H. pylori…Delivering Bad News…and I Get ‘Healed’

When I first started working with Tandana in March of last year a one-day, quadruple drug regimen for Helicobacter pylori was brought to my attention.  At the time, I was familiar with the 10-14 day, triple-drug regimens, the current recommendations by the American College of Gastroenterology.  The ACG recommendations are the current standard of care for H. pylori in the USA even though there is preliminary research showing it may not be superior to short-term treatments.  With the constraints of a one-day mobile clinic, the one-day treatment has become the standard Tandana protocol.  I was curious about cure rates between the two regimens and have been able to find only 2 or 3 publications on the topic; One is a review article and the others have very weak n-values. Additionally, no comparison studies with large statistical significance have been done, to my knowledge, during the past 5 years.  After using the one-day treatment at Tandana clinics, observing which patients return (or do not return!), and reviewing patient charts, I have become increasingly convinced that the short-term treatment is equal or superior to the long-term treatment. On the next day, in Mojandita, I encountered one of these patients that encourages my belief in the superiority of the short-term regimen. This young man brought with him a bag of mixed pills and said that he had been prescribed them the previous week for “stomach pain” and stopped taking them 3 days later after he had felt better.  Now the pain had returned and he was seeking further help. I could identify the omeprazole tablets (part of H. pylori treatment) and immediately sent him for confirmation of H. pylori. It came back positive as suspected and then the task was to educate him on the infection and explain the one-day treatment. It has been suggested that GI upset is more severe with the one-day treatment although there remains no scientific evidence to support this; however, a more complex schedule for pill ingestion is a part of the short-term treatment so making sure patients understand as much as possible is an important part of the treatment. One trick in making sure a patient fully understands the instructions for taking a medication is asking her or him to explain how, when, and with what the medications will be taken, without any help or hints. After he was able to do this he was on his way and I really, really hope to see if his H. pylori infection has cleared. In essence, reducing the time period that a patient must remain compliant to a regimen, should reduce the failure rate of the regimen.  Naturally, it is important to put some hard data behind such anecdotal evidence, and I look forward to doing so in the future.  Below is a table showing eradication rates from the 2003 paper.

Image not available.

Arch Intern Med. 2003;163(17):2079-2084. doi:10.1001/archinte.163.17.2079.

Another patient in Mojandita was a 12 year-old girl that had suffered from right, temporal headaches and decreased vision since 5 years. She was able to trace these symptoms back to a specific incident in which she had been hit by a rock, thrown by another child, and the symptoms had been there ever since. The Snellen acuity exam confirmed a discrepancy between the eyes and she had never sought medical help besides NSAIDs so Tandana was able to organize an Ophthalmology appointment for her. The clinical thinking here was that if we can get glasses that correct the vision in the one eye, we can reduce the headaches since they were likely being caused from each eye having a different acuity. This is one more patient that will hopefully have a resolution to a seemingly chronic problem.

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A group of school children in Mojandita

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Patient intake station

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The patient with previous eye trauma. Hopefully, corrective lenses will remove the chronic headaches.

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Dr. Varma and I examining patients

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Dr. Varma with translator and patient.

Moving on to the next day in the town of Achupallas, I came across a case that really got to me. Delivering bad news is as much an art as it is a science and this is the main learning point I took from this clinic. The patient was a G7P7, postmenopausal 55 y/o woman presenting with worsening left lower quadrant pain.  The history became increasingly troublesome after she reported approximately 500 mL of vaginal bleeding the previous weekend. The most serious concern with post-menopausal bleeding is endometrial cancer. A study showed that 5-10% of such presentations are subsequently found to have endometrial carcinoma. The differential diagnosis is also quite extensive, including cervicitis, cervical cancer, atrophic vaginitis, endometrial atrophy, submucous fibroids, endometrial hyperplasia and endometrial polyps. So, this patient would have to get a further workup, but first she would have to be informed of the concerns.  I found this algorithm while reviewing the topic and included it here for any colleagues that are interested:

AbnrmlUtrnBldAlgorhythmafp19991001p1371-f3

Am Fam Physician. 1999 Oct 1;60(5):1371-1380.

Education is often a large part of the process of delivering bad news. Before I spoke with the patient, I sought out the opinion of Dr. Varma, who by this time in the week had become more and more of a mentor. Part of me wanted Dr. Varma to find another, more likely diagnosis, or even say something like, “….there is ‘xyz‘, of course, which would be much more probable and less scary for the patient.”  I could then avoid the conversation I was worried about having, but these weren’t the words I heard. He concurred with my assessment and, for the first time in my medical career, I had to go deliver bad news to a patient by myself.  I had previously been part of a team: another medical student, a nurse, resident, or attending, and I appreciated during this clinic how delivering news as part of a team is easier.  I have read about the science of delivering bad news but learning from experience is by far the best way to improve the art of it.  Especially since it is such an important moment of human interaction. In the hospitals the worst news, of course, was delivered by the attendings and those I admired most were compassionate, yet remained focused and a little removed. The latter does not imply any less of the former.  They cared about the family and patient’s well-being but most reserved expression of it to a handshake. Otherwise, it would make it difficult to function at work. They were also respectful of the outcome possibilities, yet clear and direct communicating what they could, using definitive words so as to leave no ambiguity. Paralysis. Severe Brain Trauma. Dead. I was glad this conversation would not include such definitive outcomes as these, but as I explained why we were concerned she started crying and was visibly scared.  She became more comfortable as we developed a plan but after this patient I needed to take a few minutes to get some fresh air.

Fortunately, the Ecuadorian physician responsible for Achupallas was the same with whom I had worked last March. I was able to speak with her on the phone, explain my concerns, and she was also eager to investigate and follow-up with this case after we had gone. I remained in contact with Dr. Jess and she later informed me that the hospital had attributed the bleeding to fibroids; however, I hope to see her again in March and see how she is doing.

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Listmaster Lizzie.

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Examining patients in Achupallas

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The people that make it all work.

