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.

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.

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 photojournalist Janet Jarman's video in the  New York Times piece, 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

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.

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.

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

The Toe

Bicycles are more and more prevalent in San Cris... a cruiser with a back rest

The late afternoon clouds were heavy with rain as I hurrying to get to the museo clinic. I was running late because I had extended my visit with a wonderful couple that has lived in the area for several years and are involved with a local charity organization, Amigos de San Cristobal.  Time had gotten away from me. They have always been supporters of Don Sergio and I had updated them on 'our amigos de El Andalón' progress.

Upon arrival, the museo was packed with patients as the clouds piqued and a gentle rain started: chipi-chipi.  There were 3 patients waiting to see me as Don Sergio worked on one of our most complex cases during my visit: a 50-ish year old male with uncontrolled insulin dependent diabetes who had a middle toe infection.  It looked bad last week and when I changed the dressing 3 days ago it looked even worse. Don Sergio and I knew what was coming for the last week so, he slowly prepared the patient for the inevitable: amputation and today was the day.

Backside of the current style of Zinacantan shawls and skirt.

As of yesterday we told the patient the toe needs to come off and we'd salvage the viable tissue. As I caught up with my patients Don Sergio proceed to amputate the distal bones of the toe (just the dried out blacked part). I put my 3rd awaiting patient on hold and helped Don Sergio with light, gauze and pressure to stop bleeding (in this case bleeding is good but too much is bad).  From a US medically trained background amputating any appendage in these conditions seems so risky. With calm hands, focused mind and matter-of-fact ease Don Sergio completed the job in a very clean fashion.

The departed portion of the toe sat in a piece of gauze off to the side: black and lifeless.

During the procedure the patient sat with his head turned away, calming holding his thigh of the affected foot/toe and his wife standing by his side, stoic with her hands on his shoulders. There were a variety of people in the museo: a group from Zinacantan, Chamula, pobre Mexicans and middle class Mexicans, kids, adults, adolescents, a total of about 15 people, mas o menos.

As Don Sergio worked there was an air of silence I cannot describe but will try. It was not like Championship point at Wimbledon but a heavy, yet soft blanket of silence. Everyone knew the intensity of the moment and no one spoke, heads slightly bowed, patiently waiting and no one moving a finger. Soon the chipi-chipi rain became heavy, then a downpour. I'd glance at the patient's face and his wife's face looking on as Don Sergio was engrossed at the task at hand.  After the operation was done and all was controlled, Don Sergio joked about the detached toe, bringing a smile to the patient's face and an abrupt laughter from the others....seamlessly.

The rain had stopped and we counseled on DM control, avoid getting the wound wet or dirty, taking Tylenol for pain (he couldn't feel anything anyway due to the DM neuropathy, but just in case), and lay off the foot as much as possible.  He said he would and we'll see him tomorrow.  He stands and leaves walking on the heel of the foot missing a toe........no crutches, no wheel chair, no walker.  This is the life here.

For the Maya, having all 10 toes and 10 fingers (the Maya use a base count of 20) means you are whole.

A visitor from France came in and told Don Sergio her Mother met him almost 30 years ago and gave him this paper in French from that time period.

Giving and Receiving

San Cristobal has the same magical charm I find every visit. Walking to the museo daily I get to experience the aesthetics of this colonial town, seeing the different and updated styles of the various Indigenous clothing, shop for hand made textiles and recuerdos, eat at tiny restaurants with wholesome food and enjoy the cool weather. This offsets the world of Don Sergio's daily work: the real depravity of what some people experience. This brings a much greater appreciation to all, those of us in the US, have and should never be forgotten.

Over the last 5 years there has been a dramatic shift from mostly burn wounds to diabetic ulcers.  Currently, we have no burn patients almost all diabetic ulcers with a few skin injuries and 3 of our 4 house-call patients have bed sores.

One of the saddest cases I've ever seen is a 20-something year old man that broke his neck 4 months ago in a motor cycle accident. He is now a quadriplegic and is in chronic 'full body' pain.  His wife and family care for him but there is much more that can be done: physical therapy, a soft foam mattress, a bed or device that can move his body preventing him being in one position too long and for God's sakes pain relief medication.  All this is just a dream and what would be done for an insured person in the US.  His sacral (lower back) bed sore is healing, thanks to Don Sergio, but this probably won't be the last. Without the proper care, he will probably have many as long as he lives.

