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4/12/2008      Pinares is hard on the skin.

On Thursdays, I drive 2 hours to a spread-out community called Los Pinares, in the region of San Marcos de Sierra, to see patients in another Shoulder to Shoulder Clinic supported by Thundermist Health System of Rhode Island and Virginia Commonwealth's Department of Family Medicine.  The temperature drops anywhere from 10 to 30 degrees in a matter of 30 minutes on the road ascending to Pinares.  The air is crisp and naturally pine-scented with beautiful mountain views.  You can imagine being in the Rockies on a summer day save the equatorial sun that can trick you in the cool air and burn your hide in minutes.  The sun, in addition to dry winds, frequent indoor fires to keep warm, poor hygiene (secondary to poverty, water shortage, and who wants to bathe when it's cold?), and probably some genetic factors, contribute to a very high incidence of skin problems.  Even one of the 2007 summer volunteers got staph furunculitis.  Maybe there is something in the air.

This region easily has triple the scabies and lice of the Santa Lucia clinic, but those are common problems associated with poor living conditions.  Other, more severe skin conditions have been both rewarding and frustrating.  This young girl of 14 was brought by her school-teacher with very painful, disfigured, and keratotic lips, worsening for 8 months.  She responded beautifully to some donated valacyclovir and has been controlled with occasional topical docosanol brought by my mom.  Herpes labialis isn't supposed to last this long, but the intensity of the sun really kept the virus going  for a long time.  She now carries a parasol, because Honduran women do not were brimmed hats.

This next young lady of 12 had eczema that had not been properly treated.  She finally came to the clinic, because she was unable to open her mouth wide enough to eat due to painful chelitis and impetigo.  A course of antibiotics and two courses of steroids later, she returned with a huge smile and beautiful skin the day Maria Montanaro, CEO of Thundermist, was visiting.

Last is a current case.  She is about 40 years old and for a year has suffered from painful, weeping, confluent vesicles on both cheeks, with small groupings on her chin, lips and forehead-no eye involvement.  I thought perhaps eczema herpeticum or an atypical presentation of herpes, which favored the lesion on her chin.  However, neither antivirals or steroids helped.  She is now on a long-term course of cephalexin for staphylococcal erysipelas advised by Steve Wolverton, a dermatologist from IU who took a look at the pictures.  I hope this treatment works, but please let me know if you have any other ideas.  

4/12/2008      Orthopedics

When we first arrived, orthopedics was really stressful for me.  Having the only x-ray machine in an agricultural area means a lot of broken bones.  Our machine is a portable unit, probably 30 years old.   Tom Kiefhaber, a hand surgeon from Ohio, has been instrumental in helping us keep it going and connecting us with technicians that can answer our questions about  settings when things don't turn out right.  We hand-develop our films in a plywood tank and hang them to dry wherever there is an unoccupied nail in the wall.  Both Tom Kiefhaber and Roy Sanders, an orthopedist from Florida, have been helpful in reviewing digital photos of films sent over e-mail and helping us determine whether to treat or refer when the case is not clear to us.  I joke that I am able to get an ortho consult faster in Honduras than in the hospital.  Thanks, guys.  

Upper extremity fractures are very common here between falls from mango trees, machete fights, and drunk men falling out of pick-up trucks. A less common case this year was a complete proximal femur fracture in an infant resulting from the mother falling while carrying her on her hip.  With Roy's coaching and Travis Johnson's help, we put her in a chest-high hip spica with a broom handle between her knees for 4 weeks and she did beautifully - commonplace for an orthopedist but something new for this family doctor.  



8/3/2007        Say Ahh, No, really.

A 60 year old gentleman was referred to us from an outlying public health center with seizures and a preliminary diagnosis of meningitis.  To be fair, the outside doctor only examined him while convulsing.  He was still convulsing on arrival.  After IV diazepam enabling a physical exam, it became clear that this was not meningitis.  His chief complaint was throat pain, I think, or maybe neck pain.  He was hard to understand, because he couldn't open his mouth.  