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This brings me to the last clinic of my trip.  In Agualongo, I saw a patient that was known by staff of the Tandana Foundation. He was an elderly man that had been hit by a car 40 years ago. His right lower extremity had been snapped like a toothpick, as I could ascertain from the history. I can’t remember if surgeons had attempted to salvage the fibula or how extensive the surgery had been, but what was clinically important at the moment was the foot. He had undergone skin grafts to replace tissue on the right foot but the damage had been so severe that it had never completely healed. The scar tissue was quite extensive distal to the ankle and most concerning was an ulcer on the heel. There was not enough granulation tissue to completely regenerate skin on the ankle and without the protective barrier he was constantly vulnerable to infection. This risk was amplified by decreased sensation in the foot and also because he continued to work in the fields on a daily basis, most of the time with no socks and porous footwear. Tandana had helped him with wound care over the years, and despite the medical desire to do something to completely resolve the open ulcer, I came to accept that the best we could do is clean, debride, and dress the wound. We tried to teach him how to use crutches but it was not possible to remove the weight-bearing habits he had become accustomed to. So, educating a family member on cleaning and dressing the wound as well as flagging his chart for follow-up at the next visit was the best long-term planning possible in this situation.

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The final day of clinics.

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Cutest. Patient. Ever.

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Having some fun on the last day.

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Fun with auscultation part dos

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A rapid test station

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Second. Cutest. Patient. Ever.

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After removing the shoes

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After several washes, still needed more.

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Amount of scar tissue was quite extensive.

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Trying to explain weight-bearing vs. nonweight-bearing.

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Weight-bearing vs. nonweight-bearing was a hard concept to get across.

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Week 2 Group. Well done.

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interpreter, doc, interpreter, doc

I started out my accounts of my trip with the unexpected case of the woman that was attacked by a swarm of bees. I mentioned that there was another unexpected, emergent case and this came unexpectedly on the last day. After the clinic on Friday we went to visit a natural healer who was called ‘Abuelita’ and was a long-time friend of the foundation. She was a sweet elderly woman and it was entertaining to listen to her, especially her comments on marriage. She said I needed to be healed, so I thought, “why not?”.  I have included pictures below and it basically entailed sitting on the lap of a tiny, elderly woman. She recited a traditional rhyme and poured cheap cologne down my back. The unexpected case came after the group had left.  Abuelita needed a checkup and as I was putting my instruments away, a boy standing next to me dropped to the floor.  It was completely out of the blue, but he was exhibiting a classic tonic-clonic seizure. His family had brought the boy to be cured by Abuelita for his seizure disorder. There was not much to do in the moment except keep him in the lateral decubitus position, monitor the ABCs, and reassure the family who had become quite scared and a little hysterical. It was the longest episode I have seen in my short medical career and as time went on I became more concerned. From the little history I was able to get, it seemed as though the boy had epilepsy and I did my best to explain the disease to them and suggested they see a specialist.  This incident reminded me of a phenomenal book I read called: “The Spirit Catches You and You Fall Down”. I highly recommend the best seller which provides a good account of differences in cultural beliefs regarding medical conditions and modern medicine.

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Abuelita, the natural healer

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Liz was ‘healed’ too.

I had wonderful experiences during the previous year and have immensely enjoyed sharing some of the events and interesting cases.  The cultural experiences and people I encountered, both from my country as well as Ecuador, made a great impression on me and I have always returned a little different of a person than when I left.  This has proven the rule more than the exception during my life travels and many people know the feeling of returning home after an incredible experience.  The feeling is well-stated by Jennifer Connelly’s character in one of my favorite movies, “…It’s hard to go back to sipping lattes and talking interest rates”.

Below are some final photos from my last days on the trip…

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I had WAY too much fun playing jump rope.

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How many dogs do you see? Hint: not 4.

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The Otavalo open-air market.

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Andean nights.

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The “Humanitarian Space”…Obesity…and A Really Small Worm

Our work in Ecuador is, in part, possible by the geopolitical stability of the country and region. As we are fortunate for the warm, friendly environment, it is not the case on other continents. The concept of foreign humanitarian aid organizations operating in a country is complex and fascinating and I want to share a specific topic regarding this aspect of humanitarian aid before continuing with week two.

There is a concept of the ‘shrinking humanitarian space’ that has been debated in the humanitarian aid community. Several scholars have written about a ‘golden age’ of humanitarian aid, including Dr. Marie-Pierre Allie, president of the French section of Medecins Sans Frontieres (MSF). The concept supposes that there was a period when NGOs were regarded as relatively neutral entities in foreign countries by governments, rebels, insurgents and other actors in a conflict. As Dr. Allie describes it in the MSF publication ‘Humanitarian Negotiations Revealed’: “…a so-called “golden age” when humanitarian actors supposedly occupied “a special position on the international political chessboard, within a privileged space, untroubled by the geostrategic and political considerations of governments.” This changed, as did many things, after September 11, 2001. Governments, lobbies and interest groups increasingly co-opted non-governmental organizations (NGOs) to achieve their own geopolitical or religious ends; thereby increasingly blurring the distinction between roles of government, military and humanitarian organizations. As a result all actors, states and insurgents, become increasingly skeptical as to the stated intentions of NGOs. There are many examples of this. Perhaps the most well-known example was the use by the CIA of doctor Shakil Afridi to organize a humanitarian vaccination drive campaign in Abbottabad as a front for collecting DNA samples to identify relatives of Osama bin Laden. Many people and organizations have been warning about the repercussions of such actions. Especially after the recent targeted killings of polio vaccination workers last Thursday and Friday. The Abbottabad incident was cited as the reason for the attack. Polio remains in only 3 countries on the planet, and is close to going the way of the guinea worm, small pox, and the dodo bird.  So it was encouraging to read last weekend in the Annual Letter from the Gates Foundation that they are continuing with the push to finish it off.  The other view of the Humanitarian Space is that the number of NGOs has been increasing so drastically in recent years that there has been an inevitable ‘shrinking’ of the space such groups can occupy.  It is certainly a luxury to give people the health care they need in a friendly environment…..as was most certainly the case when I woke up for the next day of clinics…

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The view after waking up was beautiful, the lack of coffee was not.

