Friday, July 6, 2012

The June 2012, Trip Summary

This trip felt as productive as one could, given the circumstances and difficulties our patients face daily. Although the supplies I brought restock for Don Sergio for the next two to three months at the most, it will not go to waste as it would if left here in the US. The blood glucose monitor and strips will help Don Sergio show and educate his patients on the need for blood sugar control, hence better wound healing. For me, the continued experience of providing healthcare in limited conditions, seeing the changing needs of what I can bring from the US and acceptance and trust from the indigenous people enhances my usefulness for return visits.

I've posted this before, but this picture says a thousand words.

As for the medical cases, the increase of diabetic ulcers seen on this trip is astounding. Four years ago I started working with Don Sergio and most of the patients were burns and few were ulcers. There are still many burns just at this moment there are few, however the type of diabetic ulcers we see are severe and most would require some type of surgical procedure (if they were in the US). The majority of these patients have poorly controlled diabetes and don't seem to have a good understanding of this disease - hence the moniker "the silent disease". I can't help but notice the infiltration of the Western processed food diet and high consumption of sodas playing a significant part in the Mexican diabetes epidemic (same for the US).

Traveling Back to Tucson

Carol, Jim and I left at 4:30 am for the taxi ride to Tuxtla (Albino Corzo) Airport. Our plane ride to DF (Mexico City) then to Hermosillo was uneventful. The unpleasant part of this whole trip was the bus ride back to Tucson from Hermosillo. We were lucky to grab the last three seats departing Hermosillo at 1:30 pm however, these three seats were right in front of the bus's toilets… that were overflowing! Luck struck again after five hours — we stopped in Nogales to pick up others and had the restrooms cleaned. The border crossing was easy but we had to hang out on the US side for an additional hour for some unknown reason. Bruce picked us up at the Tucson Tufesa bus station on time and we delivered Carol and Jim to their doorstep.

The following day I returned to St. Elizabeth's Healthcare Center for my afternoon dermatology clinic for uninsured patients. This community clinic and our patients have very limited resources and the clinic relies on volunteers, grants, and private donations. Still, walking in I felt a sense of relief, "I'm back in the US so these seriously afflicted patients at least have a chance".  It saddens me to know there is so much suffering in the world. The patients I see in Chiapas are only a small sliver of how others suffer without adequate healthcare around the world. I urge everyone reading this to reach out and do what you can to help those without the luxury of good health… we, born in the US, are just plain lucky!

Many Thanks!

Organizations that help me help the patients in Chiapas are:
World Care
Arizona Burn Center
Northwest Wound Care Center 

Of course, to support Don Sergio carry on his one-man wound and burn care please click here or on the PayPal button on the upper right of this page. If you would like to make a tax-deductible donation please send your check to IF Integrities with a letter stating this donation is earmarked for Sergio Castro Martinez.

The 30-minute documentary about Don Sergio, El Andalon, is on sale to the public. A portion of the proceeds are donated to Don Sergio.

A special thank you to Bela at Bela's Bed and Breakfast for sharing your friendship, local knowledge, food and making my stay in San Cristóbal very comfortable.  !Gracias a Manuela, Teresa y Anna también!

All blog posts are my personal opinions and experiences while working with Don Sergio. Thank you all for your support. Patricia Ferrer, PA-C

To follow are photos I love to share and I can't help it but they are related to food: YOU ARE WHAT YOU EAT!  Diabetes is changing the face of health in the world and its cause it at the root of what you put in your mouth. Please think about the long-term effects of high-sugared, high-carb and processed foods on your and your family's health.  ¡Disfruta!

The hands of a superb cocinera, Manuela, stuffing flor de calabas with quesillo.

More than once, twice, thrice… a photo of fresh squeezed OJ on the street for 10 pesos (seventy cents USD)

Rambutan, a leechy nut-type fruit. It tastes like a pulpy not-so-sweet green grape and the seed tastes like a nut.  They look so interesting - an export fruit for Mexico, brought from the far east some years ago.

View from patient's home: field of greens… field of food!

Tuesday, July 3, 2012

Saturday Rounds

June 30, 2012

The last full day of this trip has arrived and it is business as usual. Sergio wanted to get an early start as we have many house calls and the photojournalists are with us today. These ladies are so professional and hard working and will get in any awkward position to capture this story and Don Sergio kindly obliges them.  So, off we go to see our the eight patients for the day shift. 