He was prone to drunkenness and had not eaten in some time, but his family was fairly certain that he had not been with his bottle of guaro in 5 days.  I had heard that one before, so EtOH withdrawal was at the top of my initial differential.  Physical exam showed a disheveled gentleman with elevated blood pressure and no fever.  He had a frankly purulent left otitis media, no mastoid tenderness, and no neck tenderness.  However, his neck was stiff and he was unable to actively or passively open his mouth.  His gag reflex was in-tact and he was able to swallow a straw-full of water given between his conveniently missing teeth.  His neuromuscular exam below the neck was normal.  His reflexes were not particularly brisk.  He had no evidence of recent  wounds.  He had successfully avoided clinics and doctors since he was a child, before the time of vaccinations in these parts of Honduras.

I brought the book into his room and began to read.  I had never heard of acute tetanus otitis media, but it is not unusual.  I also didn't know that tetany most commonly affects only parts of the body. This was classic lockjaw.  Now what worried me were the seizures.  His family agreed to transport him to the hospital as he was going to need parenteral nutrition and surveillance of his respiratory status.  As Damon, one of the visiting medical students,  moved him to a wheelchair, he began to seize again, unable to handle his secretions well.  We placed him back on the table and gave more diazepam.  We then loaded him into the ambulance via military gurney and sent him on his way.  He managed to survive the ride to Esperanza, where he seized again upon transfer.  The hospital transferred him on to Tegucigalpa.

Reading about tetanus later, I learned about tetanic convulsions and how they are triggered by movement and stress.  The ideal treatment includes moving the patient as little as possible and keeping them in a quiet, dim room.  Tetany lasts anywhere from a few days to a few weeks. Treatment with antibiotics does not necessarily resolve the tetany faster, though he will need treatment for the otitis.  I hope this is the first and last time I ever see tetanus.  Please check and make sure you have received a vaccine in the last 10 years.

3/6/2007        La Sarna

"La Sarna" is scabies.  I have been trying to write about unusual experiences, but scabies here is almost as common as a headache.  Everyone has had it, has it, or will have it by the time I finish this paragraph.  Scabies was so rare in the states, I often forgot to keep it in my differential of skin conditions, at least for people who didn't live in homeless shelters (The mites prefer crowded conditions and shared beds).  We learned in medical school to think of it when we saw kids with linearly-arranged small pustules between the fingers and toes and on the genitalia who were itching like a stray dog with fleas.  I have maybe seen one case of scabies here with pustules on the fingers and toes, but I have seen hundreds with various manifestations of these little critters that mimic everything from nickel dermatitis to psoriasis.

Scabies sarcoptei is an 8-legged mite not visible to the naked eye.  The fertile female burrows under your skin to the layer of the stratum granulosum to lay her eggs, moving about 2 mm per day under the skin to spread them about.  The eggs turn to larvae and then adults, which make their way back to the surface to find a date and mate, starting the process over again.  The eggs, feces, and mite all cause a type IV hypersensitivity allergic reaction that itches enough to drive one crazy.  

Here is what I have learned about scabies in Honduras that I didn't know before:  
We treat scabies with the following protocol:
                 Adults: Benzyl Benzoate (not available in the US)
                 Children  1-10 years old: 50% strength Benzyl Benzoate
                 Children <1 year old and pregnant women: Permethrin 5% topical cream.
   
1/31/2007        Resources and Medical Decisions

She came in 3 hours post-partum, still bleeding, with a retained placenta, easily removed with traction and pushing.  Her BP was 88/75, Pulse 160 lying down, conjunctiva white as snow, skin cold and pale.  Two liters of NS and a shot of Oxytocin later, she was 100/70, pulse 130, still unable to stand for more than a few seconds on her own.  I have seen one just like her approximately every 3 weeks.  They come in the backs of pick-up trucks or riding in hammocks swinging from a long bamboo pole (aka bambulance), complete with cotton in their ears (they keep in for 1 month to prevent bad air from getting in) and a towel around their head, often holding their newborns who are sporting a piece of fabric tied around the midsection, which they believe prevents them from having an "outie."

