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.

Wednesday, June 20, 2012

Day of Rain

June 20, 2012

Cathedral is empty, usually this place is hopping.

When it rains things slow down. There may be a few gutters in this city but the only ones I've seen are in the barrios and they are usually open channels next to a road or stairs. When it rains the streets turn into rivers and you better be prepared to get doused as the cars go by. Afterward the streets are very clean.

When I arrived at the museo Sergio was in the large costume room and he was giving a tour to a school group, the kids appeared to be nine to 13 years old and were so well behaved. For example they weren't touching everything, they were not yelling nor running around. They actually walked in pairs arm-in-arm and were politely greeting me with, "Buenos dias".
Of course the boys like to act up when they know they are getting their photo taken. This is only part of the group, the rest are outside. The two women infront of Don Sergio are the teachers.

While he gave the tour I changed the bandages on the man with the radiator burn. He is doing very well, "gracias adios"— he is a healthy 30 year old. His wounds are epidermal and superficial second degree, so thankfully he should heal well. Unfortunately, he said he can't work. He is a taxi driver and since 90% of his chest, most of his left forearm and his right upper inner arm were burned he cannot get comfortable to drive. These people need to work, they want to work and even when they have a true reason not to work, they still want to be at work.

Another example of an accident waiting to happen. This burned out fire is on the floor with a make-shift grate (three rebars bent to hold wood) in a small room. What you don't see here is great grandma sleeping in a bed to the right. It makes sense to us this is dangerous but they have lived many years like this as fire provides heat. Electricity is out of reach for them, they can't afford wood burning stoves or chimneys; this is the best way they can manage for the comfort of warmth… most of us can flick a switch.

The afternoon brought more rain and this makes for a slow evening, which was fine with me as I must have picked up a virus and was not feeling well. We saw four patients which allowed me to get home by 6:00 pm. I showered, chatted with my compadres here at Bela's and was in bed by 8:00 pm.

The streets are glazed with water and off the curb is 5 inches (sometimes more) of rain.

Posted by P. Ferrer

Tuesday, June 19, 2012

The Presence of Diabetes

June 19, 2012
Typical Maya hairdo.

In the US 8.3% of our population has diabetes, this is over 25 million people and it is believed that 3 x that many have pre-diabetes, which means 79 million people are on their way to getting diabetes.  Our western sugar-laden and processed food has worked its way into the Maya diet and all our venous and foot ulcer patients are diabetic. As much as I talk about how good and healthy the food is here, people by nature, enjoy sweets. It is not easy to find something as sweet a Coca-Cola growing from a tree or grown from la tierra and its much easier to buy. Kids naturally get hooked on the sugared candies and it becomes a hard habit to break… just like cigarettes. It is believed Mexico's diabetes rate is 11% — more than the US and their soda pop consumption per persion is 160 liters.
A short and long term accident waiting to happen, burn and diabetes, respectively. Family deep fries tortillas and sprinkles with sugar to sell, this may be the only way they know how to make a living.
Our ulcer patients are usually 40 years old and up and all with ulcers have type 2 diabetes. What is interesting is they are all thin, or at least not overweight or obese, unlike in the US where most type 2 diabetic patients are larger (girth-wise) in size. When I ask if they have diabetes many say yes, some say no; I check their sugar levels and prove to them they do have it and for almost all of them it is uncontrolled. Most have been given one medicine but I'm never sure if they take it consistently. Sergio and I spend quite a bit of time educating them on the importance of compliance. I also check their eyes but I can't get past their cataracts to see the vessels which is not surprising. Their cataracts most likely are caused by their life-time of sun exposure of working in the fields and the uncontrolled diabetes does not help.

The way we should all eat: beet soup, fresh leafy green salad and the agua del dia is watermelon. This is one of my favorite Chiapanecan dishes!
The solution here, as in the US, is education. We MUST educate the masses on diabetes, young and old. Whatever happened to public service messages? Health education in the schools? Diet in the schools? When people are diagnosed with diabetes or they have it poorly controlled, I've resorted to, "Well, if you don't control your diabetes you can lose your eyesight, have nerve pain in your feet, develop ulcers and if these don't heal may lead to amputation, your kidneys may stop working and you'll end up on dialysis" and for the men I add impotence.  One physician told me he tells patients, "You'll die slowly, piece by piece".
Blue corn atole is a breakfast soup that is soothing to the stomach.
A couple of years ago Sergio had a of a 44-year old woman with insulin dependent adult onset diabetes patient with a 5 x 5 inch full thickness ulcer on the back of her neck (started as a ruptured cyst). She would not take her insulin as she was given an antibiotic and did not want the meds to interfere with each other. I told her the wound would have a better chance of healing if she took her insulin as directed. Although, the wound was so large, infected and really needed a full-thickness graft I was doubtful it would heal. She took her insulin and antibiotic, Sergio continued to clean and dress her wound and it healed. The photos before and after are REMARKABLE which I'll spare the reader.

The large blue-green stalk in the background is a brussel sprout tree.

When patients have infections their blood sugar goes up, when their blood sugar is high, their wounds don't heal; a vicious cycle has started. This is what we are up against with wound care, what we need is a combination wound care clinic with a full-time endocrinologist and promotorasquisiéramos!  Don Sergio seems to almost always be successful with diabetic wound care although it can take months as opposed to weeks if all the right resources were in place.
We usually have fewer patients when it rains but this evening we were quite busy.

At the end of the evening a few ladies come to just sit and chat with Don Sergio, he welcomes them all.
For those interested in checking out the facts on diabetes please go to the National Diabetes Fact Sheet 2011… the numbers are astounding.

Posted by Patricia Ferrer, PA-C