Today was our last day on medical rotations in Guatemala. We started the day off with visits to the hilly town of San Jose. Hilly is an understatement. It was like climbing up a sheer cliff. We saw a handful of patients including a young little boy with xeroderma aka dry skin. This little boy was the last patient we saw in San Jose and as we were walking out the door, his mother (our first patient of the day) walks back in with him. This happens time and time again. When you think you are all done with the day and you are packing up, something comes up out of left field. You step back, get ready and catch the ball to finish the last inning. Needless to say we were able to regroup, help the patient, and head back to the Naturopathic Medicine for Global Health Clinic in Panajachel.
After a quick lunch in Panajachel at our favorite lunch spot (Chef Alex), we headed back into clinic with a small team of students. It turns out that Dr. Jaun-Carlos had to leave early to head back home to his family in another region of Guatemala. So when I arrived, I instantly had 4 patients and 12 students all waiting for me. Talk about hitting the ball rolling. We had so many really interesting cases on this — our last — day that its hard to keep them all separate. The students did a great job on a patient who had chronic migraines for years. This patient could not find relief. After the care of the students at NMGH and some Cranial Sacral/Osteopathic Medicine, Homeopathy, Traditional Chinese Medicine Massage, Naturopathic Manipulation Techniques, herbs, and love, the patent left migraine free after years of suffering.
We had so many other patients but I need to talk about two of them in more detail. The first one was a patient who was seen a year earlier who never followed up. She presented with shortness of breath, edema, an aortic systolic murmur diagnostic of aortic regurgitation, increase jugular venous pressure, etc, etc. Needless to say after the student finished the entire intake and physical exam, they came up a diagnosis of Right Congestive Heart Failure. This was a textbook diagnosis and they did great. We ran a sign lead EKG and now had to work on the hardest part — the treatment plan. If we were in the US the treatment would be obvious. We would be calling 911. This is however not always an option in rural communities such as Guatemala. Another issue we needed to consider was that it was late on Friday and there was not a Cardiologist at the hospital. We also needed to consider if the patient would be able to afford the treatment and hospital stay. There was also the sheer logistics of getting the patient to the hospital. After some serious discussions we decided that we needed to send this patent to the ER. While the patient was not symptomatic (at this point) we needed more tests (echo, 12 lead EKG, etc) so after we called the “bomberos” (local EMT’s/firefighters we treated on Monday) the ambulance came to bring the patient to the Hospital in Solola.
You might remember me talking about the Diabetic patient yesterday. Well after my day was officially over, I took one student and some Community Health Workers back to the patient’s house. We found the patient in much the same position. She was lying on the bed but she was moving her eyelids more and was not covered with a blanket. We took her blood glucose and it was in the the higher 300’s. She had shown an improvement from the day before but was still at an unsafe level. I was very surprised that the family did not inject her insulin that day but pleasantly surprised that the supplements we prescribed had lowered her blood glucose down by about 100 points in just a few doses. After making sure the patient was taking all her medications, her family was preforming exercises for her, and her grandchildren were reading to her, our next step was to address the insulin problem. It seems that the patient’s family lacks the time in the morning to give her the insulin injections, so we had to change the protocol. We had to shift the injection reengagement and dose of insulin. We decided that the first injection would have to be after the patient eats at 5:30am and after dinner at 9:00pm. We changed her units and explained the consequences of hypoglycemia and how to counteract these. We also have a community health care worker going to the patients house daily to check blood glucose levels. We would have loved to be able to leave a blood glucose monitor with the patient but we didn’t have any and the patient could not have been able to afford to buy the test strips. We also wanted to prescribe a long acting insulin regiment but we only had regular insulin in the office. So we have many future plans and when we have the resources the community health care workers will make sure these are implemented. On a happy note the student with me and myself both thought the patient had more “vitality” after her homeopathic dose the day before.
While this was the last day of our clinic rotations here in Guatemala it was by far the hardest. From walking up a mountain to some serious pathology it is one day that I will not soon forget. I am going to write one more post as a wrap up so please stay tuned. Have a great night.