Sunday, August 17, 2014

Working Gems

August 16, 2014

We have several patients in Teopisca and one family gave us Chiapanecan free-range eggs.
Yesterday I spent the morning with a local named Sebastian who works for DIF (Desarrollo Integral de la Familia). This is a foundation in which wives of the Mexican politicians help support charity organizations in various ways.

Sebastian took me to a local non-profit healthcare facility called Esquipulas. This clinic is supported (almost single-handedly) by a family out of Monterrey, Mexico and physicians that are trained there. Part of their training is working at Esquipulas for their social service. They provide primary care to those that speak a Mayan language.  In addition, they work with various non-profit global healthcare campaigns. Like Clínica Amistad  (a free clinic that provides primary care to Tucson, AZ's low-income uninsured), they provide free services and patients have to pay for their medication. The difference is Esquipulas is much better and consistently funded, has a better building, better rooms and nice equipment and they are highly culturally sensitive to their patrons (as we are at Clínica Amistad). They are also open daily M-F compared to Clínica Amistad being open two nights per week. It was quite impressive and seems a paradox since the US appears monetarily wealthier than Mexico.
Entrance to Clínica Amistad, Tucson, AZ.


Entrance to Esquipulas, San Cristóbal de las Casas, Chiapas, Mexico.





Exam room Esquipulas. To my companeros de Clínica Amistad: eat your heart out.





















They have a strong connection with select physicians from Monterrey to work there and it is a very organized operation. They have good reasons for doing it this way, which from my perception include keeping it small and collective. This maintains focus of their mission, prevents dilution of quality of care, maintains continuity of care, supports cultural awareness, and builds a family-like environment center for those that work there. Many of the employees speak a Mayan language and are born into the respective culture.

Other side of the exam room, a desk and chairs.





Esquipulas is a nice resource for Don Sergio to have to refer the Mayan patients that consult him for conditions he cannot care for.












After seeing all this it made me realize why Don Sergio has kept things small for himself; he likes medical professionals to come help, but he also likes that he can control how people are treated (cultural sensitivity), the care given (he oversees that the optimum care is given within his means), chooses his own projects (in which he receives donations from various sources), and learns from those with more expertise. This is all part of his 'healing' process and is why when one comes to work with him, their experience is so rich.

Sergio and Iker visit with Teopisca family on the patio porch after wound care is given to a abuelita.

Finding the 'working-gems' in the world like Don Sergio, Esquipulas, Clínica Amistad is inspiring. We all see the deficiencies in larger systems and instead of complaining, protesting, expending energy trying to move a mountain, there are some (gracias Adios) that provide solutions to the immediate needs and take care of those in our respective communities.
Juevos revueltos de Teopisca.
These REAL free range chicken eggs are a vibrant yellow and more flavorful than any store-bought eggs I've tasted in the US.
Posted by Patricia Ferrer.


Sunday, August 10, 2014

Unstoppable

August 9, 2014

Real de Guadalupe August 6, 2014 - Culebra.

The hot Tucson summer has driven me back to the cool climate of San Cristóbal.  I arrived on the day of a tornado that was captured by several locals on film.  This was the third tornado this summer and when the clouds gather overhead you see people anticipating another tornado.  Growing up in US tornado alley, it seems weird to have a tornado in the mountains of southern Mexico.  Wednesday over 200 homes were damage and fortunately no major injuries reported.
Friend of Bela, Ricardo from the Belil Restaurant took this foto of the tornado.

The patient volume for Don Sergio at this time is high and many of the patients I saw three months ago have healed and are no longer coming to the museo clinic.  There is a new batch though: same type of wounds just different people. Don Sergio told me the young man who lost his left leg due to an assault burn injury and severely damaged his right leg is now using crutches and is somewhat mobile. Our 5 year old boy's chest wound and the 3 y/o with a hot water burn have healed well.

On Thursday we traveled to Teopisca and spent most of our time seeing 5 or 6 patients, then back to San Cris to see several patients. The evening clinic was jam packed and thankfully we had Cesar, Iker and Amethyst (who I met last year from Cozumel on vacation) come to help.
Previous class room for elementary school, now a supply storage as Don Sergio finishes the school.
 Friday we went to work on a school in the 'burbs' that Don Sergio has constructed. It seems these are the last two buildings for this school area. Our driver Juanito and friend Alfonso pitched in and Iker called upon his 'posada' friends to help.  

Before painting.














After painting. I learned that adding salt to the paint will prevent it from washing away from the rain when the paint is still wet.

