unprepared for this outbreak. I find it hard to believe that many organizations were prepared for this and I simply cannot imagine that any hidden capacity exists.

This issue needs immediate global attention. Many organizations on the ground do not have the resources to quickly buy, deliver, and administer necessary cholera medications, like Ringers Lactate. Even if they can afford these costs, it is only the beginning of the current logistical nightmare. The airport in Cap-Haitien has been shut down and there are roadblocks between Cap-Haitien and Port-au-Prince, effectively isolating the entire North of the country. If supplies do make it to Haiti, customs holds these shipments 3 to 10 days and the backlog of supplies, not just at Port-au-Prince but around the country is staggering and costing lives every day. NGO's are unable to receive and distribute supplies and are resorting to covert and illegal means in some cases to secure these life-saving medicines. Civil unrest around the country, caused by the belief that the UN Peacekeepers are connected to the outbreak, are further hampering the delivery of supplies that eventually do get through the ports.

These hindrances to saving lives must be eliminated. Haiti needs IV fluids sent in massive quantities. Life-saving supplies must be allowed to enter immediately into the country, not sit on pallets for 3 to 10 days out of bureaucratic formality. Organizations on the ground have sophisticated software that allows all the various partners to work together to comprehensively treat the population; we simply do not have enough supplies. The immense backlog of supplies at the ports has strained the entire response grid to the point of collapse and the internal rioting makes it difficult and dangerous to move supplies inside Haiti. The world must help, and must help now.

In addition, the United States needs to seriously and objectively consider a military airlift of supplies into Haiti. While this may appear a drastic measure to some, we cannot sit idle while our neighbor to the south suffers through this nightmare. Our military provided crucial support to those suffering after the Indian Ocean tsunami, Hurricane Katrina, and the earthquake that ravaged Haiti in January, and can do so again in this dire time of need.

Cholera is a disease we can defeat if we work together. Up to 80% of cases can be successfully treated with relatively simple medicines, such as rehydration salts. So join me in telling your friends, writing your congressman, volunteering, or writing a check to one of the many worthy organizations on the ground. We need to spread the alarm, and quickly. This epidemic is larger than previously thought or reported, we are drastically underequipped to deal with it, and it's moving fast.

by Jenny Eaton Dyer, Ph.D.

Senator Frist, M.D. sat down with Jim Thebaut of Running Dry.org, an organization working for access to safe, affordable, and sustainable drinking water for all, to in the video below.

This video will be circulated throughout the House of Representatives to promote awareness and support for the Senator Paul Simon Water for the World Act 2010.

We invite you to watch!

 

by Lauren Eppinger
Vanderbilt School of Nursing
Xela, Guatemala

eppinger house

In a country so plagued by poverty, one would hope that the contrast between wealth and destitution would rile up people's desire for justice. But following conversations with my Guatemalan peers in the clinic, it has become apparent that the silent apathy has also become just as prevalent as the poverty that screams for our attention. Despite the undeniable contrasts, many people seem to view poverty as benign and even acceptable. Those who choose to acknowledge poverty here do not always know how to or take action against it.

It is not just apathy within the local community that can be so dangerous, but apathy within the global community as well. Apathy can be defined as a lack of drive to do or change things. In Guatemala it can be seen by the lack of involvement in social change with everything from education reform to recycling, and the overall contentment with the status quo. Admittedly, Guatemala's recent brutal political history probably contributes greatly to this condition, but passive resignation is essentially a form of active acceptance. There is general agreement that apathy is a sort of coping mechanism for those who experience frequent and poignant suffering and this form of psychological protection is very commonly utilized in Guatemala.

As I said, apathy here in Guatemala is alarmingly widespread. Some people have begun to recognize the gravity of this situation and have been campaigning for a change in the national attitude. Yesterday I saw a billboard defining patriotism as fighting for the wellbeing of the country. In the past I have even seen television commercials carrying the same inspirational message.