The past week Don Sergio and I have had the pleasure of working with Amethyst, a Reiki and Massage therapist from Cozumel, Mexico.  So many people have musculoskeletal complaints that she was kept quite busy this last week especially at the museo clinic.  She also helped me with interpreting, she did blood sugar finger stick testing, bandage changing and Reiki on almost all our house call patients.  This was her annual 3 week vacation (from the heat in Cozumel) and she spent her last full week working with us. She said she enjoyed helping those that would not otherwise be able to have access to her services: pure giving of herself and con mucho gusto. Don Sergio and I, and his patients, really appreciated her being with us this week and we look forward to her coming again next year.

Summer Rain in San Cristobal August 2013

August 20, 2013

 
Another day of taxi rides from one end of the city to the other.  In between seeing patients Don Sergio takes me to a nearby village to show me the plans of his next water treatment system. The area is well farmed with a variety of vegetables and I recall being in this area with him a few years ago.

The homes are separated by beautiful farmland that grow cabbage, beans, corn, broccoli and other vegetables.  A site for sore eyes for any veggie-lover. This area would like to have a larger holding tank and access to clean water and Don Sergio has a plan however, it is a big project.  Currently they go to a water holding take and scoop the water out by bucket. The new system will have 4 or 5 diverted pipes to areas in which they can easily access the water.

 

Don Sergio has known the families in the area for years and he says the 200 or so families get along very well.  The area is is 2500meters above sea level, overlooks the village of Zinacantan and appears to have incredibly fertile tierra.

As for patients, the foot ulcers and out of control diabetes are overwhelming. There is only so much one can do. It seems there is not one endocrinologist in San Cristobal (the population is ~200K)!  Many of our patients should be on insulin and those that are on insulin need better training on how to adjust their insulin to improve the sugar control.  It is so hard to heal a wound with poorly controlled diabetes....this story repeats itself.

Our special case of the day is a 10 y/o boy that got in a fight with a cousin and his cousin's tooth caused a puncture wound.  This happened 15 days prior. He went to the hospital and according to the sister, was told nothing is wrong after they took an xray. When we take off the bandage, the small puncture wound puts off a smell causing you to involuntarily step back.  Not good.


We repeat the xray (to rule out gas gangrene - negative) and it appears his 4th finger/knuckle is displaced along with this deep skin infection. We go to the ortho, get an RX for antibiotics, get a culture and sensitivity but start him empirically on the antibiotics. The ortho informs us surgery may be necessary for cleaning out the infection. If this is the case, he will have to go back to Hospital de las Culturas and hope the right thing will be done. Otherwise, this 10 y/o's right hand may be in jeopardy.

La vida de Chiapaneco....

Don Sergio in the New York Times August 2013

Don Sergio Never Changes

This visit I find Don Sergio doing the exact same thing he has done for many years: ".......crisscrosses this city to treat the intimate struggles behind its closed doors." as quoted from the recent New York Times article written by Elisabeth Malkin and video by photojournalist by Janet Jarman.

Arriving last night and expecting to have Sunday off was a mistake. Don Sergio had four patients to see today: two of which we seem to be providing palliative wound care (bed ulcers) and the other two with chronic ulcers that will take a very long time to heal with his resources. Not much has changed: same difficult wounds and ulcers, different patient, limited resources.

Our day started at 1030am and passed very quickly. Don Sergio happened to have a visitor he met several days prior during one of his tours:  an alternative healthcare provider (a Reiki and massage therapist) who has lived in Cozumel for the last 15 years. Her English and Spanish are impeccable which came in very handy for me.  I consider myself proficient but not fluent and her ear is much better than mine.

I had the pleasure of showing Don Sergio the hard copy NYT article today as he rarely gets on the internet and of course does not receive the NYT on his doorstep. He was very pleased with this, more so than I expected. He knows Janet put and enormous amount of time in doing the photos over the last year which required several trips. The 'behind the scene's team' that has been helping Don Sergio for the last several years was elated. We've known all along the value and magnitude of his work, the need of support and we've embraced his "just do it" ideas for the betterment of his community for the short and long term. 
 
From Don Sergio "Gracias por su apoyo".


  
Monster Green (the suitcase) has carried hundreds of pounds of medical supplies over the years..its time to leave it here. Don Sergio will use it for storing the extra Indigenous gifts he's received over the years.

 

 Succulents at Casa de Bela