Wednesday, February 12, 2014

Dr. Mateo's Experience



February 12, 2014



Tucson wound care physician Scott "Mateo" Bolhack has returned from his first 'working vacation' in Chiapas.  I asked for his comments and observations of his experience....I believe this may be a bit different from his private practice in the US.






There are no appointments.

The patients come in and wait on the bench patiently.

No one complains if they are waiting and no one complains how long they may have to wait.

No one says that they are in pain. No one complains of pain.  They thank you with a kiss -- your right cheek to right cheek or handshake – always.

They are given their leftover supplies and they return the next day with the supplies for you to use.

They hold the flashlight for you.

Sometimes, the waiting families and patients who are waiting to see you hold a flashlight also.


Don Sergio's Tenejapa black saints placed behind the green waiting benches.

There are no barriers to care: no insurance, no phone calls, no confirming coverage, no appointments to make, appointments to cancel.

This is Sergio's office. You ask him for for 'permiso' to take care of a patient or he directs you to do so, so that the patient knows that he has approved.

  
The kind man with neuropathy/heal wound due to an electrical injury 20 years ago comes in. He was offered an amputation by the local doctors. Don Sergio says no [amputation] ”not necessary".

I have now worked on this man's foot every day since I have been here and every night his family comes with him. He waits patiently to be seen.

Much better;"mucho mejor" I tell him.

He comes with his wife, who wears a traditional dress. His boy, age 4, looks directly over my shoulder each evening. So small in stature, he looks like a two-year-old.

He never cries, he never winces, stares intently analyzing what I am doing. He is my little inspector.

Last evening, I held this hand and walked him over to the supply room. I handed him a soccer ball that was as large as his entire torso. Before his parents could instruct, he says open "muchas gracias".

Nadia, my special interpreter told me that the wife asked if I eat homemade tamales. More handshakes; the patient will return on Monday for further care.
-->
 
Iglesia de Guadalupe.

 This is a city filled with cultural humor.


 




It is a city of neon Guadalupe Saints, Negro Jesus Christos, and water trucks that announce themselves by playing Burt Bacharach's "Raindrops Keep Falling on my Head" (in a city where very little English is spoken). 









It is the same city in which the mannequins displaying woman jeans are turned so that you can see the buttocks.  

The Chamulas, a native Mayan population punish their prisoners sometimes by making them spiritual leaders in the community.


Chamula community leaders, photo taken 2009.

Our only accessible pain meds, although you can buy Tramadol OTC.


And so for the elderly gentleman who fractured his femur was sent home without a brace, he cannot be treated with any opiate pain medications. So that in the country drug wars and drug lords, it is very difficult to order any opiate medications for any patient in pain.







Written by Scott Bolhack, MD, posted by Patricia Ferrer, PA-C.






Sunday, February 9, 2014

The Experience of Sharing and Caring


February 9, 2014

Carolina, Dr. Mateo and Don Sergio share photos of their medical cases. The night before Don Sergio brought out a couple of volumes of photo albums: Mateo uses his smart phone. Interestingly, the wounds are just as severe in the US, but we have specialized wound care centers.

Over the past years various medical professionals have shown a desire to work with Don Sergio after hearing my experience.  We all agree on one thing: Don Sergio needs help.  Many ask, ‘ Why doesn’t he train someone locally to help’.  The answer: Don Sergio does not charge patients any fee, he feels the stress of paying interferes with healing.  Also, when a local does want to work with him, they don’t last long as they need an income to live.

Carolina debriding on a chronic diabetic ulcer.
 
During this visit, Ricci (here last week), Dr. Mateo and I were pleasantly surprised to meet Carolina. She is a nurse that works at a nursing home during the day and met Don Sergio when he came to care for one of her patients.  Over the last month she volunteers with him every Friday night and if she has time she comes more often. 

Dr. Mateo and Carolina working together.
 