Despite these small efforts towards raising awareness of our power as global or local citizens, I have heard numerous people openly express their acceptance of their perceived powerlessness in the situation. Unfortunately, the struggles here seem to accumulate at least as fast as any efforts to relieve the suffering. Guatemala is a country with extremely low levels of education, literacy and health. Guatemala has the highest level of malnutrition in Latin America, and the fourth highest in the entire world. Healthcare is unattainable to many people due to many elements of access, and almost no one receives adequate primary care by the standards expected in the United States.

As an international volunteer working in a clinic in Guatemala, I do my best to pay attention to how my actions affect my environment. Naturally, I want my work here to be effective, and to help elicit positive change. I have heard my Guatemalan peers express strong support for the work being done by NGOs in Guatemala. This kind of acceptance of foreign aid is a good sign in a place where people are somewhat quick to resign themselves to a bad situation out of habit.

Although it may be easy to imagine that my job here is to work in the clinic and see patients as needed, I believe that I should be doing much more. It is my personal belief that people should use all of their available resources (knowledge, skills, etc.) for the greater good. My motivation for getting into the medical field was to be able to have concrete skills to offer and to be an effective agent of change. What makes apathy so dangerous is that it undermines the ambition and knowledge people could embrace to achieve change for the better.

A famous medical doctor known not only for his contributions to physiology, but also for his foundation of the idea of social medicine, Rudolf Vichrow, has been quoted as having said: Medicine is a social science, and politics is nothing else but medicine on a large scale. Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to attempt their theoretical solution: the politician, the practical anthropologist, must find the means for their actual solution.... The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.

Although this statement was made over a century ago, the sentiment resonates with me and how I view my role and obligation in alleviating the cycle of poverty and its associated suffering. I interpret Vichrow's use of the word physician as being applicable to all medical professionals. Through our education and training we are given the tools to help people, and practice our science of "human beings," not only as a means to earn an income, but also to do justice to the science itself. If apathy gets the best of us, and we are unable to motivate ourselves to use the resources within ourselves, we cannot fulfill our duty and lives are left unimproved.

By using whatever resources we have access to, and working with the underprivileged, and advocating for their needs, we can indeed establish positive change in the global community. By recognizing this, we can begin to tackle some of the major obstacles, including the epidemic of apathy. Through the use of educational programs, casual conversations, passionate debate and positive examples of successful NGOs, we can appeal to the sense of hope within people and take our first steps towards achieving these goals.

As medical professionals, one of our most important resources is our understanding of the human body and the body's interaction with the surrounding environment and I feel we have an obligation to work with our patients in the clinic, but also advocate for the rights in the larger community. These skills and advocacy are our personal resources for establishing positive change, and that is what the medical profession is all about. The support of Hope Through Healing Hands, sending people and resources out into the world as well as instituting change can be an essential catalyst in alleviating some of the healthcare and social discrepancies globally and specifically in Guatemala.

by Living Waters for the World

lww creek

Creek in wet season

Imagine getting up early in the morning, standing in front of the kitchen sink, you turn on the faucet and nothing happens. Has the pump failed again? You slip on your jacket, grab a container and start walking down the hill. It hasn't rained lately you're thinking to yourself and you stop in your tracks – the stream-bed is dry. This is not an excerpt from some prairie novel written about life at the turn of the century; it's reality for many families across Appalachia.

lww crew

Gene, Bill, Bob (LWW volunteers), Tonya, Matt, Angel, Andrew

For one family along the KY/TN border, their water source was a stream-bed down the hill from their house. The county will probably never run a municipal water line down their hollow – there aren't enough families living there for it to be profitable. And even if the county did run a water line, it's hard to pay a water bill when your income is virtually non-existent. It's hard to believe that this story plays out in communities across the US but it does. Luckily, there are people who care and are willing to do something about it.

lww water system

LWW Standard UV Disinfection Clean Water System

In this instance, the family's water source had dried up after a long dry spell and it was the attentiveness of a grade school classmate that something wasn't right that brought the family to the attention of Living Waters for the World. Now, thanks to a grant from the Hope through Healing Hands Foundation and Brad Paisley's H2O World Water Tour, and additional contribution and volunteer labor from Rivermont Presbyterian Church in Chatanooga, the family now has a sustainable supply of water that is safe to consume.