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A farmer already working on his steep-incline field is in the background. Also, I think Jordan handled the lack of coffee much better than myself.

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This little guy was definitely more awake and perky than both of us.

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The community center where the clinic would be set up later in the day.

Spending the night in Padre Chupa and waking up on-site was an interesting experiment.  Interesting not only in the sense of testing the predicted outcomes but also, as with any experiment, observing those unforeseen, including both benefits and drawbacks. Traveling at night (a trick learned from my backpacking days) would of course utilize the daylight hours the next day for access to a physician.  As they live off the land, it was necessary for the people of the indigenous community to tend to their crops and livestock in the early morning as well as walk to the community center. So it was unknown, the frequency with which the patients would come.  Those that came in the early morning were either traveling between fields or had made arrangements to free them for a short time or had access to cars to bring them from farther away.  Accordingly, there was an increasing number of patients as the day progressed as opposed to a large number lining up very early in the morning.  The latter was the scenario I experienced at the Gualsaqui clinic from my previous post from March, which contrastingly was a permanent clinic and closer to patients homes.  The patients that were seen in the morning were able to get scripts for their medications before the pharmacy arrived which was advantageous to efficiently and quickly see the many, more straight forward cases, such as primary generalized arthritis, yet it also produced a small bottleneck of patients collecting their medications simultaneously when the pharmacy station had arrived.  Overall, the experiment appeared to be a feasible strategy for conducting a mobile clinic and ultimately seemed to me to be much more effective and useful with communities with a larger patient load and those farther rather than closer to the teams point of origin.

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The team arriving

There were a lot of patients in Padre Chupa and although I saw more patients on this day than all the others, I did not encounter any obscure conditions. The problems I encountered were all consistent with those of the rural, self-sustaining communities: Primary Generalized Arthritis, Pterygium, Prenatal visits, Parasites. There was a patient that exhibited the stark contrast between these conditions and the health of a person living in an industrialized community. My first patient of the day had driven up from a nearby town. Although this older patient had arthritis, as did the local people, it was not nearly as advanced. She also was the only patient I would see that day that had both hypertension and obesity. Body mass index, BMI, correlates with body fat in most cases and is a good indicator of obesity. It is calculated as weight/height2 and the range of normal is generally accepted as 18-24.9 kg/m2.  The World Health Organization designations for obesity are the following:

  • Grade 1 overweight (commonly and simply called overweight) – BMI of 25-29.9 kg/m2
  • Grade 2 overweight (commonly called obesity) – BMI of 30-39.9 kg/m2
  • Grade 3 overweight (commonly called severe or morbid obesity) – BMI greater than or equal to 40 kg/m2
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A waiting room in the clouds.

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The eye station is well underway.

The patients I saw from rural communities measured consistently around 20 kg/m2, while many of those closer to the modernized cities were above 29 kg/m2. This first patient showed this very clearly, as I measured her at 29.9 kg/m2. There are many factors behind this such as processed foods and hard labor; however, a way to assess these causes and more is lifestyle.  Lifestyle: A mosaic, if you will, made from the personal choices made in areas such as transportation mode, food, entertainment, exercise, activities, sports, technology.  Although genetics play a role in some cases, there are numerous studies that have shown the effect of lifestyle.  One such study compared US-born and foreign-born Asian Americans and showed that birth in the US conveys greater risk of obesity. The question was whether retention of Asian culture might be protective for obesity despite acculturation to US lifestyle. Acculturated respondents had higher adjusted odds of being overweight/obese than bicultural respondents, but bicultural respondents had similar odds of being overweight/obese as traditional respondents. Among the bicultural, second and first generation respondents were equally likely to be overweight/obese. In this study, biculturalism in Asian Americans as measured by Asian language retention appeared protective against obesity. So, cultural lifestyles greatly influence obesity. A visualization of the results from the study is below and the paper is available on PubMed.

Microsoft Word - Asian_American_Obesity__Figure_1_

Age-adjusted percent overweight or obese by Asian American acculturation category and generational status. Age-adjusted percentage of respondents in each category who had BMI ≥ 25 are plotted as bars, with error bars representing standard error of mean. Solid bars represent respondents grouped by acculturation category; checkered bars represent respondents grouped by increasing generational status.
J Immigr Minor Health. 2011 April; 13(2): 276–283.

Parasites were one of my favorite things to study in medical school. Science fiction writers had not come close to imagining such cool, complex life-cycles that natural selection had created over millennia and I suspected that one or two of them had opened a parasitology textbook at some point. Parasites are extremely common in the rural, isolated indigenous communities and must remain on the initial list of differentials.  Symptoms from parasites vary drastically; they can be completely asymptomatic, mimic conditions of any organ system, as well as complicate the presentation of another condition already present, therefore it is helpful to verify clinical suspicion in complicated cases using a microscope. This is done by visualization of the organism itself, it’s eggs, or evidence of it’s presence in a blood smear. This can be done rather quickly with a compound microscope; however, during the October trip we did not have access to a microscope so it became a diagnosis of exclusion. Of the hundreds of patients treated for parasites during my time at the clinics, there was only one I saw (on this day) with every textbook symptom for Enterobiasis.

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Gina and Liz brought stickers for the pediatric patients…..smooth move #1.

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Note: he is not enjoying the intake process with Liz…..

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….and now it’s not so bad…smooth move 2.

