Friday, June 15, 2012

Back to Work

June 14, 2012

The potted rabbit just outside my door.

Sergio was waiting for me at the museo at 10:00 am as we planned and we saw one patient with a small injury on her left foot then we were on our way for the morning.  He has a new driver named Juan who has a child-like laugh and happiness about him. Juan was missing his right thumb from a lassoing injury as a child and he joked about it as he drove us around.

Fresh-squeezed OJ for 10 pesos (70cents).

We had four patient house calls this morning and three of them had deep (full-thickness) heel ulcers. One man's was so deep amputation should be a consideration, however Sergio is confident he can get it healed. We debrided it successfully but I'm not sure if it will get us anywhere as the odor of infection is muy fuerte. Of course these patients have diabetes and we're not sure if they are being followed properly as it seems they have not had their blood sugar levels checked in a long time.
Mexican decorations so brilliant in color.
We were done at 12:30 so I walked back to Bela's to relax and have lunch. Manuela cooked a saboroso bean soup with a chile poblano side dish and pico de gallo. All the food is fresh here, the beans were not dried but fresh picked and shelled, the peppers, tomatoes, onions, cilantro and even our 'agua del dia' was made from local berries.  It was a striking red with a foamy top and very good.

Manuela is Mayan and is a strong woman with a quiet confidence about her. Bela and I talked about the Maya and she informed me they do not use "right" or "left" in regards to orientation but will use directions of up and down, i.e., up hill, down hill, north/south.  We, who use right and left, think we are the center and things are oriented around us, the Maya naturally know their orientation on the flow of the tierra. An interesting concept to consider and practice.

After a brief siesta I was back at the museo at 4:00 pm and about 30 minutes later the patients flowed in. I saw 14 patients from 4:30 - 7:00 pm (see below for patient cases) and left around 7:30 pm. I do not know how Sergio, this 71-year-old man, can take care of all these people. Many do expect miracles but he is clear in telling them when to go to the hospital: some will, some won't, some return to him.
Another gift to Sergio given 5 months ago, new in the museo.
Carol, Jim and I went out for dinner at Napoli, the best Italian restaurant in town. It's a small quaint restaurant ran by a man, his wife and they had an eight-year-old son dressed in his soccer attire helping. The day ended in a lovely evening, a long chat with Bela and I was in bed at midnight.

Coco, she's a lover not a fighter.

The cathedral in San Cristóbal, a landmark.

Here is a summary of some of the patient visits for my medical friends. I will not post the clinical photos but will do a PPT at the end of my stay here.
  • 6 x 5 cm partial thickness scalp injury, Mayan woman ran into tree branch and scraped her scalp severely, this is almost healed.
  • 16-year-old Mayan woman w/HSVI entire lower lip, had to explain no cure but if she can take proper med at onset she can prevent episodic lesions or shorten duration.
  • 17-year-oldMayan woman w/HSVI entire lower lip, just like the previous pt but she is nursing a one-month-old baby, so patient education on transmissibility, etc.
  • 15-month-old girl with mild eczema. After I addressed this problem the mother explained that the child has not yet crawled nor can she sustain standing up next to a table as most children can do at this age. Per mom, the doctor told her not to worry about it. I examined the patient's muscle strength briefly and could see what the mother was talking about. My pediatric and neurological experience is not strong so I will have to some research, but just from the history, there is concern.
  • 60-year-old Mexican Mayan woman with her right great toe amputated and now severely infected hobbled in with her family. Her second toe is necrotic and looks mummified, this needs amputation. Sergio cleaned the wound explained exhaustively how she needs to go back to the hospital and have this amputated. Her son listened carefully and I could see and sense his anxiety as he looked on at the wound which is grotesque, the cost of having an amputation done, the Mother's resistance may have been overwhelming. I checked her BS levels and it was so high the monitor could not measure 'HI, out of range'. It is almost impossible to heal a wound with out-of-control BS.55 y/o woman with varicosities and partial thickness left leg ulcer, she too has DM (BS 145). She could really use light debridement and good compression...difficult in this environment but we will try.
  • 58-year-old Mexican man with wide spread chronic allergic dermatitis vs eczema. His hands reveal a typical presentation of dyshidrotic eczema but the rest of him looks like contact dermatitis. This has been going on for six years and he looks miserable. I would love to do a bx, give IM TAC to give him relief, then after a washout period do a patch test.
  • 30-year-oldMexican man with acne mid chest… thank goodness an easy case.
  • 50-year-old Mexican woman with dyschromia on face, another easy one.
  • 20-year-old Mexican man with a human hand bite on his thumb (from a fight). Occurred one month ago, he did not seek treatment for three weeks, now it is painful and he has a couple of small abscesses. He can barely tolerate the pain when cleaning the wound (pain out of proportion of what we are seeing which is concerning). My US medically- trained mind wants him to go see an hand surgeon so this can be opened and cleaned properly… this is a puncture wound of the thumb… it can turn ugly if not cared for properly.  I cleaned and dressed the wound, tried to pack it gently. Will see him again today or tomorrow.
  • 30-year-old Mexican woman w/irritant dermatitis on her chest from her plastic and elastic bra.
Many of the patients I can write down what they need and send them to the pharmacy for the meds.

Posted by Patricia Ferrer, PA-C

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