Unstoppable

August 9, 2014

Real de Guadalupe August 6, 2014 - Culebra.

The hot Tucson summer has driven me back to the cool climate of San Cristóbal.  I arrived on the day of a tornado that was captured by several locals on film.  This was the third tornado this summer and when the clouds gather overhead you see people anticipating another tornado.  Growing up in US tornado alley, it seems weird to have a tornado in the mountains of southern Mexico.  Wednesday over 200 homes were damage and fortunately no major injuries reported.

Friend of Bela, Ricardo from the Belil Restaurant took this foto of the tornado.

The patient volume for Don Sergio at this time is high and many of the patients I saw three months ago have healed and are no longer coming to the museo clinic.  There is a new batch though: same type of wounds just different people. Don Sergio told me the young man who lost his left leg due to an assault burn injury and severely damaged his right leg is now using crutches and is somewhat mobile. Our 5 year old boy's chest wound and the 3 y/o with a hot water burn have healed well.

On Thursday we traveled to Teopisca and spent most of our time seeing 5 or 6 patients, then back to San Cris to see several patients. The evening clinic was jam packed and thankfully we had Cesar, Iker and Amethyst (who I met last year from Cozumel on vacation) come to help.

Previous class room for elementary school, now a supply storage as Don Sergio finishes the school.

 Friday we went to work on a school in the 'burbs' that Don Sergio has constructed. It seems these are the last two buildings for this school area. Our driver Juanito and friend Alfonso pitched in and Iker called upon his 'posada' friends to help.  

Before painting.

After painting. I learned that adding salt to the paint will prevent it from washing away from the rain when the paint is still wet.

Afterwards Don Sergio and I saw a few patients in the city and I went back to Bela's in the afternoon for a siesta. The museo/clinic gets rolling at 4pm and started slow as it appeared it would rain but then numerous patients showed up. Cesar, Alfsonso, Carolina, Iker and Amethyst were all there so everyone pitched in. There is never a need to talk to each other while working as we all know our places and positions. Its like an orchestra playing a well-known piece of music.

One room before cleaning.

After cleaning.

Las chicas from Argentina just traveling and enjoying life, riding on the wind and sharing memories and friendships and hey, why not help paint a school.  A free life they live and thank goodness they have good health, great attitudes and open minds. They may not have a lot of money, but they seem very rich to me.

Don Sergio hires expert to coat the walls with cement. On Tuesday it will be ready for painting. We will call upon la posada amigos to help us.

At 6pm we were so busy and then Don Sergio had about 15 tourist waiting for a tour.  He ended up giving 2 tours while we saw patients and waited for everyone to leave.  I was exhausted! I don't know how Don Sergio does it, the man is unstoppable and does what's needed to get the job done.

Don Sergio works harder than any 73 year old I know.

Posted by Patricia Ferrer.

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.

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....

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.

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 promotoras… quisiéramos!  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

June 17, 2012 domingo, dias de decanso

An ornate tree of life.

Today I slept in, caught up on other projects and relaxed. Our quaint B&Bgroup went to a local restaurant for an excellent Sunday Father's Day brunch then came back to Bela's B&B.  Teresa, who helps Bela operate the B&B, is a massage therapist and gives a 90 minute massage for 425 pesos....I couldn't pass it up. So this is how my day ended.  Manana voy a regresar a trabajo.

Posted by Patricia Ferrer

The Routine

June 15, 2012


The routine has begun: my initial astonishment of how Don Sergio can take care of such critical wounds day in and day out has resolved and my dreams of getting him all the medical supplies and funding of what he needs to lessen his burden has started. Then reality sinks in: just take care of what is in front of us and on to the next patient, support Don Sergio in anyway possible and let him do what he does best.

This morning a new burn patient came to the museo who suffered a steam burn from a hot broken radiator hose the day before. We've all seen the ruptured hot radiator hose spewing steam, he was just in the way. His forearms and chest were burned but the real extent of the injury has not yet presented itself but will in a few days. Right now he has pain and all we have is Tylenol to offer and for his burns and bandages moistened with silvadene. The patient was so grateful and left with a smile even though the pain has to be intense. These people are so stoic… or is it accepting and having good coping skills? In the US he would be in a certified burn center, given IV pain meds and possibly semi-sedated as this burn is about 14% of his body surface area and part of it appears it will be partial-thickness burn.

Broken radiator steam burn.

Off we went for our house rounds and after our second pt in a barrio south of San Cristóbal our taxi broke down. Juan, our driver, called his cousin, another taxi driver, who came to pick us up. I thought of Bruce, who would have the car fixed in no time just as he did a couple of weeks ago when the same thing happened on our way back from the Grand Canyon.

Coche no funciona.

We finished our morning rounds and I was back at Bela's in plenty of time for a siesta and Manuela's lunch.

Prickly pear agua del dia, chili relleno, flor de calabaza con queso, arroz y frijoles y salsa deliciosa! Home made tortilles, blue and white corn in the basket.

The evening patient load was lighter than the day before as I saw 10 patients and was out the door by 7:20 pm. The usual wounds and luckily for me several easy derm cases (acne, eczema, benign lesions). We did have a terribly sad case of a 62-year-old Tzotzil man, wheelchair bound with a large cancerous tumor growing out of his right thigh. It was bound to the bone and the skin contracted upward toward his buttock. The hospital doctors informed him they can amputate the leg but it was not going to provide a cure.  From a brief clinical assessment I had to agree. There was firm lymphadenopathy all the way to the groin. Even if amputation removed this tumor, he most like would not receive aggressive cancer treatment (no resources).  Don Sergio informed the man of the gravity of his condition and told the patient to return so we can continue to change his bandages… at least he won't have to deal with the weeping wound, it will be kept clean. The patient said he'd return. Even though futile, Don Sergio comforts patients with his care.

One of our house calls requires a few steps.

The home was made of plank wood and had a beautiful view.

 

71-year-old Don Sergio always on the move.

By evening's end Don Sergio as always walked me to the door and we confirmed our meeting time mañana.  I'm always so tired after the evening shift, where does Don Sergio find the energy?

One of our evening pts with a hot water burn.

The cause of most of the child burns, especially little girls, is from hot water. Either it has been spilled or the pot broke while the water was boiling and the girls are always close to the mother and cooking. Young skin (and old skin) can suffer significant damage, usually a superficial burn will heal within a couple of weeks. Depending on the depth of the second degree burn it can take three to eight weeks. Usually these burns are a combination of both superficial and partial thickness.

Posted by Patricia Ferrer, PA-C
  

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