Tuesday, July 4, 2017

Where in the world is Ken? Chiapas, Mexico

The following post is from Ken Iserson, MD.

Dr. Iserson is an Emergency Medicine physician and Professor Emeritis at the University of Arizona, author of several medical related books and numerous medical publications.  He accompanied me, Ethan, Dr. Vivan Shi and her husband Khiem on this trip to work with Don Sergio.  Ken treated and counseled numerous patients during the past two weeks in San Cristobal and he gave invaluable insight about how we can continue assist in this wound care clinic project.

Where in the world is Ken? Chiapas, Mexico
            Mayans speaking their indigenous languages and wearing their colorful traditional dress, Zapatistas intermittently blocking roads and occupying the zocalo (central city square) [Fig 1], abandoned 8th century cities and pyramids, awesome mist-covered mountains [Fig 2], great food and a cool climate (during Tucson’s heat extremes). That does not sound much like my typical developing world experience—but it was.
            As part of a 5-person team, including two wound-care experts, I recently spent two weeks caring for severe wounds and burns, as well as other medical problems, under the auspices of Don Sergio Castro [Fig 3], in the indigent indigenous community in Chiapas, Mexico. The team, organized by Pat Ferrer, a dermatology/wound care PA who helps support the Chiapas operation [Fig 4], was mostly drawn from the volunteer clinicians working at Tucson’s Clínica Amistad, a facility for primarily Spanish-speaking medically indigent patients. It included Vivian Shi, a U of AZ dermatologist and wound care expert [Fig 5], her husband, Kheim Tran, Ph.D., a second-year U of AZ medical student [Fig 6], Pat’s nephew who will enter medical school this Fall, and me.
            As Pat noted, each day felt like two full workdays. Starting early, we first did home calls in the city and outlying Mayan communities. Working in both Spanish and one of the two regional Mayan languages, Tzeltal and Tzotzil (Don Sergio speaks both), we cared for patients in subsistence communities who were too ill or injured to get into the clinic. Typical patients included those paralyzed from accidents or medical disasters and those suffering from extensive diabetic- or vascular-induced wounds [Fig 7]. Our wound care supplies were those we could carry on our backs, sometimes hiking to get to the patient’s home.
            In the afternoon and evening, we helped staff the makeshift clinic outside the small museum used to help support the operation [Fig 8]. Patients, who were seen in the order that they arrived, ranged in age from infants (usually suffering burns from hot water boiled over open fires) to the very elderly [Fig 9]. Some injuries were minor; others required weeks of daily care. The medical supplies were an amalgam of donated materials from multiple sources and those we improvised [Fig 10]; there usually seemed to be barely enough supplies to care for our patients [Fig 11].
            Don Sergio Castro [Fig 12], a remarkable man who has been doing this work for 50 years, first came to Chiapas as an agronomist. With some veterinary training, he quickly abandoned his government job to help build schools and sanitation systems, and to care for wounds in the Mayan communities. While he came from a wealthy background, he lives frugally, having spent most of his funds on his work. A blog describing his work can be found at: http://sergiocastrosc.blogspot.mx/. A fascinating 2013 New York Times video about Don Sertio and his work is at: http://www.nytimes.com/2013/08/14/world/americas/in-mexico-a-healer-who-asks-for-nothing-in-return.html?pagewanted=all&_r=0.
            Over the years, many clinicians and groups have assisted him. Pat Ferrer has helped him financially and on-site for many years. On this trip, I had the opportunity to assist in an ongoing, sustainable effort for an indigent population. As a side benefit, I was able to learn a great deal about wound care from experts—and, of course, the weather was great!

Fig 1. Zapatistas occupying the San Cristobal zocalo

Fig 2. Mountains surrounding San Cristobal, Chiapas

Fig 3. Don Sergio Castro caring for burned child in clinic

Fig 4. Pat Ferrer, PA, caring for ulcers in paralyzed patient in his home

Fig 5. Dr. Vivian Shi examining woman with gout in clinic

Fig 6. Kheim Tran, U of AZ MS II, blocking large leg wound in clinic

Fig 7. Dr. Ken Iserson examining girl during home visit

Fig 8. Dr. Ken Iserson working in Don Sergio’s clinic

Fig 9. Typical open-flame kitchen—the cause of many burns

Fig 10. Anita, RN, making medication powder with hammer

Fig 11. Vivian, Ken & Edit (nursing student volunteer) treating man’s extensive burn in clinic

Fig 12. Don Sergio Castro and Pat Ferrer, PA, treating elderly woman’s infected foot at home

Post written by Dr. Ken Iserson, posted by Patricia Ferrer.

