by Cody Bowers
Vanderbilt School of Nursing
Xela, 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 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 Cody Bowers
Vanderbilt School of Nursing
Xela, Guatemala

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. 

by Lauren Eppinger
Vanderbilt University School of Nursing
Quetzaltenango, Guatemala

The Guatemalan school year has ended, and mobile clinics and educational programs for school children from Primeros Pasos have also ended. All of these initiatives are a part of the healthy school program that Primeros Pasos runs, but only take place during the school year. Now these children are on their own for care and education until the beginning of next year, although the clinic will be open through mid December.

The mobile clinics are extremely useful, because they serve as screening programs for malnutrition, infection, and serious illnesses, and also offer a great educational opportunity for the children. We were able to identify several acute infections, as well as some chronic diseases. Several children with wheezing—and likely asthma—were sent to the clinic for asthma medications. Asthma can be very dangerous if not treated, and referral for proper treatment can save a child's life. Last week I referred a child back to the clinic because of a heart murmur, to run some tests and assess further to ensure that he was not anemic and malnourished. Although I am not sure what the outcome of his situation was, it was important to be able to identify children like this who are at risk of more serious problems, who can be treated.

All of the children are supposed to give stool samples at the schools. This leaves a huge amount of work for the lab to do, checking to see if there are any parasites or signs of bacterial infection, but it is worth it. A couple of days after the initial visit to the school, another group goes back to the school to distribute medicines to all children who were not already treated based on their symptoms. The children are given a bag with their medication (free of charge) and dosing information is written and illustrated for the parents to read. Although many children are treated for intestinal infections based on their symptoms, a significant amount of infections still go untreated until the stool samples are analyzed. Intestinal infections can cause discomfort, malnutrition, dehydration, and impaired growth. Therefore, identifying and treating these infections, even when relatively asymptomatic, is extremely important for a child's health.

Now that school is on break, the clinic will start bringing mobile clinics to the daycares, where pre-school aged children are cared for. Many of these children, like in the elementary schools, have few resources at home. Similar screening and treatment programs are done with these young children. I am excited for the opportunity to continue to work in the community, and identify children in need of treatment. As sad as it is to find a sick child who nobody managed to bring to the clinic, it is rewarding to know that we are able to help.