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Getting some pharmacological recommendations from Dr. Varma

Pinworm infection is caused by Enterobius vermicularis, a white, slender nematode (roundworm).  The female is characteristically 8-13 mm long and the male even smaller at 2-5 mm. It is normally a pediatric condition, but infects adults as well in areas of high prevalence and poor hygiene, and this last patient of the day was in his 40’s.  It is actually the most common helminthic infection in the USA, but the vast majority of cases are asymptomatic and almost exclusively in children.  Humans are the only species that can transfer the parasite and it’s life-cycle is one of the most straight-forward of all the parasites I have studied.  It is acquired when a person ingests the eggs, which are 50-60 µm X 20-30 µm.  The larvae hatch from the eggs in the small intestine and the adults reside in the lumen of the cecum, which is the blind pouch at the beginning of the large intestine and the location of the opening to the appendix.  At night, typically, the females migrate around the large intestine, lay the fertilized eggs in the perianal region and then return to the cecum.  This action triggers an itchy sensation and the unconcious host will then reflexively contaminate the fingers and spread the eggs.  As unpleasant as this sounds to us, it is actually quite a clever reproduction cycle for an organism.  Since the eggs may survive for up to 3 weeks ex-vivo, become airborne, and survive on fomites such as towels, clothes, carpet, etc., many people living in close proximity can become easily infected. So this gentleman steered our thoughts to Pinworm with the complaints of difficulty sleeping, loss of appetite and noctural perianal pruritus.  Additionally, he mentioned a discomfort in the right lower quadrant of the abdomen at McBurney’s point.  All physical exam signs for appendicitis (Rovsing’s, Rebound, Psoas, Obturator) were negative and it was of months duration, so it all added up to a large load of the parasite in the cecum.  The final confirmation of Pinworm (and the first time for me) was on further physical examination when we actually visualized the female nematodes themselves.  So we loaded up the patient with as much anti-helminth medication as we could and educated him on transmission of the parasite.  Albendazole is the drug of choice in the Andes region of Ecuador because it is effective against most of the parasites found there.  Sometimes medicine isn’t cute and clean, but it’s pretty cool.

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The life-cycle of Pinworm.  Found at: http://www.cdc.gov/parasites/pinworm/biology.html

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Hanging out near the end of the day.

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We had dinner with friends of the Tandana Foundation that evening. The Tandana leadership are here with chef Claudia and her family.

Larcacunga

During the weekend between clinics I took time to meet with my Ecuadorian family that had welcomed me into their home six months earlier. As before, they were so welcoming and were quick to open their home, share their family, and create a feast for an old friend.  I played guitar with the dad, Segundo, and if I had not fully developed a taste for cuy (guinea pig) during the previous week, my family made certain I had the opportunity at their house. I believe they prepared around 12 to 15 of them for the meal. It was a very kind gesture on their part and I didn’t shy away from a second chance at this cultural delicacy.

Cooking up some guinea pigs with my Ecuadorian family

Cooking up some guinea pig with my Ecuadorian family

At the end of the weekend I met members of the new group. Some people remained from the previous week and many of the new arrivals had participated with Tandana Foundation in the past. Among the freshman volunteers was the physician with whom I’d be seeing patients. Dr. Varma had long supported the foundation and this next week would be his first time coming on a mission. On previous missions I had worked with a pediatrician and PAs and this time I was excited to work with an experienced anesthesiologist. Each physician brings her or his own personal, clinical experience and knowledge with them and, as is common practice in medicine, there is a lot that can be learned in the mentor-protégé relationship. I was definitely looking forward to see how this developed between Dr. Varma and myself. As for the rest of the group it was quickly apparent to me that the group of ER nurses from Portlandia brought with them not only a great fountain of knowledge and experience but also their sprightly sense of humor and zappy personalities to be expected from people from the second best coast in the USA 😉 . Even the participants arriving with no previous health care experience were so positive and motivated that the second week was shaping up to be as good as the first.

Larcacunga was the first village for the second week. I had never been to this community, so as was the case at the beginning of last week, I would not have patients that I had seen before. Big G (from the previous post) picked up our well-rehearsed and prepared group in the morning and we set up quickly upon arrival at the community center. I didn’t notice until later in the day but the bus’s axle had completely snapped after I had gotten off the bus…see photo below.  The pathologies that day encompassed many specialties:

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The axle is shot but Big G, in true form, made a call and had another bus for us by the end of the clinic.

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Setting up the clinic stations at Larcacunga

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Liz, an awesome ER nurse from Portlandia, assessing patients.

Gastroenterology: One of my first patients had classic symptoms, signs and history of alcoholic liver disease. He complained of intermittent, right upper quadrant pain, exhibited right hypochondral tenderness on deep palpation and noted that the pain occurred mornings after he had consumed alcohol.  Although there were no signs of jaundice present in the skin or sclera, he complained of chronic pruritus as well. His past medical history was significant for problems with his gallbladder, although he could not be more specific than that.  Because of these facts, it was important that we educated him on alcoholic liver disease and it’s consequences as well as refer him to the hospital where they would be equipped to further investigate.

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Jordan at the acuity station.

Obstetrics: I previously mentioned we had received a donation from DRI of an ultrasound.  One of Dr. Varmas patients knew she was pregnant but had not sought out prenatal care as of yet.  This provided the opportunity for us to use the ultrasound that we had used the previous week.  It didn’t have visualization capabilities, so a referral to the clinic was indicated but before she left, Dr. Varma and I examined the fetal heart sounds, prescribed prenatal vitamins, and educated her on the importance of visiting a doctor for continuous care during her pregnancy.

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Dr. Varma and I assessing fetal heart rate in a patient.

Gynecology: I had a patient that presented with metromenorrhagia, dysmenorrhea, and dyspareunia.  She came with her two daughters, who also needed a checkup, but it was important to sort out her condition before moving on to the little ones.  On examination she exhibited a positive Chandelier sign which, together with her reports of a long history of gynecological complaints, indicated pelvic inflammatory disease.  Due to the brevity of our presence in the community, we treated her appropriately as an outpatient with the standard treatment of 100mg doxycycline for 14 days. Gynecological infections are very common in these communities and are more taboo to discuss than, say an upper respiratory tract infection, so it was important to identify and confirm the problem, establish a rapport with the patient, educate, and treat this case.  Then we could move on to her children…

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Teaching dental hygiene

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Brushing class was quite popular

General: The mother complained simply of her children having an intense “itching” of their heads.  On examination, lice could be seen adhering to the hair shafts.  It was a textbook case of Pediculosis capitis and the most important aspect after identification was educating the family on how to eradicate the insects.  We had topical ivermectin and shampoos in stock, and the mother had seemed quite eager to get rid of the pests, so after some instruction, they were on their way.