The main economy in Zinacantan is the flowers and there are numerous green houses throughout this community. The home we visited had a plot with various flowers and plants. The Zinacantan women would not allow me to photograph them but I did snap a glimpse of their Zin Garden.

Yesterday, we went out to Zinacantan to see an elderly woman who is not feeling well and quit eating and we were to meet another man with a skin condition. The latter did not meet us at the locale he mentioned so we headed to the home of the former. Turns out bisabuelita (great grandmother) has an intestinal ailment and needs a proper work-up; there is nothing we can do for her. This is a perfect example of having to understand the cultural differences. These Zinacantanecas/Tzotziles trust Don Sergio more than they do the hospital but if he tells them to go, they will (well, might).
I love seeing and trying unrecognizable local food. This fruit is called "mamay" and looks like a large kiwi but has reddish pink pulp that taste like sweet potato and papaya. I'd like to make a smoothie with this. This elderly lady was selling her fresh food at the Zinacantan church square. In the background there are large yellow mushrooms and fruit from the cacti. Seeing the variety here makes reminds me of how limited the produce sections at the US grocery stores are.

Before we left the museo this morning, our crippled patient with the large cancerous tumor growing out his right thigh arrived for a bandage change. The smile and happiness in this man's face is infectious. His condition is terminal and he is unaware but seems to have a peace about him. Don Sergio speaks to him in Tzotzil afterwards and knowing we have a full day, he is in no hurry.  Afterwards we see our usual diabetic foot ulcers, pressure ulcers and our one burn patient and we're done by 1:30 pm.

Arriving at the Tzotiles' home a shy boy greets us and helps Don Sergio carry a box of clothing he brought for the family.

Our Tzotzil patient with the knee injury was also on our list and visiting this home is welcoming and a pleasure. The Tzotzil women welcome me kindly and the shy, curious children run up to Don Sergio to help carry his supplies up the narrow trail. After we're done with our wound care, we are asked to sit and eat. They put two small chairs, a table with a tablecloth outside and place homemade blue corn tortillas and a couple of omelets on top. Two days before they served us "los puntos" — the distal end of the chayote plant in soup form with homemade tortillas. Although this is not the cleanest environment I cannot refuse this incredible kind offering and I follow Don Sergio's lead. I do not want to offend as these poor people offer me one of their most valuable gifts: food. The effort to continuously feed their large family can be time consuming, costly and at times inconsistent. They let us eat as they stood in the one-room house and watched us.

Tzotzil girl watches on, her Asian features are remarkable.
Mayan hand-made blue corn tortillas with an omelet on top.  For the family to serve us their eggs is quite an offering.
Previous meal served was los puntos soup with corn tortillas. To drink is apple juice - I'm not a fan of this as it has a higher content of sugar but it may be cheaper and easier for them than to extract juice from a local and accessible plant.

The women knew it was my last day and one of them touched my hands and arms with the lightest contact as she expressed her gratitude for my coming. No words need be said, the touch conveyed everything.
The evening clinic has not been as busy as times before but the rainy season has started and many people do not like to get out in the rain. Bela had recommended to her new guests that they go to Don Sergio's museo for a tour and a few people we had met throughout the week also showed up. As he gave his tour I took care of the patients. Our local friends that come to hang out at the museo showed up and we sat and talked for quite a while. I said my goodbyes to them and to Don Sergio. Hasta pronto!

 Posted by P. Ferrer.

Saturday, June 30, 2012

 A Tourist Break

June 29, 2012
Rio Grijalva going through Sumidero Canyon.
Yesterday I took the day off to take a tour to Sumidero Canyon with Carol and Jim. Our boat launched from Chiapa de Corzo and the tour took about an hour. This place was "British Columbia Beautiful"!  Although it was warm and humid the apparent wind kept us cool. This was one of those tours I would do again as it was so relaxing and peaceful. For a minimum cost of 250 pesos ($17.5 USD), it was a steal. A must do for any visitor to this part of Mexico — Chiapa de Corzo is an interesting city to see as well, driving into the city looked like parts of San Diego. Chiapa de Corzo is known for their elaborate celebrations they have in January and from what I hear is quite an event.

