Liveblogging from Chiapas – Entry #2
09.24.06
Well, after a day of travellers diarrhea, I´m more or less back on my feet, so I thought I´d try to send a blog. We´ve now been in Altamirano, Chiapas, Mexico for 1 week, and we have another week to go. Following is a description of some of the cases that I´ve seen with some reflections interspersed.
23 year old lady with 6 months cough, white sputum, and severe weight loss. Previously she weighed 50kg, and on admission she weighs 27kg. It´s not uncommon to see ¨healthy” people with weights of 35-45 kg. And most of the people we see (especially women-I suspect girls don´t get the same nutrition as boys here) are short. Anyway, this lady had tons of bugs on her AFB (they call it “BAAR” here) and a chest xray with a whole bunch of cavitary lesions. I´m generally relieved when people are diagnosed with TB because it´s treatable, and we can test and treat families as well to control the disease. “Up to Date” describes TB as a “social disease” related to cramped living conditions, lack of air circulation in homes, etc. and I think that´s a valuable way to think about it.
18 yo G1 at 38 6/7 wks presenting with 1 day of vaginal bleeding, some fevers/chills the day before presentation. Heretofore an uneventful pregnancy and her fundal height is 35cm (which is much better than most gravida patients at this stage here) and estimated fetal weight of about 3kg (again ¨healthy¨ for Altamirano). Unfortunately, I was unable to doppler fetal heart tones, and I didn´t see any spontaneous movement or cardiac activity on ultrasound on an otherwise well formed fetus. I had a nun who does ultrasound here confirm my findings, and we admitted her for labor and delivery of IUFD. She was already 100% effaced and about 7cm dilated-when I ruptured her membranes, dark black fluid was obtained. Unfortunately, i missed the delivery because I was vomitting in the bathroom, but I´m told it was a normal looking baby aside from being in demise. I´m wondering why she had such a sudden turn for the worse. She denied itchiness, so I don´t think she had cholestasis of pregnancy. Gilbert suggested antiphospholipid syndrome. Unfortunately, they don´t have resources here to do detailed lab workup for these kinds of things, so it seems unlikely we´ll have a definitive diagnosis. This is the third IUFD (intrauterine fetal demise) that I´ve seen here, and it seems like the families usually want the baby and placenta to bury it and maybe have it baptised as well. There was one IUFD at 22 weeks where the fetus looked considerably younger than that and the grandma was sad that we couldn´t tell the sex of the baby.
34 yo man with several months complaining about dyspnea, dizziness, and palpitations. On exam you could appreciate regurgitant murmurs over the pulmonary valve, at the right sternal border (b/c of cardiomegaly) and at the apex and axilla. He also had frequent premature contractions and an old EKG with Atrial flutter. Most remarkable on exam was a visible PMI 8cm below the nipple. It looked like his heart was occupying territory normally reserved for the spleen. On an old xray you can see diffuse cardiomegaly, and make out enlargement of all cardiac chambers. Despite serologies negative for Chagas disease, we think it most likely this young man has Chagas cardiomyopathy. Again, he´s not getting the detailed workup that we would do in Los Angeles. The nuns weren´t keen on us checking his iron level for hemochromatosis because that´s a sendout lab here and costs the hospital. And there´s certainly no echocardiograms here.
18 mo old with failure to thrive weighing 7kg (less than my daughter who´s kind of tiny and 3 months younger) with large ankles and wrists bilaterally (kind of looks like a puppy) and 1 large axillary node, several palpable inguinal nodes. They´re going to try to refer him to Tuxtla Gutierrez, or some other tertiary center where he can be worked up for genetic disorder or rheumatologic disorder. (after ruling out TB).
There are a whole lot of skinny, mangled looking stray dogs guarding different neighborhoods here. It can be scary walking around because they´ll start barking at you intimidatingly. I don´t suppose that the government considers neutering these animals a priority. Many houses have horses hanging out nearby and the locals use them to carry items back and forth. I don´t think hardly anyone has a car here unless they´re driving a taxi. Often, we admit people who arrive in the late afternoon from far away cuz it´s hard for them to get back home in the evening. Many houses have a special tin one-room hut where women cook and you can see dark black smoke emanating from the spaces between the roof and walls. Most COPD (they call it EPOC-enfermedad pulmonaria obstructivo cronico or something like that) here is in older women from years of inhaling fumes from these huts. Because of the recent elections here, there is a lot of political paintings on the sides of buildings. Apparently, businesses sometimes paint the political party they support on the side of their establishment. My spanish isn´t good enough to assess how tense things are right now with the official winner of the elections in question. We´re supposed to find out soon what the courts have decided. A lot of patient´s families wait in the outdoor areas between different wards, and many of the men have bandanas around their necks. I´m told that´s a sign of support for the Zapatistas. One interesting cultural observation is that whereas men are frequently dressed kind of like Americans-shirt w/ buttons, jeans or corduroyish pants, the women are generally dressed in traditional outfits reflecting their particular villages. Most women of child-bearing age have a blanket they´ve tied around their bodies hanging from one shoulder in which they carry a child from infancy to about 3 years of age where the kiddo can nurse on demand. I´m sure my spanish is improving significantly as all our notes and orders are in spanish. Many of the patients don´t speak spanish but rather indigenous langauges, and the nurses have to translate for us. Various noises you hear throughout the day and night-lots of roosters crowing, stray and domesticated dogs barking, the guy selling tortillas or something in the street squeezing a hand held little high pitched horn letting you know about his presence (at 7AM ugh!), the intermittent pitter patter of the heavy rains that happen about four times a day and last from minutes to about a half hour. Most rooves are corrugated tin and that amplifies the noise of the rains.
Except for my encounter with E. Coli, I´m having a great time, learning a lot, and enjoying working with my colleagues from Harbor.
–Mark Bunin Benor, R3 Harbor UCLA family medicine
