Honduras, Weeks 2 & 3

3/12/12

Posted by Hadia Siddiqui, MD (a third year pediatric resident from Kaiser Permanente, Oakland) while serving a global health elective in Roatan, Honduras at Clinica Esperanza.

Honduras Week 2

It’s the end of my second week here and so far I have learned a great deal about the locals and the standards of medical practice. Working in a resource limited setting has it’s many challenges but also offers many wonderful rewards. You quickly learn that the history and physical exam are your best diagnostic tools. Of course this was one of the most fundamental teachings in medical school but can easily be underrated in our practice with the plethora of diagnostic tests to guide us. Every time I think of getting a test here, I have to ask myself, “is it going to change my management?” Is it really worth the cost to a family who barely makes $50 per week or the burden of getting to an outside lab? Fortunately, the clinic offers several important labs for a very reasonable price, such as a CBC with a differential, stool O&P, UA, and HIV testing to name a few. There is no CT scanner or MRI machine on the island so patients would have to go to mainland Honduras for CTs. The one X-ray machine on the island has been out of service for the past week. There was a young lady who presented with a pus oozing sore on her shin for two months despite being treated for cellulitis initially. We advised her to get an x-ray to rule out osteomyelitis but I was skeptical she would go, not because she was being careless but because getting the study would pose a large burden. People here put a lot of faith in antibiotics, which are rather liberally prescribed and can even be obtained without a prescription. I am still worried about her but hoping that she just had a bad skin infection that will get better with a 14 day course of Septra.

One of our chief responsibilities as doctors is to educate our patients and families. I am constantly giving anticipatory guides to my patients and parents but here the challenge for me is deciding what would be culturally and geographically sound guidance. In my first week, I felt a bit lost and found some parents looking at me like they were getting the silliest advice in the world. “Make sure you put your baby down to sleep on her back in her own separate crib,” is something I often tell parents of newborns. In Roatan, I learned most parents co-bedded with their infants and children because they simply had one bed. I can’t change this but can still discuss safe practices with a growing cultural understanding.  

If time permits, I often try to take a social history, which has proven to be valuable and fascinating. You hear about people taking the bus for 2 hours to get to the clinic and sacrificing a whole day of work. Often children are brought in by their extended family or grandparents. One little boy was brought in for multiple medical problems. Halfway into my history, I learned that the good natured, middle aged woman he was with was not his mother but the caregiver at a local orphanage. She had found him abandoned at a gas station for one whole week by his mother who was reported to be a drug abuser. He, unlike many of the other 6 year olds I had encountered was extremely withdrawn and would not utter a word to me. When asked a question, he would look at his caregiver as if to ask for approval and then shy away from giving an answer. He was dressed in the nicest clothes he probably possessed, shiny, black dress shoes, a white tank top, and beige slacks but hiding underneath it all were numerous large scars, probably from years of neglect and abuse. One could only assume, since his story was still a mystery that he will hopefully feel comfortable talking about one day.

 Honduras Week 3

I can’t believe this is our last week in Roatan. Time passed a lot faster than I anticipated. This week, I realized that most patients come to the clinic with a preconceived notion that every ailment will be treated with some form of medication, often antibiotics. This notion is probably perpetuated by the liberal use of antibiotics, often for the common cold. Therefore, explaining to patients that their child had a viral illness had to be followed by discussing why antibiotics are not needed and the risks of using OTC cold medications for young children can cause more harm than good. Despite this, a few patients were disgruntled and will probably not return to me if they had the choice. When Neelu and I spoke with the clinic attendings, they were on our side and agreed that they would probably not give antibiotics but sometimes it’s hard to tell if the child will progress to a bacterial infection and was not preemptively addressed at their only point of care. There is also the concern that patients would lose faith in the clinic and go to another doctor who would readily prescribe a medication that may pose more risk. Indeed it’s a hard decision, but Dr. Solis, the clinic pediatrician, appreciated our feedback. I have a great deal of respect for him and the other doctors at the clinic as they are highly skilled practitioners with a great deal of experience. It will be hard to say goodbye but I look forward to going back home.

Infant getting nebulized treatment for an asthma exacerbation.

Week 2 in Honduras

2/21/12

Posted by Neelu Ghaderi, MD (a third year pediatric resident from Kaiser Permanente, Oakland) currently serving a global health elective in Roatan, Honduras at Clinica Esperanza.