Inverse cascade along the canyon wall.
Back at the museo for the evening we had a busy start but it thinned out around 6:15. My first patient was a 62-year-old gentleman who had a couple of toes amputated and was healing very well except for this last two-inch by 0.5-inch opening. He wanted his blood sugar checked since he had a history of diabetes and he quit taking his insulin because "no me siento mal" — I don't feel bad. His blood sugar was over 500 (the monitor won't read it above this level so it just says 'HIGH'). We talked with him about the importance of diabetes and control and how it can be silent until things go "bad wrong".  Education is so important with this disease, and the lack of it seems too common.

The evening ended having dinner at one of the coolest restaurants I've ever been.  Clair and Benjamin (author of the Daily Good article about Don Sergio) took me to a place east of el centro. This restaurant had no name and served only fat wholesome quesadillas. Clair told me they have different quesadilla fillings every night but its always fresh. They also serve a warm fruit drink of whatever is seasonal. Their kitchen was a small enclosed cart with two women making the quesadillas and one young lady delivering the plates to the five tables (three of which were communal). The lighting was soft and the surround restaurant looked like an open garage with one back room… perfect ambiance.
Peaceful porch of Clair and Benjamin's rented home.
It was a magical evening with Clair and Benjamin, they are a unique multi-lingual world-traveled couple who only own their basic necessities and live simple and fulfilling lives. All their needs are met and they are able to telecommute and hence travel anywhere in the world and work (with internet of course). Clair loves her job and Benjamin loves being in San Cristóbal and learning more about the local Maya folk and learning the language Tzotil! The home (kind of a duplex) they are renting is more than 300 years old and was once a women's jail and winery — it has so much character and feel-good energy. The photo journalists spending a few days with Don Sergio and I interviewed me on their porch.

Thursday, June 28, 2012

Tight Spaces… and Politics

June 27, 2012

A Tzotil girl had arrived at the museo this morning as Sergio and I were going through our daily patient list. She said her father-in-law, su suegro, had fallen and scraped his knee and is now having swelling and a lot of pain. She described their home being in barrio Santa Cruz. We already have a patient in Santa Cruz so Sergio thought we could squeeze him in. When he asked how far up on the hill do they live she said, "no tanto mucho" — not so much. She would wait on the main street until she saw us to take us to their house.

This is typical for the barrios; you can't find a home by an address and it’s not unusual for the resident to meet you on the street to guide you. Barrio Santa Cruz is in the southeast part of the city as the east mountains rise. If this were the US, this area would have the finest homes as the views of the city and mountainous surrounding areas are spectacular. Instead, in Santa Cruz there are concrete block or plank-wall homes with flimsy tin or tarp roofs that are more like rooms instead of homes.
The trail.

Getting to this house was a tight squeeze up a narrow rocky trail that followed a wooden fence held together with barbed wire. Water was continuously running downhill and maintaining the moisture on this steep trail so holding on to something to avoid a fall with our medicine bags was necessary. When we arrived to the home we found el suegro lying on his back covered with blankets. His right knee was exposed and we could easily see the problem: the pre-patella bursa (the fluid filled sac that overlays the knee cap under the skin) was infected. There was a quarter-size scab on top and this swollen mound was hot and red, the patient felt as if he had a fever and he answered, "Yes," when asked if he had chills. It appeared to me this guy was really sick, possibly becoming septic.
We had two photographers with us today who are very interested in Don Sergio's humanitarian work.

El suegro, by the US standard of care, needed to be in the hospital, his bursa drained of infectious fluid (which would be sent for culture and sensitivity), on IV antibiotics and pain medication. But we are in los barrios de San Cristóbal and this is a Tzotzil patient. The indigenous folks do not like to go to the hospital for various reasons. One is that they have to have someone stay with them the entire time of admission to feed and monitor them, but mostly they wait until they are almost dead to go, hence many visits to the hospital end in death and the hospital means you most likely will die. They don't realize the severity of an acute illness and if it costs money, they can't afford it and they think the patient can outlast the illness.

I informed Don Sergio of my concern and recommended draining the bursa. With sterile syringes I drained  as much as possible but could not get it all out. I preferred to remove the scab now to allow drainage from the point of injury entry but Don Sergio was persistent to let topical medication moisten the scab and remove it tomorrow (he too feels the patient can outlast this infection). We gave the patient amoxicillin (our best option of what was in Don Sergio's bag) and told the family we'd return tomorrow to drain the infection. The Tzotzil women of the house chatted with Don Sergio in their native tongue and tried to pay him but as usual he refused. When offered he never takes money from these people, hence all the gifts in his museo. Down the treacherous trail I stopped and admired the view despite the poor barrios on the other side of the mountain.
Tight spaces.