Thursday, June 29, 2017

San Cristóbal de las Casas

Tourism in Mexico is down, including San Cris. Usually, North Americans vacation at the Mexican beaches and don't realize the beauty of the pias adentro, country inside.  More than 60% of Mexico is 5000 feet above sea level and there are numerous old colonial cities throughout.

San Cris epitomizes all the charm of Mexican colonial cities. It is over 7000 feet above sea level, has historical landmarks, and el centro is a tourist mecca with shops and restaurants and tour agencies. The downfall is it's not so easy to get to.  Coming from the US you have to fly into Mexico City, then to Tuxtla Gutierrez, then take a taxi or bus 1.5 hours up into the Highlands.  From Tucson, I'd be thrilled if I could get here in 12 hours, however it is usually an average 15-hour day of travel.

Despite the 3 plane rides and taxiing here, its worth the visit.  The climate is cool in the evening and early morning, the sun is brilliant and strong during the day and right now we are getting afternoon showers. The flora and fauna are a mix of pine forest, similar to the Pacific Northwest, with desert cacti and agave plants. The local Mayan wear their traditional and fashionable textiles daily and you can learn to recognize which outlying village they are from by the clothes they wear.

El Centro has colonial structures including elaborate churches from the 16th century.  Even older Mayan ruins; Toniná is 2 and a half hours away and if you want a full day excursion you can go to Palenque, one of the most impressive ruins in Maya Mundo. To learn about the local Mayan textiles and culture, Don Sergio's tour is a must, however, he will only give it if he has a larger group and there is also a nice Textile Museum adjacent to Santo Domingo church. (If you do go to Don Sergio's tour, please donate generously - reading this blog will inspire you.)


Atop of Toniná.

Lastly, Bela's Bed and Breakfast is the most charming place to stay in San Cris. For me, this is my San Cris home. The rooms are decorated with local artesanía textiles and crafts and I get to feast my eyes on a beautiful garden and planted succulents when walking downstairs to the salon for breakfast al gusto that always includes fresh squeezed orange juice. Last year Bela added a room with a loft that has a king bed on the bottom floor and 2 twin beds in the loft, perfect for a family with 2 children. The beds are so comfy and the location is perfect: in the el centro zone and one block from the Santo Domingo Church and market.

If you are looking to get off the beaten 'gringo path', but not too far astray, San Cristobal de las Casas is definitely worth the visit.

Posted by Patricia Ferrer.

Monday, June 26, 2017

Learning from Each Other = Making Progress

June 25, 2017

As our time comes to a close, our connection with Anita and Edith continues to bond.  They are receptive to our ideas that make sense and are interested in us showing them how to make wound care solutions from locally available inexpensive products.  Most importantly, we are receptive to listening to their needs.

Anita, Edith and Ethan.
A former visitor and wound care physician Scott Bolhack has been a constant resource for this project over the years and sent me the recipes for these homemade wound care solutions. Bela had most of the ingredients, I simplified the recipe, and Ethan translated the recipe for Anita and Edith.  We gathered in Bela's kitchen and went to work.  There were a few experimental mishaps but we managed to do what we wanted.  Vivian's and Ken's idea of making iodine gel was also helpful and with adjusting the recipe we were able to make homemade iodine gel.

Anita, Edith, and Ken.
 Anita had told us that she has used the vinegar solution before helps considerably with many wounds. However patients complain of pain as the vinegar solution burns.  Ken talked with Anita and Edith for a while showing them how to apply hypnosis to help people through the pain. As I watched him I immediately recognized that Don Sergio performs the same method but without telling the patients what he's going to do; he just slides into and it works.

Posted by Patricia Ferrer.

Saturday, June 24, 2017

Coletas Voluntarias de Don Sergio

Local Volunteers for Don Sergio

The following is an interview with Edith and Anita given by Ethan. They are local volunteers and come most evenings when they can, Don Sergio trusts them and they trust him. They work together quietly saying very little as everyone knows their place; it's zen-like.

Interviewing Don Sergio's Volunteers - Ethan Hartman
In the great body of every healthcare setting, nurses are the backbones and hearts that keep it running. In the case of Edith and Anita, this is no exception. Both of these young women are coletas, or locals to San Cristobal de las Casas. Together with Don Sergio Castro, they have treated hundreds of wounds, burns, and ulcers of the indigenous and marginalized Mexican people of Chiapas. They have seen numerous people living with pain, needing treatment, dealing with loss, and experiencing recovery.

