9/21/09 The clinic at last.

I got an e-mail from someone who's been reading my Pop Wuj journals, asking essentially, “What is this, some sort of initiation before you're allowed to do the work you know how to do already?” And in a way it is. The Cultural Competency lectures were invaluable as well as riveting. It's not enough to know a right way to do something. It has to be a right way in a given context. And a week isn't nearly long enough to grasp the context of a way of life so different from my own. It's just enough to help me grasp how much I don't understand, but that in itself is a good beginning. Last week was a hectic one since Sept. 15, El Dia de Independencia, is really at least a week's worth of parades & a fair. Sadly, we missed two Clinic days because of the holidays. Also, there are 5 or 6 medical volunteers who have been here for a couple of months in addition to the 3 of us, fresh from Cultural Competency, all looking for somewhere to help. As it happenned, the others all left after an hour & a half for a field trip, & we were understaffed. Pop Wuj Clinic is now housed in the aged school-building itself, taking over a large lounge area which isfor the intake area where volunteers take a brief history & measure weights & blood pressures, (no temperatures because there are no thermometers.) The Clinic also utilizes 2 small adjacent rooms which are locked when not in use. The first serves as the rudimentary exam rooms, divided in half by a screen. Of course, to get the second half, you need to avert your eyes as you walk past the patient in the first half. The second room is a remarkably wellsupplied pharmacy, albeit with an excess of Lotrimin AF & hydrocortisone cream & slim pickings of liquid antibiotics. The only sink in the area is in a decrepit bathroom & emits a trickle of cold water. I haven't wanted to dry my hands on the adjacent bath-towel. I've brought a supply of antibacterial wipes, & there is already a container of Purel that I saw used sporadically. Nobody seemed as horrified as I was by the lack of hygiene. The doctors, however, are a pleasant surprise. One has been involved for quite a time but has dropped back to an hour a day because of his own practice. The other is a young woman who is there for all 3 sessions. She does not have a practice of her. She's recently married to a German & leaves for a job in Hamburg in June. As we talked, I was impressed with their thought-processes & struck by how little our overall approach to medicine differed. At the end of a visit, they write directions for medication, and the patient takes the note to the “pharmacists,” a bunch of nervious volunteers trying to find the called-for medication on crowded, cluttered, dusty metal bookselves. The medications are varied, some in English, some in Spanish, in numerous strenghth & assorted package sizes. Many are whatever our friends didn't need, sample-sizes of infrequently used, odd drugs,that the reps were pushing. When don't have what we need, we rummage around & make do with whatever substitute is available. (For instance, I saw a 22 month old boy with an ear infection who had failed to improve with amoxicillin. Amoxicillin is the only liquid medication we had. I suggested a prescription for augmentin, but they were so concerned about the cost that I sent them home with three 250 mg Zithromax tablets to crush & give him daily. (It's reminiscent to what I tell my patients,”Brand A is my first choice for these reasons, & I'll give you a prescription for it, but if the pharmacist calls to tell it's not on your formulary, I'll prescribe something that is.”) The patient mix in small sampling I've seen similar to ours over-all, colds, gastroenteritis, allergies, asthma, urinary tract infection with a smatterring of patients I'd waste no time in referring. They care for a severely burned 10 year old girl & a woman whose ulcers look gangrenous to me. They managed the admission, evaluation & surgery for a 15 year-old with a large unrepaired myelomeningacoele

(spinal bifida) whose decubitus ulcers have become infected & are further lessing her quality of life. Pop Wuj is associated with a midwife in an outlying Mayan community with whom I visited yesterday. In the course of a busy morning, she care for numerous pregnant women including 2 who should deliver in the 2 days. (Dona Anna has delivered over 1400 babies.) The mother of one delivered 2 months ago was still bleeding & received a shot of Vitamin K, flagyl & an antibiotic. This was a recurring pattern here as well as the Clinic. She administered a depro-provera shot to a woman who appeared to be in her forties. She also confirmed 2 pregnancies. The first of these is a 15 year-old (still dressing in traditional clothing, but wearing lightly. beautifully applied made-up) who has been denying any possibility of pregnancy to her mother for 4 months. The second was a young mother of four, now 4 weeks pregnant. Her husband has been an illegal worker in the US for 4 years, & she would have liked to have an abortion, but Dona Anna told her sadly that is illegal & impossible. But Dona Anna's practice is not limited to OB/GYN. The morning we were there she saw a several. children as well. But the saddest case we saw was a aged, frail, emaciated women brought in by four of her concerned adult children. For 2 weeks But there are significant differences in methods of practice. Patients routinely leave with a bag of 3 or 4 medicines, virtually always including an antibiotic unless the presenting problem is hypertension. Dona Anna gave intramuscular antibiotic injections to a few of her patients as well as sending home oral ones. More surprising to me than that though, is the paucity of physical examination. The Mayas are modest & don't care to undress before strangers & little effort is made to encourage them to do so. My first morning I hunted down a rag & scrubbed the settled dust off of the exam table, only to find that it was never used. Patients were examined around & through their clothes, often seated in a chair. The first patient I observe was a 14 year old girl with a recurrent cough through-out her life. She was currently on singulair & albuterol. She had taken several courses of antibiotics & and improved with each of the but was never well. Several days after completion she worsened again. The doctor explained to the family that in addition to asthma (for which she added a controller, symbacort, to her routine) she might have a chronic sinus infection. Rather than palpating her sinus (which I later found to be tender) she gave her a requisition for a sinus x-ray, & when she returned with it several days later at the next Clinic, she treated her for 21 days. Especial in light of the poverty of most of patients, I don't know why she didn't treat her based on history & physical. Addendum 9/25/09 Today I had the opportunity to observe the other doctor with a couple of other patients while I was waiting for pediatric patients to check in. He was very thorough, did fairly full exams & a superb job of explaining the disease processes & management plan as well as reenforcing necessary life-style changes.