Afterwards Don Sergio and I saw a few patients in the city and I went back to Bela's in the afternoon for a siesta. The museo/clinic gets rolling at 4pm and started slow as it appeared it would rain but then numerous patients showed up. Cesar, Alfsonso, Carolina, Iker and Amethyst were all there so everyone pitched in. There is never a need to talk to each other while working as we all know our places and positions. Its like an orchestra playing a well-known piece of music.
One room before cleaning.
After cleaning.



video

Las chicas from Argentina just traveling and enjoying life, riding on the wind and sharing memories and friendships and hey, why not help paint a school.  A free life they live and thank goodness they have good health, great attitudes and open minds. They may not have a lot of money, but they seem very rich to me.


Don Sergio hires expert to coat the walls with cement. On Tuesday it will be ready for painting. We will call upon la posada amigos to help us.

At 6pm we were so busy and then Don Sergio had about 15 tourist waiting for a tour.  He ended up giving 2 tours while we saw patients and waited for everyone to leave.  I was exhausted! I don't know how Don Sergio does it, the man is unstoppable and does what's needed to get the job done.

video
Don Sergio works harder than any 73 year old I know.

Posted by Patricia Ferrer.

Sunday, May 18, 2014

Spring Summary 2014






Beautiful mural in local San Cris restaurant.
 
There is so much work to be done in global health. In this region, Don Sergio is the only local safety net for wound and burn care.  It  is not a long term solution to the problem.  It is not sustainable and he knows it even though he's been working 6 days a week to give help to those who need it for more than 40 years.

Don Sergio is now 73 and although his energy level is good, he's not going to live forever.  There is no system in place to provide for wound and burn care in the future. 

In Mexico there has been little emphasis on prevention of diabetes.  Don Sergio sees more and more foot ulcers, amputations and other related type 2 diabetic complications.  It can be overwhelming and limited resources contribute to poor outcomes (see previous post).


Colorful mural painted on a home in Colonia Mexicanos.


My last day working with Don Sergio we saw an insulin dependent T2DM (type 2 diabetes mellitus) patient with a partial left foot amputation complication. The 71 year old wheelchair-bound man had an above the knee amputation of his right leg done a few years ago secondary to diabetes. His left foot, now is malodorous, there is pus, and the top and bottom of his foot are held together by large deep non-absorbable sutures (take these out and his foot will flop open like a book). Clearly an infection and the top of his foot is becoming dusky purplish (impending necrosis). His mental faculties are sharp but he complains of diminishing eyesight.  He discontinued his insulin as he felt it made his eyesight worse.  This is a common misconception for the people Sergio serves.  They believe insulin makes you go blind. Stopping his insulin only made his foot problem worse.
We see some serious and critical wounds so its nice to find beauty and peace in a local park.
 Lack of diabetic education is a huge problem. Prevention is the key but for those who already have diabetes they need to know how to control it.  Awareness of symptoms and proper healthcare follow-up are crucial.

It is very frustrating to me, having worked with the patients in Chiapas to never see  public health/education campaigns directly targeted to prevent diabetes on a national level.  The major advertising continues to be for soft drinks which are pervasive and easily obtained in the most remote villages.


In so many words, Don Sergio has expressed the need for a facility to provide medical care for these patients, i.e. access to care, as the work for wound care is piling up. With Dr. Mateo working with him earlier this year, maybe the idea of a proper wound care and burn center has appealed to him.  But a clinic would be more practical to begin with. Although, this is not the complete answer, it is part of the solution and other basic systems (e.g. education) can expand from there.


The local medical community is very aware of Don Sergio being a safety net and the director the hospital has asked Don Sergio to give a talk to the local physicians on causes of burns within the Mayan communities. Burns and minor skin injuries is how Don Sergio first fell into the wound care business.  Right now the burns are secondary to the diabetic ulcers.  When he speaks at the hospital it will be his opportunity to show the extent of the problem and his need for help. 
L>R: Don Sergio, Carolina, Iker, Cesar and Alfonso.  Sergio's el equipo.


I will not be there during his talk as I've returned to Tucson, but Erick will be there and will help him with a PowerPoint presentation. It seems Don Sergio has attracted a few international professionals that have taken an interest in supporting and helping. Don Sergio's connection and trust from the Mayan communities, international support, and a connection with the local medical community may one day yield that clinic.....to be continued.
Double rainbow viewed from our West Tucson neighborhood. Captured by professional photographer (and neighbor) Bob Torrez.



Posted by Patricia Ferrer.

Sunday, May 11, 2014

El Problema es.........