Anita Torres, Enfermera

Anita: Registered Nurse
Languages spoken: Spanish, Tzeltal, Chol. Learning: English.
Age: 29
Years of school: 3 years of school and one year of service.
Years in practice: 4
Ethan: What inspired you to become a nurse?
Anita: Well, I felt a need to help people, attend to people who need it the most, and provide the appropriate care.
E: What changes have you seen here in the clinic of Don Sergio?
A: It’s difficult to say. There have been so many changes since we started. I’ve been doing this for four years, and I’ve learned so much.
E: What have you learned?
A: Almost everything I know--we know-- (looks towards Edith) we have learned from Don Sergio. School taught us enough, but Sergio taught us the things that are most useful.
E: Wow. So, what are your plans for the future.  
A: Well, I hope to one day work in surgical obstetrics and gynecology.
E: That takes such dedication, I really admire that drive. I could never handle those hours.
A: Of course! You really have to love it or else it’s not worth the time commitment. Me, I just love to clean and debride wounds.

Edith Jimenez, estudiante de enfermera.
Edith: Student of nursing
Languages spoken: Spanish. Learning: English.
Age: 21
Current year: Second year.
Expected graduation date: July 2020  
Ethan: What inspired you to get into medicine?
Edith: Well, I would have to say the same as Anita. I just wanted to help people. I saw a lot of people who needed help. You know, out in the communities there are not many doctors and the people who live in those communities are the ones that need the most help. I would like to work in those areas that really have nothing, so I can make a difference.
Ethan: How long have you been working with Sergio and what have you learned?
Edith: I’ve been working with him about 3 years. Just like Anita, I’d say I learned most of what I know from him.
Ethan: You had told me that you wanted to go into surgery as well. Were you thinking of general surgery?
Edith: Yes! ….well no… (everyone laughs)…actually I am really interested in Cardiology. I may actually go back to medical school eventually for that.
Ethan: That is outstanding.
Edith: Thank you! So what do you want to specialize in? General medicine?
Ethan: Emergency medicine.

From there we discuss the proper pronunciation of “Emergency room” in both English and Spanish, and we laugh at each other’s’ accents throughout the rest of the evening.

As I think back to the times I have come to San Cris, I am always impressed with these young women. These women have strong minds and even stronger hearts that are capable of overflowing with compassion for other people. As I meditate on the future of this long-term project, I can see that these girls are going to carry the torch of change they wish to see in the world.  

Ethan Hartman

Ethan Hartman is my nephew who was accepted to University of Central Florida Medical School in Orlando Florida, he will be starting this August. This is his 3rd trip here and he usually stays a week or two longer after I leave.  Being their contemporary (they are all in their 20s) they all enjoy each other's company and learn from each other. It is my hope they continue to build a bridge that benefits them, Don Sergio and especially the people of the Highlands of Chiapas.

Posted by Patricia Ferrer.

Friday, June 23, 2017

Suffering and Service

June 23, 2017


Every visit I see someone who has suffered from an injury or problem that touches my heart deeply more than others.  This visit's story is of a young man of 23 years old who was working in Teopisca (30 minutes from San Cris) that was electrocuted while at work.  The electricity went through his right hand and out both feet on the outer sides and blew off his left great toenail.

His feet are healed but his dominant right hand was severely damaged. He lost his right index/pointer finger and part of the electricity came out his wrist.  He went to the hospital and when the doctors tried to stop the bleeding they cut all his tendons in his wrist leaving his already damaged hand completely useless.  The wound created by the injury and the surgery has healed, albeit slowly, thanks to Don Sergio's care. However, his arm bone remains exposed which will lead to eventual osteomyelitis and it is possible the skin will close over it, but possibly not.  In the long run, the best thing to do may be amputation of his hand, which still has some life but it does not move, grasp or contract. The right hand is left in a semi-grip state.

Caution looking at the photo below.

This bright energetic young man's life is significantly altered. When I see suffering like this, I think this could be me or a loved one and it reminds me how privileged I am to be a healthcare servant to humanity and I could not ask for a better role model than Don Sergio and his volunteers Anita and Edith.


When choosing a career in healthcare and to work in underdeveloped areas of the world we need to explore the reasons we do this.  Is this to have the 'unique' experience to see conditions we normally don't see in the US?  To work in challenging conditions and finding ways to improvise and test our mettle? To help those already drowning in the overwhelming number of patients? To elevate our own status in others eyes? Or is it out of guilt for feeling you don't do enough in your daily life? Or guilt for having such a good life?

Regardless of any answer, when coming here our own personal gain needs be left at home, egos stripped, and desire to push our knowledge on those doing the daily work suppressed.  It is we who need to listen and learn in order to help and serve.  Those here have to accept us first and see our dedication is to help them. We need to respect them, use caution in implementing 'what we would do' and not take more of their already expended energy. Attitude and action speaks more clearly than any medical or clinical jargon and is better understood by all. Once a connection is made then slow implementation of what could benefit their treatment(s) will be accepted.  I am so grateful and privileged to have learned this from humanitarians I have known in my life time and to serve along side them.