ENT: There was even a case of cerumen impaction but nothing to rival the cases I described from Monday of the previous week. Nevertheless, I became acquainted with the alligator forceps again.  It was a 9 year old girl coming for a regular checkup and I discovered a left ear canal completely occluded with wax.  This blockage was much, much easier to extract than those from the previous week. There was also a child with acute otitis media with perforation, which we had seen before in other communities and treated with a 10-day course of amoxicillin.

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Dr Varma and I contemplated the need for manual extraction of cerumen from the auditory canal.

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Myself becoming more proficient with alligator forceps and clearing auditory canals

The clinic at Larcacunga was not fast-paced that day which provided a good ‘ice-breaker’ for our newly formed medical team.  That evening we reviewed our stations and teamwork and discussed how to improve for the next day.  We would be going to a rural village, Padre Chupa, that is more isolated than Larcacunga.  After the group dinner that evening Jordan, one of the Tandana staff, and I got a ride from Segundo (from my Ecuadorian family) up into the mountains and through the thick fog and clouds to Padre Chupa.  It was the first time I experienced fog so thick that you could not even see beyond the front of the truck.  In anticipation of a large patient turnout and a long commute we camped at Padre Chupa that night and started seeing patients early as the trucks made the long drive the following morning.

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Asleep at the wheel.

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A local woman showing her artisanal skills. This intricate needlework common on the blouses of the indigenous women.

An Extremely Rare Condition…and a World Cup Match

This post brings me to the final clinic for week one.  As always the week went by quickly.  We returned to Panecillo, a community on the outskirts of the town of Otavalo, where we stayed every night.  Since it was only a 10-15 minute drive away, we had a more relaxed morning. At the prospect of attending a FIFA World Cup qualifier match that evening in Quito (2 hour drive), between the Ecuador and Chile national teams, a few of the staff went up to the community a bit early so we could get started immediately. The Tandana Foundation helped to build the community center where we would be working, and as you can tell in the photos, it is one of the more luxurious buildings in which we have set up our clinics.

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The new community center in Panecillo

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Patients registering for the clinic

There were the usual complaints that morning and it was a busy day.  Panecillo had many of the modern luxuries such as soda, obesity, potato chips and hypertension. These were all practically non-existent in the self-sustaining, rural communities we visited.  Mixed in with the usual conditions, there was an individual with an extremely rare condition.  He had been seen during Tandana clinics previously, but not by myself.  His left, lower extremity was very enlarged and beckoned a glance from any passerby.  This was, however, not the reason he had come to us. He had been told cholesterol was important and had come because of a concern that it might be too high.  He presented to me the herb he had been taking from a traditional healer and since we couldn’t test LDL and HDL at the clinic, I gave him a general check-up and wrote a referral to the hospital where they were equipped to check cholesterol.  In addition to the deformity of his extremity, there was a peri-oral port-wine stain.  I reasoned that since the observations of the birthmark and the enlarged leg indicate a congenital malformation, there was a high probability of an additional, internal malformation that had been overlooked.  On auscultation, there was a grade IV systolic murmur.  He had never been told this, so we made certain to refer him to the hospital for an echocardiogram, EKG, and complete cardiovascular workup.  After I returned to NYC, I investigated this condition because it seemed so unique.  PubMed research has led me to….drum roll please…..Klippel-Trènaunay syndrome!  It’s so rare that it’s exact prevalence in the world is unknown. It was fun to learn about this condition.

Klippel-Trènaunay syndrome is also known as angio-osteohypertrophy syndrome, congenital dysplastic angiectasia, elephantiasis congenita angiomatosa, hemangiectatic hypertrophy, KTS, and osteohypertrophic nevus flammeus. The criteria for KTS are: 1) Port-wine stain, 2) Abnormal hypertrophy of soft tissue and bones, 3) Vein malformations.  The etiology is unknown; however, researchers suspect that the condition may result from changes in one or more genes that regulate the growth of blood vessels during embryonic development. No associated genes have been identified and it is also hypothesized that the condition is sporadic since there is no family history of the disease present in cases of KTS.  These somatic mutations (altered DNA after zygote formation) occur very early in embryogenesis and affect only specific areas of the body.  Usually only one leg.  Rarely this disease is associated with syndactyly (fused digits) or polydactyly (extra digits) and as you can see below, this was the case in this patient.  The known complications of KTS are cellulitis (due to the large volume of interstitial tissue that increases risk of infection), deep vein thrombosis and pulmonary embolism (because of the venous malformations), immobility, and psychological concerns. There is no cure for KTS and it treatment is conservative and symptomatic.  These patients should avoid anything that would encourage a hypercoagulable state, such as contraceptives, because of the already high risk of a venous thromboembolic event (VTE).  Naturally, when desired, surgical amputation would greatly reduce this risk of a VTE, increase mobility, and possibly help with self-image concerns.  Here is more on KTS for those interested. I am continuing to learn more about KTS and I am yet to find any documented heart malformations specifically associated with the disease.  If anyone has any information on that, please send it my way.

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Klippel-Trènaunay syndrome. Two of the three criteria are visible, the enlargement of one leg and evidence of an enlarged vein. Also, the rare characteristic of syndactyly can be seen. Patient consent was given for educational purposes.

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Patient consent obtained for educational purposes.

When the clinic was over many of us jumped on the bus with our always-reliable driver, Don Galo.  I must insert that his driving skills and awesome personality have earned him a celebrity status with myself.  ‘Big G’, as I refer to him, raced us directly from the clinic to the sprawling capital of Quito and right up, through the crowds, to the stadium.  We took our seats just as the game started.  It was interesting to see a match in Ecuador, let alone an important one, where the pitch was surrounded by a 20-ft high chain fence and a 20-ft deep moat in front of it.  Oh, and police every 2 feet.  Ecuador won, so that was just icing on the cake.  The team for week one worked wonderfully together and we enjoyed a pleasant Saturday together before most people headed home.  The next group would arrive over the weekend for week two….

