Pop Wuj Clinic

Here I am, back from my first shift as a doctor in Guatemala!

I had a ton of fun working in the Pop Wuj Clinic. I got to do what I love -- medicine somewhere totally new. All the staff (ie- med student volunteers, a guatemalan doc and one nurse) were super friendly. I have to say, though, the gem of the experience yesterday was the patients.

These are people from a wide cross-section of guatemalan life. I had a 24 year old woman who hasn´t had a menstrual period in a year and is desperately trying to find out why however she can´t afford the neccessary lab tests.

An 11-year-old boy who looked about 8 was brought in by his school teacher for concern of malnutrition. The school was concerned and had been saving for 2 weeks to have enough money to pay the 20Q ($2.50) fee to be seen in the clinic. His family did not know the school was bringing him.

An affluent woman who refused to take the free meds from the clinic -- she said to keep them for those who need them. She would buy hers at the pharmacy if I would write down what she needed.

My favorite patient of the day was my last. At the end of the morning a single couple still sat in the waiting room -- an old woman in tradition al Mayan dress accompanied by a younger woman in a T-shirt and Jeans. It would be difficult to exemplify the changes Guatemala has undergone in just 1 generation better than these two did.

My patient was the old woman. She was weatherbeaten and deeply tanned with dry, leathery skin. Her face was beautiful -- wrinkled and wide open with bright, laughing eyes and a constant smile. As soon as I call her into the exam room, she smiles, hugs me and kisses my cheek. She is tiny -- barely 4´6" and was wearing the traditional layers upon layers of brightly colored mayan dress and her hair was in long pigtail brains with ribbons hanging down her back. She should have been on the cover of a National Geographic.

Despite the differences in their appearance, the woman and her daughter were the same. Smiley, laughing, open people with significant caring for each other and those around them. They were a pleasure to muddle though my spanish with.

Fortunately her complaints were simple -- I diagnosed her with arthritis and a corneal abrasion. Ibuprofen, eye drops and out the door. I asked her to return in 2 weeks for a check of her eye -- I look forward to seeing her again. Her memory is one of guatemala I will cherish always. My beautiful laughing mayan grandmother.

http://www.pop-wuj.org/medical-spanish/medical-spanish.html#PopWujMedicalClinic

Destination: guatemala

Hi all! (or no one considering how long it has been since my last post)...

I decided that it was time to re-visit this whole blog concept. Lots of things happening in my life. Getting married, becoming a senior resident (scary!) and currently spending a month working in a clinic in beautiful Guatemala.

At the last minute in a five-week rush I managed to arrange an away elective at a medical clinic in the city of Quetzaltenango (Xela). The clinic is located at a spanish language school called Pop-Wuj. Xela is a city located in the mountains of Guatemala about 4 hours by bus from Guatemala City.

In fact, let´s start there. THE BUS. My introduction to life in Guatemala. A smoke-belching old-style greyhound. Comfortable enough to sleep on, yes? ... until you put it onto a guatemalan mountain. And give it a driver who doesn`t like to shift gears. As we went careening up sides of mountains and down into valleys around classic 180-degree turns there was no sleeping, just lots of falling over. On the few and far between straightaways rather than shift up and then down again, the drive just ploughs ahead and the whole bus shakes. Not a little tremor. You know that dance move where you shake your shoulders so your boobs fly back and forth? The boobs, they were a flyin´. Halfway through the trip I also discovered that the seat part of my seat was not attached to the back part. Added entertainment. However, we got to Xela in 3 hours instead of 4.5, so no overall complaints.

The bus ride was also amazingly beautiful - driving through little town and small cities, up into the clouds and then back out again. Women walking along the side of the road in brightly colored mayan dress. All beautiful.

Xela itself is a city known as the cultural capital of guatemala. There are literally innumerable spanish schools here as well as the two largest Guatemalan universities. Overall, the people who live here are very well off- no chickens or goats in the yard, cars, electicity, hot water, extra rooms in their houses to put up visiting spanish students such as myself. There is even a Wal Mart here in Xela (more evidence of america poisonning the world).