At the age of 20 she shows a high level of competence, confidence, and curiosity.  She truly enjoys working with Don Sergio for the sake of learning and helping.  Most 20 year-olds would be ‘creeped out’ by the severe wounds, ulcers and burns…not Carolina..she's hungry to learn to wound care and seems to have an innate sensibility.

Juan "Juanito" Pablo and his father figure.
 Eight-year-old Juanito, Don Sergio’s quasi-adopted street son, meets us daily at the museo after school. His mother Chun, wheelchair bound since birth due to spina bifida, comes to the museo to say hello.  Juanito runs in, hugs Don Sergio, me, and Mateo by hanging on our necks, and then runs off. Don Sergio helps Chun and Juanito survive by giving them 50 pesos a day. I’m not sure if she receives government assistance, but it is clear they would not survive with out Don Sergio’s help.



My two weeks are up and it will take 12 hours to get back to Tucson: a taxi, a shuttle, two planes, another shuttle, then a 15 minute drive home.  Dr. Mateo stays on for another 4 days and will have a similar schlep returning.
 
Carolina, Pati y Mateo – nuevos amigos.
 
From the bottom of my heart, I thank all my friends from around the world that care enough to want to share the experience of their own skills, time, money and working with Don Sergio and the people of Chiapas, Mexico. 

Don Sergio has a nice following of French visitors. This was the first visit for these ladies and his work, his Maya textile collection and easy demeanor enchanted them.  A local French woman advocates her countrymen to send medicines and supplies.
 
  Hasta pronto Carolina y Don Sergio!!!


Posted by Patricia Ferrer. 

Saturday, February 8, 2014

Improvising and Modifying

February 8, 2014


There are many situations that requires one to be creative to get a job done. Today our project was to help an elderly man who had fractured his femur (thigh bone) a week ago while trying to ambulate from his wheelchair. The patient went to the hospital and was told he was too high a
risk for surgery, kept there for a few days and sent home. Our job was to create a splint to immobilize the fracture as much as possible and make him as comfortable.


Making split with school rulers.
Modifying splint for patient.

Adding cotton wrapped in Coban to prevent chaffing or irritating the skin.

Shopping for bed foam to help prevent bed ulcers.

Sometimes, this is a good as it gets.


We used an Ace wrap to hold the splint in place. It took 3 ppl to help raise the man and push the foam underneath him and with me pulling to cover the bed.  Life is not easy here and I continued to be impressed by how tough and resilient the people are and how they do whatever it takes to get the job done.

Posted by Patricia Ferrer.

Thursday, February 6, 2014

First World Medicine in 3rd World Conditions

Peach tree flowers.

From a US trained medical perspective it takes some getting used to in these working conditions: poor lighting, dull instruments, bad ergonomics, modifying dressings and being creative with medicinal products obtained locally.  This is good in that it takes us from our comfort zone an pushes us to learn "poor man's medicine".

Tucson wound care specialist/physician, Scott "Mateo" Bolhack and his staff have been very generous since my seeking them out for good/unused wound care supplies 4 years ago. They are always interested in hearing about my working in Chiapas and after seeing Times article, the timing is right for Mateo's first visit.

Mateo works on one of Sergio's most challenging cases.
He arrived on Tuesday morning (red-eye) and that evening we threw him right in to the fire. I prepared him as much as possible about the conditions and he's adjusted well, although it has been physically uncomfortable for him with the knealing, bending and contorting himself to work on patients that sit on small wooden chairs.  And, like our patients during their wound dressing changes, he does not complain.


 Sergio gives Mateo all the difficult patients then quietly watches him work, learning new techniques and proper use of branded products. Many supplies that have been donated are good quality but Sergio and I are not sure of which wounds would benefit most. Mateo patiently explains how we can maximize these products. He has also brought supplies donated by companies that are interested in his coming to work here. We hope his being here will help improve what Don Sergio already does and knows so well.






Wound care team.