by Cody Bowers
Vanderbilt School of Nursing
Xela, Guatemala

pesticides in guatemala

      There will always be patients that leave an indelible mark upon your career, future treatments and personal emotional strength. Yet medical providers do their best to find coping mechanisms to prevent the emotional burnout of seeing tragedy after tragedy, but these barriers can be overcome. I've had a few very influential patients in my short time working with medicine, but there is one at the Primeros Pasos clinic who continues to interrupt my thoughts because of his illnesses and how he his plight affects my deepest personal values. I've seen this patient three times now and he has become a frequent forethought during my time here in Guatemala. He came in once for a follow up clinic visit after going to the hospital a week before and then he came in a second time to introduce himself and discuss his future treatment options with Lauren and me. This patient, named YE for the sake of identification, went to the emergency room two weeks prior to visiting the clinic with vomiting, diarrhea, diaphoresis (sweating), abdominal tenderness, anxiety and all the other side effects of the body's attempt to ride itself of a poison. He was diagnosed with "intoxication" given fluids and some medicines to control the symptoms and sent home. In my realm of possible medical diagnoses, 'intoxication' only triggers thoughts of alcohol poisoning and a mistake perpetrated by alcohol. In Guatemala however, the diagnosis of 'intoxication' is entirely different and it was an enlightening, but very depressing learning experience for me. Intoxication is very common among men, especially farm workers and is at the top of emergency room differential diagnoses. These patients come to the hospital because they are poisoned from significant pesticide exposure in the farm fields and their bodies cannot cope with the poison properly. The field workers are absorbing the chemicals through their skin and then their bodies go into a form of shock in an attempt to filter the foreign matter as fast as possible. There is a form of chelation therapy treatment in the local hospitals that can help bind the chemicals and flush them from the body and assist the liver in the purification process, but rarely is it used due to cost and the less than impressive results. 

      One of the studies I found during my research on pesticides cited that the immediate consequences of exposure to small amounts of pesticide include a rash, nausea, vomiting, and blurry vision. Immediate effects of a larger and more prolonged exposure include disorientation, loss of continence, coma, and even death. Delayed consequences of pesticide exposure may include sterility, birth defects, neuro-degenerative disease, and cancer. It sounds as if YE was fortunate enough to fit into the first category where he only had the nausea, vomiting and blurry vision, but with waves of the more significant symptoms like abdominal tenderness (liver damage) and disorientation. The first time I encountered YE he was with his 5 year old child in the clinic and complaining of persistent paresthesias (symptoms of tingling and burning) up and down his legs and significant fatigue. The medical director recognized that with YE's recent intoxication diagnosis and that the legs being the frequent site of absorption for pesticides, YE's ailment was a result of the chemicals. These toxic pesticides were hypothesized to have been absorbed through the skin of YE's legs when he was spraying the crops and the subsequent exposure caused nerve damage throughout his legs and lasting discomfort.

      Children of migrant workers are also at a high risk for pesticide intoxication because they come in contact with the agricultural chemicals as their family members, who work in the fields, bring the chemicals into the house via their boots, clothing, or work equipment. There have been multiple research projects in the United States studying the levels of pesticide metabolites in children's urine and the neurologic complications of organophosphate toxicity from pesticide exposure. One study, with a sample of 60 children and performed in North Carolina by Acury et al., found that one of the children studied had no evidence of pesticide metabolites in his/her urine, ?ve children had one pesticide, another had two different chemicals, 16 children had three pesticides, 17 children had four pesticides, eight children had five, nine children had six pesticide detects, and three children had seven different harmful chemicals in their urine. A combination of several toxins in a single child may have a synergistic effect and among the 60 children in the study by Arcury et al., 54 had at least two or more pesticide metabolites. Another study by Eskenazi et al., discovered that children whose mothers were exposed to pesticides during pregnancy scored lower on IQ tests and about 50% of the exposed kids at age 2 had some neurological/developmental deficit. These statistics are not merely meant to draw shock and drive fear by depicting the trauma the farmers and children of farmers suffer, it is only meant to illuminate the fragile connection between food production and health.