I am staying with a family which is... interesting. We`ll leave it at that for now. They are very nice and have been nothing but extremely hospitibal. The matriarch of this three-generation family was quietly waiting for me in the kitchen upon my arrival and promptly sat me down for a meal of rice, beans and tortialls. She also immediately noticed that I don`t like beans when I barely touched my half-plate full. Since my arrival the bean portions got smaller and smaller to the point where she doesn`t even put them on my plate anymore. Smart grandma :-). In fact, most of the time I interact with my host family is with grandma over meals in the kitchen.

Pop Wuj itself is a very interesting place. Currently it is overrun by medical students between their first and second years of medical school looking to get some clinical experience as well as improve their spanish. Other than the hired doctors (2), I am the only physician here. As a result, I was instantly asked "can you cover the clinic on Friday?" I have my army of medical students to oversee.

Pop Wuj as a school firmly believes in community service in all different forms in addition to learning spanish. In fact, all of us "newbies" have been in Cultural Competency class all week where we have been recieving lecures about guatemalan history, philosophy, mayan mysticism and traditional medicines from an AMAZING anthropology professor from one of the Universities. These are the kinds of phenomenal lecutres I wish I had in undergrad -- and they are all in spanish! With a little fuddling through and help from each other, the entire class is able to understand lecutres which jump from spirituality to quantum physics to botany all within a few minutes.

Tomorrow morning is my first shift in the clinic (as supervising physician, no less), so more on that at another time. For now, good bye!

http://www.pop-wuj.org/

Delivering babies

Let's see... what is going on in my life since last time I wrote?... I did a month of Toxicology at Bellevue hospital which was fascinating as always. I did two weeks in the Columbia ER where I got pretty effectively bitch-slapped once or twice (can always count on Columbia for that) and I caught babies for 2 weeks up at the Allen Hospital (Inwood) on Labor and Delivery. Basically, life has been good.

I wish I could regail you with "The tales of labor and delivery!" I basically walked away from my time on L&D thinking "wow, what a wasted, boring two weeks! I saw about 2 patients a day!" However, upon further reflection, I realized that I saw some very important things.

An eclamptic mother in status epilepticus seizing uncontrollably all the way to the operating room to emergently c-section her baby. She has since been in and out of the ICU twice for further complications of eclampsia.

A woman who I now have the highest respect for who did the entirety of labor and delivery without ANY pain control (and let me tell you, it was NOT an easy delivery by any means even if she would have had pain control). I'm actually not entirely sure if she deserves an award or a brisk shaking and an exclamation of "why in the world did you DO that?"

There was the "day of post-partum hemorrhage" where it seemed that every patient was bleeding uncontrollably after delivery (I got very good at calling for HemeAbate). Those are interesting. Looks like a faucet running red water.

Then there was my last day on L&D. I had a 23-week patient who presented in active preterm labor. There was no way to stop the process. The issue is this: there is a 50/50 chance of survival with all of the modern NICU technologies possibly available if a baby is born at 24 weeks. Younger than 23 weeks, there is no chance. 23 weeks is the grey zone. 10% chance of survival, only 5% chance of survival neurologically intact. As we laid the facts out for a distraught couple whose primary language was not english (we used a spanish interpreter for ALL conversations), the emotional stress began to completely block their ability to understand the situation.

Finally, they were able to make a decision, to rationalize SOMETHING out of the entire situation. The attending who had been explaining for an hour that the two options were to a) deliver the baby and provide warmth until the baby passes away in a few minutes or b) delivery the baby and intubate the baby and do everything humanly possible for a long-shot of survival. Finally the father looks at the attending and says "we want an abortion."

HUH?? Abortion wasn't even an option. The word abortion was never even SAID and yet, this was how they were able to rationalize their desire not to have the potential of having a severely disabled child for the rest of their lives (assuming best case scenario). Our jaws dropped and there was silence where we didn't know how this leap had been made. Then the husband went on to ask for us to just take our instruments and tools and go inside and take the baby out. We went through all of it again... explicitly. Mom was going to have to push the baby out. It was a delivery. She was in labor. We were NOT going to go in and take the baby out, it was coming out on its own. The family agreed to let the baby be born and pass away. No heroic measures.