From Don Sergio, we learn from watching his quiet ways, his compassion and persistence in providing care and his not getting frustrated with a few non-compliant patients. Most importantly,  we are learning Sergio's own "poor man's medicine"



While watching a fireworks display at church, this 5 year-old was severely burned by a stray fireworks rocket. Sergio visits him daily to change his bandages. The child tells his parents he does not want to go to church anymore.

Posted by Patricia Ferrer, PA-C

Sunday, February 2, 2014

February 2, 2014 Sergio's Keen Eye

 Sunday Feb 2, 2014
Sergio playfully uses his museo camera to photograph Ricci.
Our work week ends on Saturday night.  The day-time patient load is constant and fortunately the evening patient visits vary and Saturday night was lighter than usual.

A visit to el campo, a family grows their own vegetables: cauliflower.
This is the high season for San Cristobal due to the cool temperatures and fortunately tourism is moderately bustling.  Sergio has given evening tours at least 4 times this week and our being there caring for patients frees him up to give more attention to his visitors.

While he was ocupado with a tour, a new patient arrived with an poorly healing abdominal surgical wound. This the story of this ~38 year old male:
Nine months ago he had his gallbladder removed and 6 months later he complained of abdominal pain and returned to the hospital. They found the surgeon left a gauze in his abdominal cavity and it became entangled around his intestines requiring another abdominal surgery and partial removal of his small intestines.  Now he has one vertical abdominal scar and one horizonal scar that have not healed over the last 3 months. The patient is unable to work and the surgeon is requiring the patient to pay 250 pesos ($20USDs) per visit to help heal these unclosed wounds.

He shows up on Don Sergio's doorstep asking for help. With Sergio just starting his tour, knowing he'd be at least 40 -50 minutes, of course we cleaned the wound, dressed the wound and told him to return tomorrow.  What would these people do without Don Sergio?: they would suffer unnecessarily.

Our evaluation revealed his wounds have a build up of bacterial slim which need cleansing and application of a topical antibiotic and the appropriate dressing to allow drainage. However, the following day, Don Sergio's keen eye and experience revealed he had a tunneling effect, hence the tunnel is probably coated with slimy bacterial debris as well. I am confident this man will achieve good results with Don Sergio's care.

Sergio has started a well project between Zinicantan and Chamula.

Near the catchment tank, the locals leave their water containers to collect water.
This is the catchment tank they obtain their water.
After moving to Tucson in 2009 I have been fortunate to meet many wonderful medical professionals, several of which have become good friends. One fellow PA, Ricci Silberman, I met at Clinica Amistad: Tucson's free evening clinic for the low-income uninsured.  I was thrilled to see another PA volunteering for the under-served and knowing she worked full-time I asked why volunteer at this clinic, she simply answered "it's the right thing to do".  Four years later here we are in San Cristobal extending our skills beyond Tucson.

Amigos.
Ricci leaves tomorrow and returns to her full-time practice and I will remain the rest of week. Bela has made her stay comfortable and welcoming and had an immediate connection their being from the same generation. The charm of this city, the people, working with Don Sergio I hope have a tug on her heart to return.  Mil gracias Ricci, eres una santa.

Thursday, January 30, 2014

January 2014

 
My return to work with Don Sergio finds him as I left him in August: still no dentures, in need of funding, and a heavy load of patients with severe wounds.  We have 4 children with burns, some severe, all of which will leave them with a mild - severe disability due to the contractures.

Bela framed Don Sergio's NY Times article  by Janet Jarman and Elizabeth Malkin.


This trip my Tucson friend Ricci (primary care PA) has come with me. We arrived at 2am on Sunday and awoke to perfect San Cristobal weather: 70 and sunny.  Bela and a couple of her guests took us to for a lovely lunch and we walked all walking streets and shopped a little. 



We meet Sergio at his Museo on Monday morning and it felt as if I never left.  Our day begun with 4 patients in the museo then 8 house calls. Mostly diabetic ulcers as these people can not ambulate too well. 