Hadia and I just completed our second week at Clinica Esperanza.  Our attending pediatrician was gone for 4 days (as there was a ventilator course for the new pediatric hospital) so aside from a family medicine attending with a rather busy schedule, we were on our own.  The most interesting case I saw this week was one I was relieved that I consulted him on, as it turned out to be a case of Strongyloides!  We also saw a case of Chickenpox this week; unfortunately families are told their kids “have had all their vaccinations” so this girl’s mother was puzzled as to how her child developed chicken pox when she had been “fully” vaccinated.  We later discovered after talking to our attending that the place she was immunized at doesn’t carry the varicella vaccine even though it does exist on the island.

It’s impressive to me how many children we see for colds and other viral syndromes when families are waiting so many hours to be seen.  I’m told some families come in as early as 5:00 AM to get a spot and the earliest we start seeing patients is 8 AM.  By the time we show up to work, the indoor and outdoor waiting areas are pretty full.  After learning more about the prevalence of mortality from pneumonia and diarrhea in developing countries, I now have a better understanding of why patients must present for what seem to be rather benign illnesses.  Interestingly, one of my families presented again this week after I saw them for a URI last week.  She said she took her baby to the hospital for her 6-month vaccines the prior day and they said the baby had noisy breathing and was too sick to receive the vaccines.  They sent her home with loratadine and PO albuterol!  She did not feel comfortable giving them and returned to see what our thoughts were, at which time the baby sounded great and was afebrile; we advised against either medication and to proceed with the vaccines the next day.  Fortunately, Honduras has been quite strict about making sure children have their vaccines so we don’t have to really convince families to get them done(especially since we mostly just carry the flu vaccine for high-risk individuals and have to send them off-site).  It felt nice to know she trusted us and didn’t want to give her child any medications she was unfamiliar with without checking with us.

This week there is also an Emergency Room doctor from the US  who visits the clinic about half of each year so it has been nice to see what his take is on some of the local practices.  I also enjoy working with the pediatrician and having the chance to exchange stories about how we each manage certain conditions in our respective countries and teaching each other our respective languages.  I continue to learn about alternatives for medications we would like to use but don’t have; fortunately many rather young kids swallow pills out here but sometimes we have them just crush the adult pills if they can’t.  We also can send them to a pharmacy with a prescription if it’s something we don’t carry but they may not be able to afford it.

We just had our second and last weekend to enjoy the beautiful island; it has been rather hot and humid but fortunately it looks like the rainy season is finally over for the year!

Week 1 in Honduras

2/12/12

Posted by Neelu Ghaderi, MD (a third year pediatric resident from Kaiser Permanente, Oakland) currently serving a global health elective in Roatan, Honduras at Clinica Esperanza.

Hadia and I have just finished our first week on the beautiful island of Roatan, Honduras.  We are working at Clinica Esperanza, or “Ms. Peggy’s clinic” as it is often better known on the island, referring to the nurse whose vision it was to create a clinic for the underserved residents of Roatan and has worked very hard to make it a reality. While the outpatient clinic opened nearly 5 years ago, a new pediatric inpatient unit has recently opened and this week 2 patients were admitted for dehydration; prior to that, the closest inpatient unit was within a hospital that does not even have running water.  There is also a newly opened birthing unit, where there was a successful delivery this week.

Managing a clinic with limited resources has been challenging yet educational, as I have to often seek alternatives to my usual care.  Sometimes I cannot offer an immediate solution as it requires a service not offered at our clinic(or possibly the entire island!) or one that exceeds the patient’s ability to pay for it.  Clinica Esperanza has definitely exceeded my expectations; I have found a much larger range and quantity of medications available than I had expected to and we have a visiting lab tech who performs simple lab tests as well.  We also have the luxury of having a basic electronic charting system, though they are still working out some kinks.  As the pictures had suggested on their website, the clinic is clean and has nicely painted walls (with otoscopes/ophthalmoscopes mounted on them in both of the pediatric rooms!).

There are many Honduran patients(of whom the great majority do not speak English) and some English-speaking islanders as well.  Many of the Honduran patients come from a nearby village of about 4,000 people referred to as “La Colonia,” where immigrants from the mainland live with limited water and electricity.  The clinic has a Honduran pediatrician, Dr. Solis, who is very friendly and available to answer questions about the local practice of medicine.  He doesn’t speak much English so, while I am rather fluent in Spanish, interacting with him and my patients has helped me better learn how to think and communicate in medical Spanish. I have also been learning tropical medicine and becoming quite familiar with patients wanting to “desparasitar,” a frequent chief complaint that wins them a dose of albendazole and often a one-month supply of multi-vitamins.  On Friday alone I had 2 patients with GI parasites(either seen by the parent or confirmed on labs)! 