I presented them with two options:  1.  My preference - go to the hospital now for blood products and quit scaring me.   2.  Stay here in the clinic overnight, so we can send her if she continues to hemorrhage.  I was only presenting option 2, because she was otherwise healthy and they were obviously poor.  The hospital is 3 hours away on a very rough unpaved road in back of our USAID sponsored ambulance, otherwise known as a Dodge Ram 4x4 with a gurney and a camper top. The gas costs 2,000 Lempiras, approximately $110.  They were unable to make a decision.  The patient did not have any say in the matter, as the sick are often not included in medical decision making.  This was up to her husband and her step-daughter, who was the only one with clean clothes and likely the one who would foot the bill.  They couldn't decide, because they wanted to go home. They didn't come to stay.  They came to get the placenta out and that was done.  To prove my point, I stood her up for a minute and let her start to pass out before catching her and laying her back on the gurney.  I thought it was rather clever and convincing, but they were not impressed.  These are the times I rely on Dr. Ruben Martinez to put his command of Honduran expressions to use in convincing people that their lives really are in danger, but he was gone.  There was no convincing them.

In the US, physicians do make choices about treatment according to a patient's resources, but we are also obliged by our oath to treat people with life-threatening conditions without consideration of their ability to pay.  Honduras is becoming more affluent.  It is indeed "developing" at lightening speed, but there are still people who have to decide between years of debt and medical care for life-threatening conditions.  Do they pay now and subject their extended family to months or years of resource shortage or do they take their chances and pray that God will have mercy on them once again?  "Fatalismo" is a word used to describe the worldview that "what will happen will happen, and my actions will not change that."  It is a survival mechanism that is part of the psyche in impoverished areas everywhere, from Bangladesh to inner-city slums in America.  Fatalismo allows the poor to escape from feeling responsible for bad consequences of decisions that they are forced to make in order to meet basic needs.

So, how do we as physicians interact with this cultural ideal when it comes to sick people in trouble?  Where and when do we press patients to adopt our values of life and risk avoidance in exchange for their acceptance of risk as necessary for survival?  If we press too much, we may be understood as imposing severe hardship in order to calm our own discomfort.  When we don't press, we have to live with the consequences - that someone may suffer and/or die as a result.

As always, I would appreciate your reflections and stories about this dilemma.  By the way, the patient is now 3 days post-partum after going home and, while pale, is doing fine.

andy

12/29/2006     Escarlatina

Today, a 14 year old came with the complaint of foot pain.  After looking at his feet, I asked him about other illnesses that he and his grandmother forgot to mention, like 10 days of fever, severe throat pain, and a red rash all over his torso that ended just 2-3 days ago.  Though we are unable to check ASO titers or rapid strep tests here, this looked like a classic case of scarlet fever.  When American feet desquamate, it is an impressive sight.  When Honduran feet desquamate, they lose a mocassin's worth of skin.   I saw my first case in the states this year, so I can't say it is a tropical disease, but it is certainly more common among people who do not have ready access to medical care.  This 14 year old was the size of a 10 year old, approximately 4 SD's below the normal growth curve.  After further questioning, his grandmother is raising he and his 3 siblings.  They eat most of the time, when she has food.  The father moved away and the mother was not mentioned.  I talked to Nelson Requeno, head of community programs, tonight about making a family visit to weigh all of the kids and see if they need food supplementation.

12/28/2006    Dermatobius Hominis - "Torcelo"

One of the most unusual and therefore infamous condition seen here by the American clinician is the subcutaneous bot larvae, aka dermatobius hominis.  This is a common condition known by your average Texas cattle rancher or veterinarian, but we humans generally don't get larvae growing in our skin.  Two or three times per week, patients come in with an itchy, raised, red, 7-15 mm papule that often has a 1 mm hole in the middle.   We give them what we have coined "the vaseline test."  The larvae growing inside uses the small hole to breathe.  Occlusion with Vaseline typically reveals a pinpoint white moving object just under the shiny surface - a positive Vaseline test.  If left alone, the larvae will eventually mature into a 1+ cm long x 5 mm  oblong  worm that makes its way out, falling to the ground to complete the maturation process into a black fly.  That black fly manages to deposit her eggs on the legs of a mosquito (not sure how they do that) who then lands on the next host and leaves some microscopic eggs on the skin that easily migrate into the dermal layer.