La vista del barrio Santa Cruz.


The gubernatorial and presidential elections are going on right now and its nice to be a foreigner and not have an opinion. I was told this is the last day the candidates can campaign for votes until voting day July 1st. Surprisingly, the candidate promoters were giving out bottled water and other gifts to the masses… would this be like buying votes? One candidate was giving out caps and flags with the candidates name and logo. Many people wanted the flags because they were attached to useful wooden-dowels, plus the satin material of the flag could also be used. An action juxtaposition: the "well-to-do politicians" giving their campaign displays away and the "indigenous people" who are taking them for their physical value… I wondered if they had a political opinion, or if they’d even vote.

Riveter Rosie redone.

Bottled water give away.

Every event must end with fuegos artificiales.

During this "rally" they kept playing a song that started out saying “vota vota”. It is permanently stuck in my head… ugh!

Tuesday, June 26, 2012

Los Barrios de San Cristóbal

June 25, 2012

During this time we have not been out to the surrounding villages like the times before; our house calls are mostly in the poor barrios (neighborhoods) around the city. When we arrive the families are so grateful and not ashamed of their poverty. Some homes have non-potable water, no flush toilets, dirt floors, no refrigerator; they may have a small stove next to the bed and cardboard to insulate the home. Some do not have stoves. Despite this poverty it pleases me tremendously that we are always greeted with a smile, a small chair and, "Would you like a cafecito?".  A smile, generosity, gratitude, bendiciones cost nothing but to me yield a comfort money cannot buy.

Some of our patients do not have stoves - here are tire rims modified into grills.  This would be camping for Bruce and me but is a way of life for some here.

This lady is so grateful to us for coming to care for her foot; she had two toes amputated. Her family carries her outside and they set up the make-shift floor.

Note the plank walls and the cardboard filling in the gaps and the tin roof. Necessity forces innovation and imagination, it also promotes coping skills. People can be so resourceful!
I'm glad to know there are no serious burn injuries in the villages that Don Sergio is called upon but I do miss our 20 - 30 drives out to who knows where to see how the Maya of el campo live today.  This trip has been an eye opener because of the seriousness of uncontrolled diabetes in the poor population, it was not like this before and I was here six months ago. All our house calls since my arrival are to treat heel, toe, venous ulcers, as are most museo clinic patients are. I am not optimistic about this trend. We have only one burn patient who fortunately is well on the mend.

Free range chicks, keeping warm in the comfort of their mother's breast.

Room for one more?
Telemedicine at the Museo. This man came from visiting his 27-year-old sister who lives four hours away. She has severe arthritis and is on immunosuppressant medications and has two large ulcers on her left leg. With no access to wound care he asks for our help and Don Sergio gives his recommendations. What he doesn't know is that this may not be the 'typical' venous ulcer but something related to her autoimmune condition.

Don Sergio demonstrates how many people without clean water consume water: they take a bandana/handkerchief and put it over the mouth of the bottle to filter the obvious particles. Not quite the cleaning process we prefer.
Home of Maya women hang their corn to dry.
These photos are by no means representative of all people in this area but a sampling of what life is like for the poor in the barrios for people living on the fringe. We do have patients with nice homes, however unless they have a filter (like Bela), all the faucet water is non-potable. Also, diabetes is an equal-opportunity disease so rich, middle-class and poor are affected. Despite these photos, Mexico, Chiapas, and the San Cristóbal region have so much to offer any visitor. The natural beauty and aesthetics of the Mexican and Mayan culture is a sight for sore eyes.

View from patient's home.

Posted by P.Ferrer.

Saturday, June 23, 2012

The Flow of Things

June 22, 2012

In the jungle of Chiapas many years ago.
San Cristóbal streets are old and narrow and mostly one way. There are no obvious stop signs (at least that we're used to), there are corners that are hard to see around, there are pot holes, people crossing the street in all directions, high curbs, people parking and blocking traffic, etc. With all this, at all types of intersections, the traffic flows smoothly and people get to their destination. It is Zen like.

Real de Guadalupe 1950s looking toward Iglesia de Guadalupe. Will post the "today's" view later.

The view from Iglesia de Guadalupe 1950s.

