Outdoor Medicine

Posted on | March 18, 2008 | Comments Off on Outdoor Medicine

Hospitalito Atitlan

I’m delighted to be able to contribute to Health Commentary by sharing some of my important posts from my blog at Healthline entitled "Medicine for the Outdoors," which can be reached by visiting Healthline. I recently completed a week working at the Hospitalito Atitlan in Santiago, Atitlan, state of Solola in the highlands of Guatemala. I decided to spend this clinical week prior to lecturing for the third consecutive year at a continuing medical education course for physicians on the topic of tropical medicine.

In addition to serving as a doctor and seeing patients at the hospital, I was able to evaluate the experience for its value as a service and educational opportunity for the emergency medicine residents (in training) and post-residency fellows in emergency medicine at Stanford University. After having spent time working at the Hospitalito, there is no question about it – this would be a phenomenal opportunity for these highly motivated doctors.

It is difficult to express in words all of my experiences, thoughts, and emotions from the week, so I will limit my writing to expressing just a portion. Foremost, I am grateful for having had the opportunity to spend time at the hospital. Second, I was very impressed by the doctors and staff – all were dedicated, hard working, collegial, and open to both teaching and learning. Third, Guatemala is a beautiful country, and the people in the Atitlan region deserve the support of their government and whatever resources can be mustered from philanthropic efforts. Finally, there is still much to be done, so I hope to be back.

I operated under the handicap of not speaking Spanish or the local Mayan language, Tz’utujil, which is a situation that I must rectify in order to be more effective in the future. Still, I was surrounded by both Spanish-speaking and Tz’utujil-speaking physicians and assistants (technicians, nurses, nursing students, and volunteers), who assisted me with their linguistic expertise and understanding of local culture and customs.

We saw a wide variety of patients, with many different conditions, diseases, and social situations. In some circumstances, the medicine was straightforward, but in others, we were hampered by lack of specific drugs and/or equipment. As opposed to what we enjoy in the United States, there was no immediate specialist backup – no neurosurgeon, plastic surgeon, cardiologist, dermatologist, and so on and so forth. A transfer meant that the patient would need to travel by ambulance under the care of the local “bomberos,” who could not accompish anything more than transportation. The closest hospital was in Solola (a rugged, bumpy ride one hour away), but all that could be accomplished by a transfer to that facility was perhaps a more rapid trip to the operating room in the event of something like non-cardiac trauma or appendicitis. Individuals requiring hospitalization for something particularly severe, complicated, undiagnosed, or needing specialty care (e.g., a complicated pregnancy) needed to be transferred to Guatemala City, four hours away over winding roads. There is currently no capability for "routine" helicopter evacuation.

Local healers, bonesetters, midwives, and family members figure prominently in the medical culture and decision making. The patients are not necessarily accepting of the advice offered by western practitioners, although this is improving. On more than one occasion, a dozen or more people would gather to pray (loudly) outside the door to the small emergency room (literally, a room) in support of a friend or family member being treated inside.

To a patient, everyone I treated was gracious and grateful. I was never arguing, but spent a great deal of time explaining, which is something I wish I had more time to do in my U.S.-based emergency medicine practice. What was particularly rewarding was the repeated opportunities to teach and even better, to be taught. There was a lot of sharing of information, and the patients were the beneficiaries of multiple opinions.

A few patients and episodes exemplify the clinical diversity we encountered, the remarkable learning process, and how we were able to sprinkle our practice with improvisation. In a series of posts, I will describe some of these.

An enormous commotion and the squeal of automotive brakes announced the arrival of the victim of a bicycle accident. The young man was riding down a hill when his front wheel locked or he struck a large rock (I lost the details of the event in translation), throwing him over the handlebars. According to bystanders, he landed on his head and shoulder, directly onto the pavement. He had not been wearing a helmet. I ran out the door to witness him in the back of a small pickup trunk, blood oozing from the left side of his scalp, while he moaned loudly, obviously in a great deal of pain. There were a few people in the back of the pickup truck pulling at his arms to unload him, which made him scream in agony, because he had a badly broken collarbone. I reached into the back of the pickup, and with the assistance of my physician and medical student colleagues at the Hospitalito, replaced the friends and family with more knowing hands. We held his neck steady, slid him onto a gurney, and wheeled him into the small room that served as the emergency department.