      YE has been victimized by the chemicals used to farm here, but his medical history began 8 years before I met him and in a much more serious manner. I had heard the story of a special patient at the clinic and due to his medical history and the story I was told, I envisioned an old man, but upon seeing a strong 29 year old man with a 5 year old wrapped around his leg, I was surprised to find the contrast between my imagination and reality. I saw YE the first time when he was seeking follow-up care after the intoxication diagnosis, but it was not until hours later that I was relieved of my ignorance that the 'special patient' was the 29 nine year old man I'd treated moments before. YE moved to the United States when he was a teenager and the time when he returned to Guatemala is still unclear. He was living well for himself and was pressing for the American dream 8-10 years ago when devastating headaches started afflicting him daily with sequelae of serious visual disturbances. He had been in the United States for roughly 4-5 years and working in northern California when the headaches began. The profound headaches and visual changes were devastating and he dragged himself to the one of the best emergency rooms in the country. At the hospital he was able to use health insurance to receive the rapid and necessary testing for optimal medical care. The doctors ordered a CT scan of his brain and noticed a tumor residing near the optic chasm and sella turcica (where the pituitary gland sits) and this tumor was pushing on his optic nerves. He was referred to a neurosurgeon who followed up with more blood tests, which showed that this was likely a prolactin (hormone released from the pituitary) secreting tumor that is oftentimes controlled with medication. It appears from the paper work YE brought with him that the surgeons performed the surgery to remove the tumor in hopes of restoring his vision because he was nearly blind in his left eye, alleviating the headaches and then after the surgery they would proceed with the medication to control the prolactin levels. The surgery went well enough and he was able to go home the next day, but in the report the surgeons mention that they were unable to completely remove the tumor.     

     This all happened 7 years ago in the United States where Y.E. received the best care at one of the best hospitals in the country. Now he is having an exacerbation with his vision diminishing further and he is running out of the medicine, which maintains the prolactin levels and prevents the tumor from growing back. Y.E. is going in for an MRI in January to get another visual of the area, but there is only one neurosurgeon in Xela, Guatemala to serve roughly 800.000 to a million people. He is 7 years post-operation and his sight out of his left eye is less than 10%, but thankfully his right eye is above 95%. The headaches and visual changes continue to ebb and flow as he struggles to pay for the medication that prevents the tumor from growing. Lauren and I are currently exploring treatment options and fundraising potential in order to get YE to his next MRI in January with his remaining vision intact. The challenges of medical treatments continue to persist in a resource limited setting. From the children with dangerous heart murmurs to pesticide intoxications and prolactin tumors, we are pursuing medical treatments amongst the perceived resource restrictions in order to restore health in Guatemala all while managing the indelible effects of memorable patients.

by Gregory Schnepper
Vanderbilt International Anesthesia
Kijabe, Kenya

schnepper kijabe 1

If first impressions mean anything, then this trip to Kenya will be one I will always remember. Not that I expected anything less. We arrived at Kijabe about one week ago, and there already are a number of things that have awe-struck me. But perhaps what has stood out more than anything to me is the people here. While many of them have little in the way of possessions, you couldn't find a more happy, gracious, or appreciative people, making this journey all the more special.

After quickly getting oriented to the operating room here, our activities thus far have consisted of providing anesthesia for a large variety of patients: including parturients, elderly, and children. We have witnessed pathology here that you would rarely see in the States: large bilateral cleft palettes, two myelomeningocele defects in one patient, etc. There is also a large amount of trauma here, and a high volume of orthopedic surgery. We have been teaching and refining some of the nurse anesthetist's skills at regional anesthesia, providing an option for patients to avoid general anesthesia and developing another means for postoperative pain control. We have also spent a lot of time teaching the student anesthetists, including conducting oral and practical exams for them.

