One of the most heart-rending patients I saw was young man with HIV/AIDS. He had initially presented to the clinic on 12/10 with advanced disease (for the medical folks his CD4 count was 3) and was started on antiretroviral therapy (HAART). He came back to clinic in January dehydrated with diarrhea, some fairly advanced skin ulcers, cough and fever. I remember the morning he arrived he was laying outside the clinic on a mat an hour before opening, I could tell from a distance that he was incredibly emaciated, I went over to make sure he was okay, and this man, despite his illness gave me the sweetest smile. He continued to have such a warm smile throughout the few days he spent on observation with us while receiving IV fluids and antibiotics, and gradually improved though he was still very weak. He was discharged on home-based care and I walked with the community health workers to his house a few days later to see how he was.
After a wonderful few days to spend time with my family and friends and recover from jet lag, I have arrived in Lwala, a small village in Western Kenya. My month in Lwala will be a combination of serving along side the clinical officers (similar to a nurse practicioner or physician assistant in the US) and nurses in clinic as well as a project focusing both public health and clinical services for malaria prevention and treatment. I thought I would provide a little context for my work this month.
A previously healthy 29 year old female arrived in the ED via motor taxi, accompanied by her family, early in the afternoon on a day I was working in the outpatient clinic. I stopped by the ED on my way home, and saw that Turno doctor had her hands full with the patient, so I stopped to help. The patient was hypoxic (74%), tachypneic (58 breaths per minute), and somewhat hypotensive (90/50). She complained of chest pain and shortness of breath for 3 days, and also thought she may have had a fever although she was afebrile on arrival to the ED. Her EKG showed sinus tachycardia, but was otherwise normal (we were only able to obtain limb leads). She appeared chronically ill. We were unable to get labs because of the time of day, and the patient was too unstable to transport for a chest x-ray. Pulmonary embolism was a major concern even though she had no risk factors, thus we gave Heparin for anticoagulation and started to arrange transfer to Guatemala City for diagnostic testing and treatment. After two hours of preparing for transport, collecting supplies (as there are none on the ambulance), and deciding which family member was going to accompany the patient, we were finally ready to go. Just prior to departure, the lab was able to run a rapid HIV test, which came back positive. This added more to the list of possible diagnoses. By this time the patient was on 10L O2 and a Dopamine drip. We added on several antibiotics for possible infection, and started the journey.
I have spent the last three weeks working in the Hospitalito in Santiago Atitlan, Guatemala. Santiago Atitlan is a city of 50,000 people, located on beautiful Lake Atitlan, surrounded by three towering volcanoes. The hospital consists of a four bed ED, two labor and delivery rooms with two beds in each, three inpatient rooms, and an operating room. The two upper levels are currently under construction, but will greatly increase the capacity of the hospital. The staff consists of mainly volunteer physicians and local nurses and technicians. The main language spoken by the patients is Tz'utujil, which is then translated by the nurses to Spanish for the physicians. Patients came to the hospital from towns all around the lake and surrounding area. They often arrived via Tuc-Tuc (motorcycle-taxi), but sometimes walked, were carried by family members, or arrived by Bomberos (volunteer firefighters without medical training or resources).
I have been back in the United States for a week and a half now. Coming home from Guatemala during the holiday season is a strange transition. I couldn't help but look at all of the (admittedly exciting) products and services being offered, and think "oh, that money for that completely useless thing could pay for 'x' children's medicine, or food." I have been trying to adjust to life in the US, and accept the differences between life here and the poverty in places like Xela, trying to enjoy the luxury but maintain the perspective. In the midst of all of this enjoyment, I am reminding myself periodically that too much acceptance of this sort of disparity leads to complacency, which only further harms people.
As I am nearing the end of my time in Guatemala, I have been wrapping up all of the projects I have been working on here. Cody Bowers has been writing about the Oral Rehydration Solution (ORS) project, so I will let him update about that in a different blog. The project that has been taking most of my time here is the creation and implementation of protocol for the screening and treatment of malnutrition.
I have put my faith in my education and dedicated myself to continuing the effort of supporting people's health with the knowledge imparted to me over the past two years. Doubts certainly cross my mind as I question if what I am doing is effective, right or even necessary, whereas other times my faith is supported by the curative effects of medicine. There are nuances to the body which we cannot control, but we must rely on continued research to improve best practice techniques. Despite occasional skepticism and my desire to permit my body to heal without medicine, I will take cold and flu medication just to reassure myself that I support the practice that I preach. The advancement of science has helped us prolong life and alleviate illness, but occasionally signals are left unnoticed or the wrong test is ordered, despite the good intentions and full payment of diligence. Sometimes medicine can't control everything it encounters and last week entailed two very difficult patient cases who were both attended to properly, but something was missed.

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