                                 
Patients can feel something moving around and are tempted to squeeze it, hoping something will pop like a pimple.  But, killing the larvae may actually make the situation worse.  The larvae itself is sterile, living off of necrotic tissue.  A dead larvae, however, is a potential for infection.  There are three options to deal with this: 1.  Leave it alone and let it mature and come out.  This is hard to do, because it itches like crazy. 2.  Place raw meat over the air hole, encouraging the larvae to move into the meat.  I have recommended this to two parents whose children would never have tolerated option 3, and I have not heard back from them.  3.  Surgically extract.  This looks easy at first, but in fact the larvae is much deeper than one would suspect.  The tiny proboscis that comes up from air can stretch a long way, so the larvae itself may be 1-2 cm under the surface, well encapsulated in a tissue plane.  Extractions may require significant exploration.  4.  Experimental - I have one older gentleman with 6 subcutaneous larvae which we killed by covering for 24 hours with an IV-site occlusive dressing, as he wanted to avoid 6 incisions.  He checked back in to let me know that they all had died and ceased itching.  We are now waiting to see if the dead larvae form abscesses, form encapsulated nodules, or become phagocytized and disappear.  I'll update this post when I hear back.  

Torcelo Update:

The gentlemen mentioned above returned in 3 weeks with small, pigmented, subcutaneous nodules where the parasites were.  He was happy to have avoided surgical extraction.  On the other hand, I saw a 9 year old boy whose scalp larvae were "injected," likely with lidocaine at a local health department., who I sent to the hospital.  He presented 3 months after his initial "treatment" with a 8 cm fluctuant, bald spot on his head, somewhat resembling tinea capitus, that on exam was eroding into his calvarium.  It did not appear infected.  I don't know whether this occurred as a result of the Torcelo or untreated abscess formation.  I do know that I will routinely remove these larvae from the head after seeing this.

12/27/2006    Toxic Epidermal Necrolysis?

I have never diagnosed TEN, so I would appreciate any other opinions from those of you who have done so. This 56 year old gentleman was given Bactrim DS for a urinary tract infection as well as Diclofenac IM x 3 days and Ibuprofen for severe back muscle spasm.  He returned to the clinic in 2 days with 5 red, raised, tender plaques, measuring 4-6 cm in size, some of which were beginning to desquamate, giving the appearance of a 2nd degree burn.  His glans was also desquamating and very painful.  He had no lesions in his mouth.  He had no other rashes and was otherwise healthy.  If I had seen this picture in class, I would have answered nummular eczema or psoriasis, but the story screams drug reaction.  I stopped the Bactrim (most likely culprit) and Diclofenac.  He will follow up soon.

This just in from Joshua's dad (aka Dr. Willie H. Smith, internist with Emory University School of Medicine):


12/13/2006    "Truckload Patients" and the Medical Consult

During my third week of seeing patients here, I began to recognize that certain villages were highly represented on certain days.  After asking, I learned a simple explanation:  someone in the village was sick enough to hire a pick-up truck that day. So, every sick person within earshot climbed aboard and came to town for a visit with the doctor, sometimes because they were sick, and other times because there was not much else to do.  A significant percentage of our patients live beyond easy walking distance to the clinic.  So, the decision to seek medical attention includes weighing potential benefits and costs.  It may be worth the 2 hour walk or the money to pay a passing truck if your child is having trouble breathing, but certainly not for controlling your hypertension.  If a free ride is available or a brigade is in town, it may be worth one's time to come for a simple headache. Walking, however, or paying for transport, may in fact make one's headache worse.

So, the question we are all taught to ask in medical school about why one came on a particular day may not reveal the true answer without a little prying.  And, if the physician recognizes that there is a truckload from a certain village, the physician will do well to pay careful attention to discrepancies between the physical exam and the review of systems.  Often, I have found that certain patients attempt to present themselves as they were at one time during the past week, hoping to obtain treatment that they might be able to use the next time they are sick and cannot make it to the doctor.

There is an inverse correlation between patient distance and preventive care or tight control of chronic but asymptomatic medical conditions.  If, for example, a patient has diabetes that is not particularly symptomatic, their tendency to come in for medicine regularly is very low.  Even if they understand that poor glycemic control will result in vascular, visual, and neurologic problems earlier in life; getting to the clinic may in fact present a greater present problem that is assured rather than worrying about a potential problem existing in a future that is unknown and may not be.