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Had to get a pic of me with Big G.

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Ecuador vs. Chile!

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After the game out for dinner in Quito with beautiful view of the city.

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Me, my translator/mountaineering guide Vinicio, and Big G with Quito lights in the background.

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Beautiful Quito at night

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The farewell dinner for week one.        IMG_1051 Some local music

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Le Lechero Tree

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Some of the group got some horseback riding in before heading home.

 

Minas Chupa: Returning to the Top of the World

Before I report on the events of day 4, I wanted to comment on the current humanitarian crisis in Mali. The Tandana Foundation expanded it’s work into this Western African nation several years ago, which has until recently been considered a fairly stable, albeit, impoverished democratic country. There have not been medical missions as of yet; however, there were yearly missions improving village infrastructure, sanitation and agriculture until they had to be suspended due to escalating turmoil.  While I was in Ecuador during the March 2012 health mission, there was a military coup half a world away.  I specifically remember reading about it online because it happened on my birthday. The military officers took control of the government while the president was out of the country then several factions and rebel groups saw the opportunity to take advantage of the situation. Unfortunately, the prevailing group was Ansar Dine, part of Al-Qaeda in the Islamic Maghreb, and took control of the entire north of Mali.  Not surprisingly, they are mostly foreign fighters, religious extremists, have destroyed UNESCO-protected Sufi statues that were centuries old, and implemented a barbaric, inhumane rule of law on the Malian peoples. Here is a timeline of the political history of Mali, from which one can see why France has stepped forward recently to save it’s former colony. In December 2012, France called a UN Security Council session to address the devolving situation and a resolution was passed to retake Mali from it’s captors.  I predict this story will pick up momentum in the coming few years and here are a few current, brief articles from todays buzz on humanitarian aid websites:  Doctors Without Borders; AlertNet, CNN International, AlerNet 2.  Now back to the fourth day of health clinics from October….

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I was looking forward to returning to Minas Chupa for a long time.

It is no secret that Minas Chupa is my favorite community to visit during clinics in Ecuador.  This is because every part of the day is amazing, starting with getting there.  The drive is well over an hour, depending on conditions, and took us up, and up, and up. Driving from paved road, to dirt road, to gravel road, the latter of which hugs the mountainside of around 10,000 ft.  There isn’t a distinct village per se, in contrast to the other destinations we had during the week.  The family’s homes are spread out over a large area, literally hanging onto the side of the mountain and there is a ‘community center’ which provides a location for education, meals, meetings of elders, etc.  Getting to this center can entail a significant trek from their homes, as some of the peaks are separated by thousand-foot drops.  The community center is nestled amongst these peaks, cliffs and valleys of the Andean mountains. Spring provided a clear view of the surrounding peaks and valleys, but my most recent visit in October was punctuated by stronger winds and a dense cloud with semi-frozen rain pounding the tin roofs of the buildings.

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Beginning of the caravan up to Minas Chupa

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Scenery along the way to Minas

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Still going

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Closer to the top of the world

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These little guys were making the trek to the community center.

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The clouds obscure the view of the cliff which was a couple feet from the left side of the truck.

Here are 30 second videos of the drive.  I couldn’t figure how to upload them here, so I am linking to the YouTube.  One Two Three Four

Once there, the amazement continues for me with the people themselves.  They are completely self-sufficient in their world up there.  They spend long, hard, full days farming their subsistence agriculture which is easy to imagine but when experiencing the incline of the fields, intense and constant solar radiation, cold temperatures, rain and winds, it is quite impressive.  Medically, they are fascinating as well because being a self-sustaining community, they tolerate a lot of wear-and-tear on the body.  This makes sense, considering the long journey to get to a clinic, let alone a hospital with full facilities.  Accordingly, upwards of 90% of the complaints that day were caused from primary generalized osteoarthritis.  One of my patients, however, had returned to us from the March clinic.  He was one of the several patients that had been in my mind between March and October because he had signs consistent with an underlying pulmonary condition.  I described it in more detail in this previous post.  It is a rule-of-thumb that most of these patients will not follow-up with a referral; however, this man had indeed traveled to the hospital for a chest X-ray which showed no signs of pulmonary pathology.  It was a happy resolution to my months of wondering about him and it was a pretty cool feeling to hear him say he remembered me and had come back for a general check-up.  There was also a patient encounter that indicated to me these clinics are having a positive, deeper effect within this community that I like so much.  She was an elderly woman that had never, in all her years, visited a ‘western medicine’ doctor.  When I asked why now, why us, she answered that her friends had come in March and strongly recommended she come to one of our clinics for her condition which had been present for years.  She presented with intermittent vertigo, nausea, vomiting and migraines after her husband had “stomped” on her head multiple times several years ago.  I was surprised at how open she was about her situation and was happy that she had left him years ago. I was surprised that she had left him because the reality of social stigma, and sustaining oneself as a woman in such communities is very difficult.  In the end, she seemed just as happy to chat about her life as try something for her condition so after examining and then listening for a bit, and seeing what medications we had available, I decided to try a small-dosage antihistamine for it’s anticholinergic effects.  I will no doubt be wondering if this succeeded until the next clinic and hoping she makes the trek to see us again.

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“Hey, nice office Aaron. Love what you’ve done with the place and your instrument decorations.”

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Hope comforting a new brush recipient. And the recipient using the face I use when I remember I still have to go do laundry.

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Our pharmacist Carol chilling out with a friend.

Pterygium is a condition I have mentioned previously and encountered with every patient in Minas Chupa, although most were not aware of it’s presence.  It is very, very common in these indigenous communities that are subjected to powerful, constant solar radiation and strong winds and weather.  The pathophysiology of pterygia is resultant from the chronic trauma to the eye and is characterized by elastotic degeneration of collagen and fibrovascular proliferation, with an overlying covering of epithelium. This neo-proliferation of tissue forms over the conjunctiva and can, over time, extend across the cornea. Interestingly, they can be an incidental finding, cause mild irritation, cause pain or even obstruct vision. This is because pterygia can range from small, atrophic quiescent lesions to large, aggressive, rapidly growing fibrovascular lesions that can distort the cornea and eventually obscure it’s optical center. Treatment is relatively simple and heavily reliant on patient compliance.  Very severe cases might require sugery; however, the first approach is frequent lubricating drop (RefreshTear) usage, UV-sunglasses, and for severe cases: topical corticosteroids.