Living about 10 minutes away from our clinic has really taught me how much we take simple things like roads for granted, as we often end up taking taxis for only part of our route given how rough the roads are.  There is one major paved road to clinic and the rest is dirt roads, which have been a bit challenging between the tropical rainy weather we intermittently experience and ongoing construction.  I feel grateful to have running water and electricity at both my home and in clinic.

It has been an exciting trip so far and we have found the people here to be very friendly and welcoming; I am looking forward to seeing what the next week holds in store for us!

One of the children in the inpatient unit just prior to discharge.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A baby I saw in clinic (but whose adorable laugh I was unable to capture on camera).

Honduras, Week 1

2/15/12

Posted by Hadia Siddiqui, MD (a third year pediatric resident from Kaiser Permanente, Oakland) currently serving a global health elective in Roatan, Honduras at Clinica Esperanza.

Naturally, I get a bit nervous when I am about to experience something new. So when I embarked on this journey, to a country I knew little about and my very limited Spanish, you could say I was a little apprehensive. However, as soon as Neelu, my co-resident and I arrived in Roatan, my mind was placed at ease when we were greeted by a smiling, energetic Ms. Peggy, who had an air of confidence that was contagious. As Ms. Peggy, the founder of Clinica Esperanza drove us to our residence, I tried to acquaint myself to this beautifully lush island, which has one main road running like a spine from one end to the other end of the island. The dirt roads that branched off the main road told a story of their own. Ms. Peggy’s home was off the main road in Sandy Bay, which was a humble place nestled in an impoverished neighborhood. We were greeted by small children running barefoot alongside our truck. Everyone seemed to know Ms. Peggy and their gratitude was apparent in their demeanor towards us, thanking us for being here even before we had set foot in the clinic.

 The next day, Neelu and I took a taxi from our residence on the West End, which was quite the rugged ride as it made its way through the bumpy dirt road, ridden with mud puddles from the sporadic downpours, to the clinic. After about 10 minutes, we were dropped off in front of a two story maize yellow building with a long line of patients waiting in front. It reminded me of the long queue of pregnant women patiently waiting from dawn to dusk at the maternity hospital in Kabul, Afghanistan, where I had done research 5 years ago. I recalled the dire conditions in the maternity hospital where there was no running water, latex gloves, or a working autoclave to sterilize instruments. Only, I was surprised to find that this clinic was clean, had running water, electricity with a backup generator, and a pharmacy with neatly labeled shelves stacked with a variety of drugs. The exam rooms were not that different than the ones I was used to in the United States. Each exam room had an exam table, instruments needed for a general exam, a sink for hand washing, and even a computer with a simplified EMR system that had its flaws but nonetheless impressive given some hospitals in the US still use paper records. I was told that this was by far one of the best and well reputed clinics on the island.

I was given my own exam room and the day began with patients pouring in, first come first serve, many arriving before sunrise. Most of the chief complaints were not that different from the ones I see back home: diarrhea, vomiting, fever, colds, and rashes to name a few. Impetigo seems to be fairly common on the island given the humid weather, crowding, and poverty; however, I was surprised by the severity of presentation. One child had large crusted lesions all over his body. In contrast to the US, many parents request vitamins and empiric antiparasite therapy. At first I was skeptical about liberally prescribing antiparasitics, but soon learned that the standard of practice here is largely experience based and seems to work well for the most part. Patients are treated with albendazole or piperazine anytime a parent asks for treatment or about three times a year to decrease the parasite load as most can be asymptomatic.

We had our first newborn on our fourth day at the new Birthing Center at the Clinica, a presumed 37 weeker with shoulder dystocia who was delivered by significant traction on the left arm. Neelu and I were asked to assess the infant. Fortunately, the infant was vigorous with reassuring APGAR scores and without any concerning findings. It was both exciting and a relief to all to have a successful delivery. I am looking forward to learning more about the Honduran people, seeing diverse pathology, and working with the staff here. 

Me and Ms.Peggy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Me holding the newborn.