An hour later we are called into the room. It's almost time. There is a new person there -- an extended family member who is fluent in english. She turns to us and demands, "What are the options? Why are they telling me that they are getting and abortion?" If I ever felt like smacking my own forehead, THIS would be the moment. The attending, however, handled the situation with grace by simply stating, "The matter is closed. We have discussed it extensively with the parents and we have agreed to let the baby pass away after it has been born. This is NOT an abortion. This is early labor." We got the interpreter again and went through it again with the parents. Their faces showed complete confusion. But then it was too late for more discussion -- the baby needed to be delivered.

I delivered at 1lb baby boy. He made a single cry and then had no further respirations. He did not move. The room was full of crying, wailing family members. They named the baby, held him, cried and screamed his name, took photos. After all the technical aspects of the delivery were completed and condolences were given, I left. I've never dealt well with rooms full of crying people. I'm a sympathy crier -- not a good trait as a physician. After the parents said goodbye, the baby was taken to the Neonatal ICU and finally pronounced as deceased 3 hours later. I filled out a birth certificate. The pediatrician filled out a death certificate and the matter was closed.

I don't know how those parents will eventually think of the events of the birth and death of their first child. Will they realize what happened -- early, preterm labor -- or will they always rationalize as somehow "choosing" an abortion at 23 weeks? If they rationalize the latter option, how many more pregnancies will they loose because they are passing on incorrect information to future physicians who may be at a different hospital and therefore not have access to our records? It is a terrible dilemma, the stress response of the human psyche.

People Watching

Something that I enjoy as a NYC resident is the so-called pastime of "people watching." Fortunately, Rob is also a world-class people-watcher and the two of us can go to a park or sit in outside at a restaurant or starbucks quietly and completely comfortable with each other watching the world go by. Occasional comments pass such as "awwww" or giggles and most often, "did you see that??"

I, however, also tend to go on a people-watching tangent. It's called dog-watching. Yes, I watch all the NYC pups go by. Take my walk this afternoon before sitting down to write this post. I was walking through a local park near our apartment and fell into my "dog-watching" routine. There was the adorable Great Dane puppy in the dog run who just didn't seem to understand play with non-litter mates yet. The Golden who, upon realizing that they were near the dog park suddenly jumped to the end of its leash to drag its owner to the run.

There was the gay couple riding their bikes on a beautiful summer afternoon -- each with a tiny chihuahua strapped to his chest. (tiny yippy chihuahuas) ... then I passed a couple carrying their CAT on a leash... kitty did NOT look happy.

One of my favorites is a woman in our neighborhood who owns two HUGE and overweight bulldogs who can barely make it around the block in the august heat. She spends most of her time futilely pulling at the leashes, then coaxing and finally tempting inch by inch with doggy treats.

The point is, new yorkers are a great bunch with hillarious dogs.

Funny stuff

So, recently I have a had a number of truly fabulous ER quotes. I thought I would share some of them... some may be funny, some may not...

"well, we come here 'cuz you got doctors good here, yo." Patient's primary language: English.

"Why are you putting in a breathing tube? He fell and his pinky hurts."
-- family of a stridorous patient being intubated for respiratory distress.

me: "are you pregnant?"
patient: "no..."
"you're pregnancy test is positive."
"I'm on birth control!"
"well, amazing things ARE happening here."
"huh?"
"Pee in the cup again."

"well, the blood transfusion raised your hemoglobin from 3 to 6."
"great! so you don't need to admit me anymore?""no..."
"so, one more unit and it will double again and then I'm ok?"
"uh, no. It doesn't really work like that. You're still bleeding. Which is generally considered bad."

"Why do I need surgery? It's just a stab wound."
"You cut the artery. That's why the blood was pumping out."
"so, you can't just give me stitches?"
"no."
"fuck."
Charge nurse: "here's your cell phone. call your mother." (patient's scowls, charge nurse raises an eyebrow and shakes the phone, patient takes phone)

In Remembrance

It has been forever since I last wrote in the blog. Many things have happened -- work, birthdays, vacations, fun times... and I plan to write about all of those, but this post is about something else.