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With patient consent, I took this picture to show a good example of Pterygium. Time to get this gentleman some Ray Bans!

As we were in Minas Chupa that day, they were building a large stone oven for the community.  Watching them work together to build this oven was quite fun.  They appeared happy and chatty as they passed stone down the line from person to person and a group of elders stood in the corner discussing the project.  So our health clinic team parted ways with the Minas Chupa construction team in the afternoon and headed back down the mountain.

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Teamwork in action as they pass the stone down the line.

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Before I got into the truck to head home, I took a peek at the progress of the oven.

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This picture is from March 2012 when it was much clearer, but it is my all-time favorite photo, so I included it. Credits to Natalie. Well done Natalie, well done.

Day 2, Day 3…..and Why Humanitarian Aid anyway?

The United Nations High Commission on Refugees estimates there are almost 125,000 refugees (UNHCR Global Trends Report) in Ecuador, a country with a population of only 15 million. While the majority of forced displacements are in Africa and the Middle East, the largest displacement in the Americas is from the country directly to the north of Ecuador, Colombia. For perspective, the USA, with a population of over 300 million, has 260,000 refugees.  Quite a heavy load for a developing country with a much smaller population, gross domestic product, and major internal issues. For example, since 1830, Ecuador has had over 20 Constitutions and most recently, after being elected President, the American-educated economist Rafael Correa immediately constructed a new Constitution which removed term limits for the presidency in a Chavezesque manner.  Next month he is running for a 3rd term.

Violence against women is most certainly a concern in Ecuador, but is also a worldwide humanitarian crisis.  The problem is so severe that it made the list of the UNHCR Millennium Goals, major world crises that demand action.  The United States has addressed this issue in the recent past. The November 29 issue of the New England Journal of Medicine reported the new recommendations from the United States Preventative Services Task Force for physicians to screen non-symptomatic women for intimate partner violence and domestic violence.  A small, easy-to-implement action that could discover hidden cases and decrease negative social outcomes. The National Institute of Statistics and Census of Ecuador reported in March 2012 that 60.6% of women in Ecuador experience some kind of violence at some point in their lives. A shocking 6 out of every 10 females. The 2010 US State Department Report on Human Rights in Ecuador provided some statistics on this issue in Ecuador: Prosecutors received 5,036 reports of sexual crimes in Ecuador between January and June; The National Police detained 1,285 individuals; 552 complaints were actually documented and filed; The Office of the Prosecutor convicted 346 persons of rape between January and October.  So if the true positive (actual, reported) cases would be a tip of an iceberg, then the tip would be the size of an ice cube sticking out of the water and convictions would be a couple snow flakes on it. Altogether, with a burden of proof heavily placed on the woman, a taboo subject matter, and a dubious litigation process, it is clearly a complicated problem.

These are only a few of the issues that highlight the importance of humanitarian aid in Ecuador and the world. As I reflect on 2012, I remember several conversations over the course of the year that impressed upon me greatly.  On different occasions, while discussing work being done in the humanitarian aid community that has inspired me, I recall several interesting responses. One was a query of “Why bother with ‘bad news’ and ‘plights’ that won’t ever be eradicated or solved?”. These comments reenforced to me that I am doing the kind of work I should be doing, because my philosophy is: although certain problems will never be eradicated, contributing to such problems how and when one is able, multiplied by many people working together, must certainly be more effective than a global apathy. Another great aspect of humanitarian aid is that it doesn’t include only medicine. After disasters like hurricane Sandy, the earthquake in Haiti, or Tsunami’s in Japan and Thailand there were people making sandwiches to hand out, distributing blankets, even writing down names into a crude, makeshift database of pen and paper to reunite people. Even in non-disaster areas, humanitarian aid incorporates teaching English, math or science, building infrastructures, and much more.

These are some of my views on the ‘why’ of such missions and now I’ll continue with sharing how fun conducting such missions can be:

During the second clinic for the week I was wondering if I would see any of the patients I treated from the March trip.  We went to Cambugan, a village that had a pretty strong turn-out of patients in March and this time there was a similar number of patients to be seen.  I was able to see the man that had had a severe concussion in March. He was doing fine and returning due to the pains of working in the fields. As to be expected, there were cases of primary generalized osteoarthritis, non-symptomatic presentations of pterygium, and cerumen impaction (but none as bad as in my last post!). I previously wrote about our discovery of a viral outbreak in Cambugan, which called for a lot of community education on transmission. Although there was not an epidemic this time, there were signs of a viral spread of another sort.  Rather than a respiratory virus, this time it was the Human Papilloma Virus. HPV was visible on many children in the community, most likely spread from communal living and lack of awareness about the mode of transmission. Cantharone was applied when appropriate size and severity of the warts was present and all were educated on the importance of washing and transmission. After the clinic we visited an indigenous, artisan family that had made traditional flutes for many generations.

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Showing us how she makes a small flute within 10 – 15 minutes.

Urkusiki was another village that was new for me, and it was our destination for day 3.  The children were lined up to greet us when we arrived.  The community center, with a backdrop of the Andes mountains, was set up in a manner that there was a narrow pathway to enter the square and many of the children were lined up next to each other along this pathway. One of the Tandana staff and I entered the ‘arena’ high-fiving along the way as though we were running onto a football pitch.

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Aaron high-fiving the team of little guys on the way into the community center

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The center square of Urkusiki community center with it’s beautiful scenery.

One difference from March for this trip was that we had received a donation of an ultrasound device from Direct Relief International.  It was not the type able to transform the ultrasonic waves into an image, rather the receiver was connected to a speaker.  It was a small but important improvement in our examination capabilities because it allowed us to amplify and monitor fetal heart rates without using a stethoscope.  One of the first cases of the day provided an opportunity to use the device and the mother smiled brightly when she heard the 126 beat-per-minute heart rate of her baby.

