Thursday, August 29, 2013

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 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.

Sunday, August 25, 2013

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.

Wednesday, August 21, 2013

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....

Sunday, August 18, 2013

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