The patient was yelling constantly, more so when anyone tried to move him. I am accustomed to evaluating and treating victims of trauma, more so than the Hospitalito crew in Guatemala, so I was able to tell from a rapid assessment (basically, running my hands over the victim’s body, looking at him carefully, and deciding rapidly that he did not have a major head, chest, abdomen, or long bone injury) that everything would be OK from a medical perspective, but that I sure needed to calm down both the patient, his friends, and those attending the patient. I was able to do that fairly quickly, and then completed a full head-to-toe examination of the patient, which revealed that he had a small cut and large abrasion on the side of his head, a completely broken left collarbone, and some tenderness posteriorly over the vertebrae of his neck. Since his chest was clear, abdomen nontender and soft, and I could find no other indication of a significant injury, the neck tenderness was of greatest concern. Because he had fallen and struck his head, I needed to be as certain as possible that he had not broken his neck.

Our x-ray capabilities consisted of a single portable machine, which was housed in the same area as the small laboratory, so we needed to bring the patient to that location, which meant wheeling him out of the E.R., in full view of family, friends, and bystanders. I wished to give him pain medications, but the supply of narcotics had dwindled to two doses, which needed to be reserved in the event of a caesarian section (“C-section"). Since three C-sections had been performed the previous week, and two pregnant women had recently presented with eclampsia (life-threatening elevation in blood pressure associated with pregnancy that often necessitates emergency childbirth), I could not use up the narcotics. So, I made due with an injection of a less potent pain medication and a couple of relatively weak pain pills. People in Guatemala are often very stoic, and tolerate much more pain than do people in the U.S. and other privileged countries.

The x-ray technician was the same young man who managed the small laboratory. He was always cheerful, and like everyone who worked regularly at the Hospitalito, was able to multi-task without difficulty. However, he had never before needed to take one special x-ray, an “odontoid view” of the cervical spine, in which the 1st two cervical vertebrae (“C1” and “C2”) are visualized, to be certain that there is not a “hangman’s fracture," or other injury at this spinal level, which could become catastrophic if present and the neck manipulated. His first two attempts at this x-ray were failures, because the films were “underpenetrated,” that is, much too light and blurred in appearance, so that the details of the spine could not be visualized. He worked with me to narrow the field of view exposed to radiation and to turn up the intensity of the beam, and on the third try, got it perfect. It was a moment of triumph, made all the more so by the fact that the next time I called upon him to shoot the same view on another patient, he produced a perfect image and a smile bright enough to light up the entire room.

In ordering tests, be they blood tests, x-rays, or others, it was important to remember that the cost of these tests to the patients, on a relative basis, was much greater than they would have been to you or me. For instance, the cost of an x-ray might represent three day’s pay for the patient. So, we always tried to be as cost effective as possible, so that we did not spend our patients’ money just to make ourselves feel better. It was, and should always be, about what is in the patients’ best interest, balancing safety with financial and social considerations. In the U.S., and many other countries, the risk for being sued for malpractice forces overutilization, which is something we did not encounter, thank goodness. This was a very refreshing aspect of the practice. I was overwhelmed by the grace and gratitude of the patients, staff, and doctors.

The x-rays did not reveal any broken bones in the young man’s neck, but we were easily able to appreciate his shattered collarbone on these same x-rays. Because his only areas of tenderness below his collarbone were scattered abrasions on his hands, hips, and knees, and because his chest was clear, he was breathing easily, his blood pressure and pulse were normal, and his abdomen, hips, and the remainder of his spine were without tenderness, we did not obtain additional x-rays. We were without sufficiently potent pain medication to manage him overnight, so he was transferred to a hospital in Guatemala City, via a local ambulance driven by volunteers. As is often the case, we would only receive follow-up on his clinical course after he or a family member returned home to report on his progress.