Lastly, I have attached a picture of the ICU nurses after Humphrey Lam (the other resident that is here with me) and I delivered some medical supplies. The big balls of white are all pulse oximeters—giving the ability to monitor patient's oxygenation—something that is not always easy to come by here. One of the nurses was so excited when we dropped off the supplies, she couldn't stop jumping up and down. It's moments like these that make you realize how rewarding this opportunity is to be here.

by Jenny Eaton Dyer, Ph.D.

Senator Frist talks about the history of Hope Through Healing Hands in the video below. He recounts its origins, its emergency relief efforts through the years -- with the tsunami, Katrina, and Haiti, and he describes our Frist Global Health Leaders program showcasing our student health professionals who have served in clinics and hospitals around the world.

We invite you to watch this short video to get a glimpse of the work we do at Hope Through Healing Hands. We hope it is a helpful tool to highlight the health care done for the world's poorest.

 

by Lauren Eppinger
Vanderbilt School of Nursing
Xela, Guatemala

lauren eppinger

(Water Source for Primeros Pasos)

According to the World Food Program (WFP), over 70% of people in Guatemala live in poverty. The country has the 4th highest rate of malnutrition in the world, and the highest rate of malnutrition in Latin America. The WFP says that 49.3% of children in Guatemala are undernourished. Most of these children live in the rural areas, and most are of indigenous descent. I can definitely vouch for having seen something of a geographically-based health disparity here. From what I have seen personally, and heard casually, there is little malnutrition in the city of Quetzaltenango (Xela) because of several outreach programs, and relatively clean and accessible water and sewage.

The United States once went through a period of time having malnourished children and adults as well. In 1946 the school lunch program was started to prevent and treat childhood malnutrition, after it was discovered that many young men were ineligible for combat when drafted in World War II. As a result, several measures have been put into place, and have virtually eliminated the issues of under-nutrition in the US. These days, aside from a few rare cases, most of the malnutrition we see in the US is actually obesity, and that’s a story for another day.

The area where Cody and I are working is only a few miles outside of the city, but those few miles make a huge difference. Those few miles mean that not all people have water in their homes; they have to collect it from a communal water supply. Some of our patients use latrines as bathrooms, since they have no indoor plumbing. The lack of clean water and adequate sewage systems is correlated with the presence of gastrointestinal infections, which can be not only uncomfortable, but even lethal. All of these factors contribute to the high levels of malnutrition, as well as sheer lack of food and nutrients, and the lack of consistent quality medical care.

One of the things I am working on at the clinic is the development of protocol for treating and screening for malnutrition. In a place where primary care falls by the wayside, because of lack of awareness and lack of financial resources, children do not get check-ups, and they often only go to the doctor when severely ill. That is not to say that we don’t deal with our fair share of coughs and colds, but people are definitely not seeking care often.

Severely malnourished children are given aggressive treatment in the hospital, or through some outpatient support programs. However, most of the children we see at the clinic are mildly or moderately malnourished. Despite the less severe name, these conditions are still quite problematic. They may not receive much attention here, but even a mild level of malnutrition would warrant a comprehensive medical work-up in the United States. These children easily fall through the cracks here because of the attitude of treating serious but not mild illnesses. The local doctors agree that it is sad, but their attention is often more desperately needed elsewhere, so these children are not treated aggressively. As a result, we see kids with growth stunting every day, and numerous other effects of malnutrition.

I have been working with the clinic on enhancing the screening process, and using every patient encounter as an opportunity for diagnosing and treating malnutrition. The hope is, that with this protocol, there will be a straightforward and regulated way to address these problems in each visit. This way, primary care can be given to a child, even though she is only coming in for an acute sick visit.

I am currently in the process of working with the clinic and the board to figure out exactly how to implement and fund the protocol. Hopefully this will help us see the levels of mild and moderate malnutrition decline in the near future for this community. It is my hope that with the implementation of such programs, we will be able to eliminate malnutrition in Guatemala, and in other parts of the world, just as we have done in the United States.

by Cody Bowers
Vanderbilt School of Nursing
Xela, Guatemala

cody bowers 3

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. 

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