-->May 11, 2014




The same in the United States but at different levels:  lack of nutritional and health education, public health services, reasonable access to healthcare with cultural awareness, and in San Cristobal, adequate resources for healthcare professionals to deliver optimum healthcare.



These statements are my personal observations while working intermittently with Don Sergio over the last 6 years. Seeing the consequences of these deficiencies brings me to these conclusions.


Lack of nutritional education.  

Sweets are hard to find in nature so our bodies have not evolved to handle consuming large amounts of sugar. This early and chronic consumption can result in type 2 diabetes (T2DM) at an early age as the pancreas’ ability to produce insulin wears out in keeping up with elevated blood sugar…hence the term ‘impaired glucose tolerance’, aka IGT. We often see many 30-somethings with out-of-control diabetes and horrific foot ulcers are their first obvious signs of this disease - they are unaware they have diabetes.  Interestingly, these people are not obese, as in the US,  some may carry 2-10 kg too much, but not all.

Typical aborrotes packed with soft drinks.


It is not unusual to see a mother pouring a refresco in her baby or toddler’s drinking bottle, or just letting them drink straight from the soda bottle (I see this in the Hispanic US population too).  The sugar content in these 400ml/~12 oz drinks is about 46 grams. There are 4 grams of sugar in a sugar packet. That means there are 11 packets of sugar in one bottle. When this starts early in life, the taste of water does not ‘taste good’, therefore continued consumption of sugary drinks seem normal. 



It is not unusual to see a 3 year-old child with deciduous (baby) rotten teeth. The acid in the soda breaks down the enamel and the oral bacteria feed off the sugar creating an imbalance of oral flora and therefore damaging the teeth.  I saw this clearly with our 3 y/o boy that was burned with hot liquid on his chest, abdomen, and hand. He had a dark brown nub of one of his front teeth and a few others were beginning to rot. His parents fed him soda to try to distract him during these wound-dressing changes. Pain medication would have been ideal but it is not available.

In some places you have to ask the staff to unlock a door to buy toothpaste, or it's behind the counters in the pharmacy.

For some reason in Mexico (this is in the north and the south) for the poor population, oral hygiene is not advocated. In Tucson, many of our Mexican immigrant patients need emergency dental care due to tooth abscesses, sinus tract development and grotesque caries due to lack of basic dental care and oral hygiene. Poor oral hygiene and early soda consumption appear to be a bad mix.



Lack of health education, aka PREVENTION, ¡por favor!

Diabetes is at ~11 % in Mexico and at ~7% in the US; these stats reflect the number of those actually ‘diagnosed’! There are numerous people with IGT in which 30% of these people will go on to develop T2DM if they are not educated and informed on how to prevent the progression. 



Global T2DM is increasing in mid- to low-income nations but high-income nations have their burden too. If we don’t educate our youth (and all for that matter), we will exhaust an enormous amount of resources.



Diabetes puts in motion the following problems: heart and vascular disease, kidney and eye disease, and neuropathy. This can lead to high blood pressure which increases the risk of stroke; kidney failure resulting the need for dialysis; eye disease leads to blindness. Neuropathy (burning, tingling, numbness of lower legs and feet) results in inability to feel a pebble in a shoe which can lead to a small ulcer, then infected ulcer, then amputation, etc. Complications from diabetic neuropathy is the main reason so many wound care centers have popped up in the US over last 15 years.  Don Sergio tries to fill the local wound care void; hence the 120 + patient visits per week.

Public health promotion.

I have not lived in Mexico long enough to comment with complete understanding of the public health (PH) system. However, Bruce and I were living in Oaxaca for 3 months in 2009 during the ‘Swine Flu Epidemic’ and it appeared the public health system rose to the occasion as did the government. PH vans roamed the neighborhoods knocking on doors asking specific questions about symptoms of illness. Well-publicized professional soccer games in large stadiums cancelled, as were schools and offices to contain the spread. It was quite impressive how Mexico responded. I don't think we in the US would cancel any professional sporting event to contain an infectious disease.








Common cooking stove.
Some people can't afford a stove and wood burning to cook is their only option.

 This being said, in the San Cristóbal region, education on preventing common burns and diabetes seems non-existent. Small children frequently get burned with hot water or oil, the ubiquitous fire crackers use can cause serious damage, and neurocysticercosis can cause epilepsy and those centrally located, non-enclosed fire blocks in the home seem to be a magnet for one experiencing an epileptic seizure. Public service announcements, posters, television blurbs could make a huge impact. The US population can benefit from these public service announcements as well and we have resources to do so, but for some reason don't implement.

Don Sergio finds remnants of feugos artificiales.

Cultural awareness is so important.