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Checking blood pressure on a patient at our Urkusiki visit

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I found a minute between patients to test out my hoola-hoop skills.

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Photo-bombing in Ecuador!!

That night, after a little rest and relaxation, the group convened at a restaurant in the town of Otavalo for dinner. Now, I had discovered in March that the Guinea Pig had a special place in the culture of indigenous peoples of this region.  One of my favorite photos is from that trip last Spring of a statue of an angel holding one of these rodents.  As if she is delivering the Guinea Pig unto the people.  In addition to being considered holy, it is considered a delicacy.  I decided that if given the opportunity, I would eat it this trip.  The name for Guinea Pig is ‘Cuy’ and when I discovered it on the menu for this restaurant I couldn’t resist the temptation.  So, after unsuccessfully lobbying others to expand their culinary boundaries, I am happy to say that I enjoyed my Cuy with avocado that evening.  A truly unique taste.  The next day, we would be driving to one of the most secluded communities and the one that remains my favourite…

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Angel delivering the Cuy!!!

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Guinea Pig du jour, served with fresh, sliced Andean avocado.

Ear Day

Introductions and orientation took place the weekend before Week 1. I met the four Physician’s Assistants I would be working side-by-side with that first week as well as the rest of the team. A couple of the PAs were from NYC, so it was great to chat with people from my neck of the woods, and the other participants were from all across the country, which is always fun to learn about life in other regions of the country.  Additionally, most of the people for that first week of clinics were veterans of the Tandana missions and with 5 providers it summed up to a comfortable way to start to the trip.

Guachingero was the first clinic of the week. I had not been there before, so the patients and families would be entirely new to me.  Everyone had chosen a desired station (patient intake, blood pressure, eye testing, etc.) and had practiced the night before.  There were not many patients on that first day, so with 4 PAs and myself I was able to devote a large amount of time to a few patients.

Kelly, one of the PAs, ready to get started with interpreter Jordan

Kelly, one of the PAs, ready to get started with interpreter Jordan

A gift from the dentistry team!

A gift from the dentistry team!

I believe I saw 4 patients that first day. They were in their 60s or 70s, with physical characteristics typical of the hard working indigenous peoples that added about 20 years to their appearance. Two of my patients came to the clinic with hearing loss so severe that my interpreter had to speak loudly directly into the ear. However, it was not their primary complaint; they came to see us regarding their primary generalized osteoarthritis. A good analogy as to the frequency of this complaint would be Diabetes in the USA.  The interesting moment came when investigating the hearing loss, on otoscopy, I could see nothing but HUGE, black masses in the ear canals. Looking through my instrument into the auditory canal, I could see that there was total occlusion.  They had never cleaned their ears and had accepted the hearing loss as part of getting old.  As expected, the Weber-Rinnes test indicated a conductive hearing loss.

Patient intake

Patient intake

Acuity testing station

Vision acuity testing station

The typical procedure of cerumen removal, both in the US and at our clinics, is to put peroxide in the ear, let it loosen up the wax, then wash it out with warm water.  (Note: even at home Q-tips are NOT recommended) This was not enough to clear out the ear canals. Such severe cases require a referral to an ENT specialist, which was done; however, a pretty standard rule during these clinics is that patient compliance after being referred is very poor.  I strongly suspect there are many factors causing this such as culture, poverty, language, education, and more. It would be interesting to do a study as to the specifics of why there is such poor compliance in these communities. So, with this low compliance in mind plus a slow influx of patients, I decided it would be best to manually remove what I could before they left the clinic.  I had previous experience removing a small piece of cotton (reason for not using Q-tips) from deep in a patients ear in the ER back home, so I thought this would be relatively easy due to the size of the blockage.  Here is where I should probably thank Hasbro for making the game Operation or whoever gave it to me as a child. If you’re not familiar with it (you poor deprived person!), it was the game where one has to remove an object from an annoyingly small opening in the board without touching the sides using plastic tweezers. Touching the sides a buzzer would sound and the patient’s nose would light up, indicating you were not precise enough with the ‘foreign body removal’.  Every emergency department has a wonderful tool for foreign body removal called the Alligator forceps.  So named because the tip of only a few millimeters opens in the same fashion as the mouth of the eponymous reptile.  Naturally, this was more delicate than a silly board game. The tympanic membrane (eardrum) lays at the end of the ear canal, separates the outer and middle ear, and amplifies vibrations received via the canal. It was important to not push the cerumen into the membrane and obviously avoid grabbing/poking it with my mini-reptile.  I found ways to stabilize myself, but the patient was another matter altogether.  Although he had been instructed not to move, at one point mid-extraction he jerked his head toward me.  I reflexively jerked my hand back and discovered just how fast I can turn from concentration into very, very angry!  As an inverse of the board game, his nose didn’t light up but I’m pretty sure mine did.  I can’t imagine how I appeared to him, and can’t remember exactly what I said, but I do remember it wasn’t with my library voice.  Anyway, he didn’t move again and I spent most of that day manually removing blockages of mixed wax, shed layers of epidermis from the canal, and bacteria that had accumulated over, most likely, decades, from both ears on two different patients. The largest was approximately 2cm x 3cm, or the size of a green table grape. Sorry if I just ruined grapes.

Alligator forceps and only half of one of the blockages

Alligator forceps and only half of one of the blockages

Each case showed exponentially improved hearing after retesting and they most likely had hyperacusis for a few days because their ears and brain had adapted to their condition over time.  The best moment was when I showed them what I had removed and explained it had been in their ear.  Their expression was priceless.  We packed up and enjoyed the evening with a local family.

Here we see the Tandana leaders having absolutely no fun after the clinic when we made dinner at with a local family. DISCLAIMER: No appetites were harmed in the process of conducting the health clinic ;-)

Here we see the Tandana leaders having absolutely no fun after the clinic when we made dinner with a local family. DISCLAIMER: No appetites were harmed in the process of conducting the health clinic 😉