Ricci does knee evaluation at one of our house calls. During housc calls many relatives come out of the woodwork to seek our consult when treating one of their family members.


We were done with morning rounds at 230pm we then home to Bela's for lunch and back to the museo at 4pm where we saw patients until 7pm. This was Ricci's first 'real' day which contrasted considerably from Sunday's shopping outing. Many tragic cases of hard to heal wounds.  I think she and I were glad when a patient presented with basic primary care or dermatologic conditions (these are easy if they are fixable).


These ceramic/clay pots are used over and over on hot fire grills, eventually they can break or explode their hot contents on the near bystander resulting in a hot liquid burn. It seems usually a woman or child.

The main changed since August seems to be the severity of the ulcers and the young age of when these patients present. The diabetic patients are not overweight, but thin and usually diagnosed in their 30s. Most need insulin and sometimes they take it, sometimes they don't. I was told some people believe they will go blind if they start insulin. There is no diabetic clinic, diabetic education or endocrinologist (at least that I know of) in the city.




53 year old male, blind secondary to diabetes with bilateral leg ulcers.


Sunday, September 1, 2013

Conditions of Care: August 2013 Trip Summary

For Don Sergio's make shift wound care clinic the conditions we work in are not the cleanest. He does the best he can with what he has and its all the locals have.

His stocked travel bag is always by his side.



The chairs we use are tiny, Don Sergio always looks up to the patient, never downward.

For house calls he adequately stocks his travel bag with what he needs for the daily rounds.  For the museo/clinic he keeps this bag at his side, on the floor and uses small chairs for a foot rest for dressing changes and the burn patients sit in an larger chair.

The 'dispensary' room.
There is no privacy as those waiting are sitting on one of two benches behind him. HIPPA patient privacy rules don't apply. He does have a dispensary/supply room with poor lighting which is where I usually work. Thanks to Clínica Amistad in Tucson, they donated a wall mount oto/ophthalmoscopy that I use for focused lighting when necessary as well as it's functional purpose.

As for supplies, here's how it works:
 - people from France and the US with access to medical supplies ship them to him. The supplies he receives differ depending on what people have access to.
 - from the US, I ship donated and purchased supplies to San Cristobal from Nogales, Sonora via Correo Mexico. (I drive across the border, have aduana's search through the items and give their stamp of approval.)  If anyone would like to donate supplies to Sergio it would be best to send them to me in Tucson. Contact me by email if you are interested.
 - if patients can afford it, they will bring in their own supplies which Don Sergio will use.
 - visitors who are aware of Don Sergio's work will have collected supplies and bring them down as well.
 - donated money allows Don Sergio to buy medications, creams and supplies locally.

Many people ask "what does Don Sergio need?".  From my observation:
 - Funding: although this is a small operation it is costly and time consuming as Don Sergio sees about 100 patient visits per week.
 - A constant stock of medical supplies (gauze, gauze wraps, wound dressings, medicated ointments, etc - see Yok Chij website Support page).

These conditions are not easy for a US-trained healthcare provider to work in. One has to keep an open mind and adjust to the patient's culture, mindset and expectations. This is challenging and satisfying when results are obtained and a positive difference is made; its disheartening when resources are so limited there is nothing that can be done.

This visit completes my 8th trip working with Don Sergio over the last 5 years and it is so gratifying to assist this septuagenarian provide needed medical services that are otherwise not available.  Don Sergio is unstoppable even after his auto accident in Febuary 2013 that caused him to lose all his upper teeth (his face hit the dashboard). An avid supporter of Don Sergio has given him the money to have him fitted for dentures, I hope he uses this for himself and not others.



Don Sergio lost some mobility in both wrists and hands in his auto accident as well. A physical therapist from Monterrey Mexico had been on his small tour the night before and came by to work on him.  He does accept help from others.

I plan to return January 2014.
Post by P. Ferrer, PA-C