This is one place in the world, in the Americas, that still has a heavily populated Mayan/indigenous culture with their own style, beliefs, dress, language and ways. These cultural identities can vary from town to town. It is a pleasure to be able to experience the diversity.  However, with healthcare, there must be a bridge and understanding their culture as to yield the best results when caring for these unique groups.



Resources for the healthcare system.

I often hear the Mexican physicians and nurses go on strike not for money, but for resources to provide better care. These physicians and staff want to help and do their job well, but resources are limited which can result in bad outcomes.



So what is the solution?

Do what we can within our abilities to improve these flaws. It has to come from within a community and we (wherever we are) must have the desire to be part of the solution. However, this is difficult when the infrastructure to support these ideas is not in place.  As with every visit here, I ask Don Sergio, “Why do you do what you do?”. His response this visit is, “I don’t want to be closed in and think about myself, I want to think of others and be part of the help and solution”….”people need help”.



Okay, I’m stepping off my soap-box. To reduce the suffering and needless life/limp/game changing ailments we must invest in education: not just in Mexico but in the US as we are no better. We have our own burden of T2DM and it appears to be taking the globe by storm…..we’ll soon match Mexico’s 11% of diagnosed diabetics if we don’t do something.

Posted by Patricia Ferrer.


Sunday, May 4, 2014

The Help

May 4, 2014

Friend and artist Violeta Abitia's color pencil drawing of a resting dog.


 Since New York Times video by Janet Jarman and article by Elisabeth malkin last year and more internet exposure more people have become interested in what Don Sergio does and want to work with him. Many locals have known about Don Sergio but the internet makes it easier to learn about his work and a way to contact him: his official website Yok Chij. In addition, the documentary done by Consuelo Alba and John Speyer, El Andalón, gives a very good overview of his 50 year history of being in the Highlands of Chiapas.



Our new friend, Erick, has decided to move to San Cristóbal for the next 3 months. Sergio will have the benefit of having constant help most of the summer.  Erick had to return to Galveston to move things out of his apartment before month's end and wanted to visit family and friends in Connecticut while in the US. He will return after I leave.
L to R: Sean, Wilhelmina, Kirsten, me, Eric. Oscar took the photo.


The Graff family from Salt Lake City, who lived here for a year 2012-2013, returned for a 2-week vacation prior to my arrival. I was lucky to catch them the last night before their departure back to the US. Sean, an RN and the father, worked with Don Sergio every Monday while here and drove him to see all the patients. They continue to advocate financial and medical material support.

As for local help, Carolina continues to work with Don Sergio 2 nights per week and a local friend has brought another young lady to see if she can work with Don Sergio. It seems as the flow of soft waves lap on the beach, help comes and goes, but always comes back.

Carolina and Iker.

Another interesting fellow has also shown up to help Don Sergio. Iker, a nurse from Spain's Basque country, and his girlfriend of 10 years, have been traveling the world for three years and have landed here for a few months.  In their desire to learn more about the places they visit, they volunteer their time. This exposes them to things the tourists does not see and enriches their life and knowledge. Iker, comes to work with Don Sergio 4-5 times a week mostly in the evening clinics. He has helped tremendously as we've been so busy.
Sergio and Iker.



Lastly, in those lulls of retreating waves, friends of Don Sergio continue to support and help from afar on many levels. This support helps allow Don Sergio to purchase supplies and sustain himself and family.

It's no surprise the draw of working with Don Sergio has on an individual. He attracts loving and kind people, those that give of themselves, those that watch his work from afar and want to support him.

For me, my gain is immeasurable: I work along side a living saint while working with the local people from various areas, meet like-minded locals and foreigners, see and learn medicine in a different setting than in the US. The experience is one of the richest one can have in a lifetime.

Posted by Patricia Ferrer.

Wednesday, April 30, 2014

Resilience and Animalitas

April 30, 2014

In one home, the women dry the corn, maiz.
The evening clinics have been packed: as many as 50 -70 people coming through. When one family member comes in for wound care it's common for 2-4 other family members to come with them.  Grandchildren bring in abuelitos, sons, daughter-in-laws tag along, and of course the smaller children come. If a child is receiving treatment, then cousins, aunts, uncles, parents; it can be as many as 5-7 people tagging along for one patient. The Latin social support is one reason why many believe the Mexicans are so happy.  Its a pleasure for me to see the family love and caring of one's clan.