Sergio directs and helps Anita debride slough from a burn injury.
Posted by Patricia Ferrer, PA-C

Wednesday, June 21, 2017

Schools, Solar, and Wounds

June 21, 2017

Our day started late as Don Sergio checks on a school project prior to our house rounds. Today he took us to another school where teachers are requesting his help to build a protective wall to keep the thieves from stealing from the school, create a garden, build a porto coche to protect the kids from the rain and prevent the ground from becoming saturated and a fall hazard. They would like to have their own electricity because now they piggy-back electricity from a nearby house.

Kindergartners happily in school.

Someone cut through the wire and stole kindergartner school property.

This wall extends about 40 yards and they want to replace the fencing wire with blocks.

Here they want to prep the land for a garden to grow fruit trees and have a natural place for children to play.

The black gate is the entrance. When it rains the ground becomes loose and muddy, they would like it covered and paved.

They have latrines, which is not always the case for all schools.

Our second stop was another school Sergio has been working on for 8 years. It is complete thanks to many foreign donors over the years. The latest addition is solar power so they don't have to plug in to the city electricity.

           This is the first solar installation in San Cristobal, thank you TOGETHER SOLAR.

Part of the school complex, you can see the blue solar panels on the middle building.

The kids have light for those dark days (lights on only for show, it is light enough outside at this time of year).

A special room was created to lock up the solar storage batteries.

Young school girls chat with Vivian.

The kids crowd around Ken as he passes out stickers and chats with them. The kids loved this!

                                           A SPECIAL THANK YOU TO TOGETHER SOLAR
Project Summary:  Together Solar, in collaboration with Yok Chij and IF, are proud to have developed a charitable solar micro-grid in Cinco de Marzo Elementary School in the state of Chiapas, Mexico.  Chiapas is Mexico’s poorest state, with significant unmet needs for life’s necessities, including energy.   Cinco de Marzo Elementary School serves over 300 students who are mostly indigenous and speak a Mayan dialect as their primary language.  Our solar micro-grid provided the school with electricity to power their lighting, school equipment like projectors, and a water pump that brings fresh drinking water to the school.   Batteries ensure that the school has electricity at night or when the solar system is not producing.

About Together Solar:  Together Solar is a mission-based company, dedicated to alleviating global energy poverty, and to expanding solar energy access.  We are focused on leading the urban community solar space, where we build large solar installations on commercial rooftops within our target cities, and sell the energy output to nearby residential customers who have not traditionally had access to solar since they often live in rented apartments, condominiums, or co-ops without adequate rooftop space.  For every kilowatt of solar that we develop, we donate at least $10 of critical infrastructure to communities in need.

Morning house rounds include an elderly diabetic woman whom Don Sergio amputated 2 toes and now a 3rd is becoming necrotic.  The hospital wanted to amputate her foot but she declined, now, even with wound care it is obvious she needs a below the knee amputation otherwise the infected foot and toes will progress.  People are very resistant (anywhere in the world) to have an amputation. However, her long term, poorly controlled diabetes, most likely caused from lack of awareness, inadequate healthcare and patient education, and inability to afford medication all play a role.

Patient number two was an anxious woman with a solitary ulcer caused from an injury a few weeks ago. Basic wound care will help this lesion to heal. Don Sergio had one more pt to see but he usually goes on his own.

Evening clinic a young boy suffered a 1st degree hot water burn on his left arm.

The afternoon clinic was busy. A 63 year old Zinacanteca woman has a 10% body surface area burn with 1st and 2nd degree burns. She was carrying a pot of hot coffee and fell and the pot contents fell on her; older skin burns easily and it penetrated her clothing. We then had the typical venous stasis ulcer patients and other wounds and patients seeking consult with Dr. Iserson.

This lady has a large tophus secondary to high uric acid levels (aka gout).
The evening's most challenging case was a man that had fallen backward into a fire and severely burned his back several weeks ago. Debridement is very painful and understandably we US medical providers want to use lidocaine and aggressively debride (scrape away dead tissue). However, if we were to do this, we do not have the resources for post pain management and we do not want to leave Don Sergio dealing with a patient in severe pain.  This case, and the older woman, would definitely be cared for at a burn hospital in the US.

Today, the area needing debridement on the man's back revealed nature doing wound care: maggots.  The dead debris on the patient's back was infested with maggots which is not necessarily a bad thing.  Maggots eat the dead skin debris leaving normal skin alone and suppress the immune system (in turn reducing inflammation) and naturally help the wound to heal. However, continued manual debridement is also a good idea and Don Sergio had Anita gently remove what she could today. The patient will return tomorrow.

This poor man has a deep 2nd degree burn on 30% of his back.

Posted by Patricia Ferrer, PA-C