This post is about a being very special to me -- Oscar, one of my family's cats. Born in late 1998, my family adopted Oscar and his brother, Felix from the North Shore Animal League in early 1999 and he was always a wonderful kitty. Being in high school at the time, Oscar and Felix were the first pets my family owned who were pretty solely "my" responsibility -- they lived in my room, their food, water and kitty litter were in my room and I cared for them (and dealt with them waking me at 4:30 in the morning with the now-infamous "double-pounce").

Oscar was instantly dubbed the "purr-box" or "motorboat" for his loud purr heard across the room and incessant demands for attention. Always more outgoing than his brother Felix, he was also the "smart" one of the pair (we missed on the odd couple naming).

Recently, Oscar's health had been deteriorating... he required multiple surgeries to repair problems with his colon. His kidneys were starting to fail. He was loosing weight. 6 months ago a vet recommended we put his to sleep. At that time, my family declined -- he was still running around, purring and head-butting everything as always.


A few days ago my parents called me to see Oscar -- his health had taken a turn for the worse and the decision was made that it was time to let him go. We all miss him sorely -- especially his brother, Felix, but we are all getting through. And so, I raise my glass and drink in remembrance of one fine kitty.

On Restraint (or Lack Thereof)

I'm sick.
For the 3rd time in the last month.
It hasn't been a good month in that respect.

So, I'm feely crappy. I sleep, drag myself to the shower and then decide "you know what? I'm going to lie of the couch and listen to some relaxing music." I sifted through my iPod and picked 1) August's Rhapsody from August Rush, 2) Massenet's Meditation from Thais and 3) Ravel's ballet, Daphnis and Chloe.

The Daphnis is actually what spurned this post. Maybe it's just because I was lying with my eyes closed the only task on my mind to listen to the music or maybe it was because I had a headache and had therefore tweaked the settings on my stereo to turn to volume down and flatten the dynamic range so the louds were softer and the softs louder... I don't know. What I do know is that the Daphnis just sounded so controlled -- too much in control.

A few years ago I had the opportunity to hear one of my favorite pieces, Stravinsky's Rite of Spring, played by first a professional orchestra and then the Julliard Symphony in the same month. The Rite is an incredibly challenging piece and is seldom performed by professional orchestras. It is much more common as a graduate orchestra piece -- something for the soon-to-be professional musicians to sink their teeth into and put on their resume. I forget which professional orchestra I heard -- not the NY Phil... maybe the London or the Berlin.

What struck me about the two performances was that I enjoyed the Julliard Symphony significantly more than the professional orchestra! Sure, the professional orchestra's version as technically perfect -- all of the complicated rhythms and counter-themes interlocked exactly. All the dynamics were there, the tempos were accurate and the precision of the performance was incredible. Amazing what a group of professional musicians do when they really concentrate!

The Julliard Symphony was not technically perfect -- a flub here or two. The themes interlocked beautifully, the tempos and dynamics did more than just give a professional orchestra a "run for it's money." They were professional. These were the best musicians in the country playing at the peak of their masters degree education. Here were performances by two groups who should have been on a par but, in my opinion, the Julliard orchestra blew the professional orchestra out of the water!

Why? The Julliard orchestra got excited over the music. You could feel in the crazy, fast, intricate sections that the orchestra was just one hair's breath away from flying completely out of control. The rhythms caught with milliseconds to spare almost like when you have two interlocking cog-wheels but they don't interlock well and there's that second when you say "oooh, it's not going to work" and then the wheels catch and turn to the next cog. The tempos pushed just on the leading edge of the conductor's beat with the conductor holding his students in with the sheer mental will of making them follow him instead of the other way around.

The professional orchestra, as I said, played the piece flawlessly. I cannot find any way to fault the performance but to say that during their performance, I sat back and enjoyed. During the Julliard performance I was on the edge of my seat, gripping the armrests chanting in my head "yes, yes, get that! Yes!! eek eek eek... yes! got it! go!" with my jaw hanging open at the sheer enormity of the performance I was witnessing. My head was reeling with the Julliard performance for days.

That's what classical music is REALLY about.