Our latest tragedy is a 3 y/o boy that was burned with hot liquid (I'm not sure how this accident happened) but his left hand, palm and back, and his abdomen and chest, 23% of his body surface area. This happened last Friday and he was hospitalized for 3 days, then the parents brought him to Don Sergio for continued care. After changing the dressing in the clinic, Don Sergio tells them he will come to their home to reduce transporting the child. These appear to be deep second degree burns: the most painful.  No pain meds are available, other than Tylenol, so our routine will be to lay everything out and change the bandages quickly. The child will soon see us coming and the anxiety will begin. Fortunately, he is healthy otherwise so should heal well, the subsequent psychological trauma will not be known. The extent of the chest burn is not yet determined as the burned tissue has to die off to uninjured tissue (damaged tissue will be removed). In the US, no doubt he'd be in a burn center and appropriate measures taken.

Our Teopisca man, the one who suffered the electrocution injury is doing well. The injuries to his feet are profound, however his grit is so strong and he manages his way through Don Sergio's debridement treatments (removal of dead tissue).  Afterwards he is fine and lets Erick shoot a photo of us.
Resilience and support. This 43 y/o man has his mother by his side during his wound care treatments. They are so grateful for Don Sergio's care.

Another reason the clinic is so packed is many people have basic dermatology questions.  Since I specialize in dermatology, many patients have questions about their skin ailments.  I see a lot of eczema, fungus and sun sensitivity rashes (surprisingly common), the latter in the agricultural worker. The convincing that some of these conditions are not curable but need maintenance for control can be difficult; try telling an agricultural worker to stay out of the sun:imposible (sombreros, guantes y mangas largas).


Bela's garden in full bloom, a Mexican paradise.
My easiest derm case was this young woman with a small child that complained of "tengo animalitas en mi pelo" (I have small animals in my hair). Ah, so easy: lice..and so easy to see along with the eggs. In Spanish, piojos y liendres. When I ask how many people live in her house and do they have the same problem, her response, "Si, todos" (yes, 15 people have it). This young woman is poor, so Don Sergio and I agree to buy the medicine and have the family treated.  I'm not so sure how successful treatment considering the crowded living conditions.

Sunday, April 27, 2014

Prepping for Growth

April 27, 2014
This time of year the ground is a bit drier and the agriculture workers are prepping the land for the fall crops. It involves burning the dried debris and according to Don Sergio, it helps to release potassium in the soil for planting, then the rains will come and things will grow. Food will be harvested and life goes on. 

The sky is a bit hazy, but brings brilliant orange colors as the sun sets
Over the last week a colleague, Erick, who has worked at the Shriners Burn Hospital in Galveston for 3 years, has contacted me about working with Don Sergio. He's been traveling through Mexico and has developed friendships with Mexican physicians that have passed through Shriners for additional training. Erick, originally from Connecticut, like many people has found Mexico wonderful and his connections make it that much richer. Over the last year he has returned 3 times and once to Chiapas, however he was not aware of Don Sergio at that time.

Saturday was my first full day back joining Don Sergio and its like I never missed a beat, however there are two critical cases we make house calls to and one is in Teopisca (25 miles out of town). This gentleman, age 43, was laying rebar for masonry work and it touched a live wire.  The electricity went through his forehead and out both feet. The ulcer on his forehead is healing well but the exit points are horrible. Erick, has seen injuries this severe or worse many times before. When I asked his thoughts he said, “take him to the OR” (operating room). Well, that’s out of the question. Don Sergio has been working with this guy for several weeks and slowly removing the dead tissue to help the healing process. Always, ‘poco a poco’. This trip takes most of the morning.

Our second case is one of the saddest. I know I’ve said this before in other postings but....  This 26 y/o man from Chenoló became intoxicated and, in his drunken stupor, decided to rob a home. He was caught in the process and was taken by the owners who pored gasoline on his legs and set him on fire. The end result is loss of his left leg (badly burned and amputated above the knee) and the other severely burned behind the knee that the contracture will not allow him to straighten his leg. He is now wheelchair bound.  Its hard to believe the brutality, but it happens world-wide.


On the brighter side the local fair had a dance show that was in full swing during 'comida'.



The fashion in the old days.
It is a pleasure having Erick here who has experienced seeing and taking part in treating these intense injuries.  However, knowing what would have been done if there were resources and what we have to work with…well, these are different worlds.

Sidewalk art, now faded.

Displaying murals.


Sergio continues to provide care to any and all in need. I find his storage room empty of the staples he needs: gauze, gauze wraps, petrolatum impregnated gauze, tape, and gloves. My large suitcase with supplies was held up in Guadalajara and just now arrived. Just in time before running out...for the moment. One objective this trip is to estimate how much he needs on a monthly basis, find a local distributor and make arrangements to keep Don Sergio in supplies.