The reasons behind a patient's attendance is a very important consideration for the brigade member, or short-term medical volunteer.  Brigades can provide a meaningful service in several ways.  Patients are more likely to receive free screening  for diseases such as hypertension, cervical cancer, and diabetes.  Certain brigades also focus on particular procedures or services such as cataract or plastic surgery ,providing a better quality of life for people who cannot otherwise afford these procedures.  For primary care and screening brigades, participants need not become frustrated if their primary service is passing out acetaminophen, antacids, diphenhydramine, scabitidal lotions, and eye-drops.  These treatments are over-the-counter and are found in most of our own medicine cabinets (okay, minus the scabicides).  They are remedies we take without a second thought.  They are for conditions which may cause the poor discomfort but which may not be worth their resources to obtain from a geographically inconvenient or otherwise expensive source. Being the bearer of symptomatic relief is not for naught.  Reducing suffering, however small, is the business of the physician.

andy

12/10/2006    "El Alacran"

Two weeks ago late in the evening around bedtime, I received the routine radio call from Rigoberto regarding "un paciente in mal estado."  Don Berto is no doctor, but he knows when to use certain words to get your fanny down to the clinic in a hurry.  Now, let me explain something about communication here in Santa Lucia.  On a good day, I can understand about 75% of what a Spanish teacher says in class.  Now, imagine you learned English in Honduras and had to get information from people in the hills of Appalachia.   This is a little like my learning to communicate with the patients here.  The less education they have, the more difficult it is for me to understand them and for them to understand me.  Add to the mix some adrenaline and excitement, 3-6 family members that usually accompany a sick patient to give their 2 Lempiras worth regarding the patient's condition, and a very ill-appearing young man; and you have a poor set-up for communication.  When I can't understand what someone is trying to communicate, I try to listen for the word that I  know I don't know.   All I could decipher amidst the loud voices and charades was the word "Alacran" being said over and over as the patient's father acted out the whole situation as if he were cutting corn with his machete right there in the clinic lobby and was attacked by a monster.

So, I took out a piece of paper and asked him to draw an alacran.  What he drew was a pretty fare representation of a scorpion, here in Honduras, el alacran.

A quick assessment revealed a 20 year old diaphoretic male who was severely ataxic, confused, nauseated, drooling and spitting, with a wet cough and tachypnea. I rated this as at least moderate distress.  A quick look in the tropical medicine book confirmed his classic presentation of scorpion envenomation.  He had been bitten 12 hours earlier and went home early from working in the milpa to lay down.  When his folks checked on him after lunch, he was not able to speak or stand up.  His tongue felt numb, his knees wobbly, his stomach upset.  As symptoms progressed, they brought him in the back of a hired truck.

Scorpion bites are very common here in the campo.  The locals say that they come out during the winds.  There are two types of venomous scorpions in these parts of the Americas.  The very young and very old may die from a scorpion sting.  The scorpion grabs its prey and uses the rear stinger to kill its prey.  Symptoms depend upon both the size  of the scorpion and number of times the scorpion is able to sting before shaken off.   The venom causes a mix of both sympathetic and parasympathetic hyperactivity, affecting many systems at once.  While most patients usually come in for neurologic symptoms such as severe ataxia and numbness that usually originates in the mouth and spreads to the extremities, death is typically due to cardiovascular or respiratory failure.  Other symptoms include local pain and swelling at the site of envenomation, hypersalivation, vomiting, confusion, blurry vision, diaphoresis, bowel/bladder hyperactivity, pulmonary edema from leaky capillaries, and overall muscle weakness.

Anti-venom is not available here, so care is supportive.  The fact is, most scorpion bites are not deadly.  Healthy adults do just fine.  Symptoms typically last for 36-48 hours.  Because anaphylaxis is possible, steroids and histamine blockers are given, but most patients here do not come in within the time frame of possible anaphylactic reaction.  Severe hypertension and hypotension are managed with blocking agents and fluids/atropine respectively.  Respiratory difficulty, if any, can be managed with oxygen therapy, vomiting with anti-emetics.  And the rest is waiting and reassurance.  Because we have no monitors or nurses here, we entrust family members to monitor  any patient staying for observation .  Thanks to the O'dea's, we do now have oxygen available, which makes us all feel better.

Since my first scorpion patient, I have managed two others, killed two scorpions of my own, and caulked the gaps between the wall and the floor in anticipation of Luke's crawling round in a few months.  And, I believe that they do come with the winds.

andy