The night before last the museo had an unusually slow clinic evening. Travel writer, Meg Pier (whose website is From The Pier) had asked me to interview Don Sergio for her website. He started out answering questions like he had hundreds of times before, then in a seamless fluid way he really started talking… then showing photos, then showing examples within his museum. I, his only audience, was able to ask questions and expand upon the things that interested me and discover more about what life was like in this area of Chiapas 40+ years ago. I never completed the first five of Meg's 10 questions.
In the 1970s there was a big flood in San Cris, Don Sergio said this was the northwest part of town.

Same view zoomed out.

This is near the periferico where Sedem Recreational center is, looking to the southwest. The two-story building to the middle right is still present today although appears abandoned.

The flow I recognized as the day started continued well into the evening and ended up with Don Sergio showing me a few items he holds in his private collection (not on display). Thanks to Ms. Pier, and a slow clinic, Don Sergio gave me an animated show-and-tell "recent" history lesson of the people of this Chiapas highland region through his personal stories and life experiences.

Chamula many years ago.

Chamula musical group.

Celebration, notice the Coca-Cola bottles, they may be filled with pox (local moonshine).

Spinning the wool.

Weaving the wool.
Photo from below back strap loom.
Somewhere in the jungle. Don Sergio says there are still undiscovered Mayan ruins.

Young Don Sergio drying coffee beans.
Making a stone oven to make bread.

Lacondon man with the essentials: head-strapped hand-woven back pack, machete and man purse, not sure what is in his right hand. 

Don Sergio expressed admiration for this 108-year-old  Lacondon chief. He pointed out how dark his hair is and that this man was very happy, 'he had six wives', and oddly only eight children. Two of his sons never returned from hunting and the Chief believed they were attacked by jaguars.  The Chief said he never went out to hunt javalina as he would sit in his house and wait for them to come in to eat his corn. Sitting quietly in a corner he shot-off his arrow to kill them at a very close range.
 Posted by P. Ferrer.

Friday, June 22, 2012

Success and futility

June 21, 2012

At this moment we have only a few burn patients but many diabetic and venous ulcers (foot and leg ulcers). Burn patients, depending on the severity of course, are much easier to help heal. They are usually young healthy individuals with good immune systems. Most of the burns I've seen this trip have been superficial or partial thickness and are almost healed over. These are the successes.

21st century juxtaposition: napkin (servilleta) with the Aztec image holding a cookie (galleta) with a Spaniard in Armor image. The cookie is processed sugar (which the western world introduced to the new world) and paper is made from natural products although refined. The weight of the Spaniard on the thin Aztec serving napkin to collect the crumbs.

The diabetic ulcers are far more challenging. Two steps forward, one step back, these seem futile… but eventually, for most of these wounds, Don Sergio will have success and will possibly have saved a limb.

Here is a simplified version explaining what happens, wound-wise, for those with diabetes. When one has high blood sugar the hormone insulin, produced by certain cells in the pancreas, take the sugar out of the blood stream into the cells so the glucose (sugar) can be used as energy. If there is too much glucose in the blood stream, it is toxic to the inner vessel walls, especially microscopic vessels that are at the ends of the toes, back of the eyes, in the kidneys, etc. This glucose also damages the nerves at the ends of the hands and feet which cause neuropathy (most symptoms are numbness, tingling, or burning sensation). If one can't feel their feet and they are stepping on a small stone that can cause trauma, they are unaware of an injury. Or if the end vessels are so damaged, no blood can perfuse to supply the toes with the nutrients it needs and take away the waste then the tissue of the toes starts to die. Whether it be injury or dead tissue, amputation or open wound, bacteria will settle into the wound and infection begins… or colonization of bacteria begins and interferes with wound healing. If the blood sugar is high, the bacteria will continue to grow, the vessels continue to be damaged (poor circulation) and the wound persist.  Hence, control of high blood sugar during wound healing is so important.

Here, for us, the other part of the equation is that we don't have a good set up to clean the wound properly.  The environments in which we work are not the cleanest, we don't have adequate clinic set up, our supplies are limited; we can do cultures but this can get costly and not yield the most useful information, plus we don't have the antibiotics (creams and pills) to treat properly. It seems to be three steps forward and two steps back.

Every visit I see this well-taken care of old Dodge.

On the brighter side, as always it is a pleasure working with someone who doesn't complain or protest but takes action on what is at hand. Don Sergio uses the resources available and makes the best of it, even when I express my opinion that things look hopeless… one day I will learn to keep my mouth shut. I'm reminded every trip, to do my best with what I have and that it does matter here and now to those you are treating.

Posted by P. Ferrer.