Back At It Again!

The one day strike that occurred earlier this week was successful, as Dr. Salete explained to us that the doctors got what they were asking for. Now, back to work we go!

There were several cases we saw yesterday. The first one was a one month old baby boy with Hirschsprung’s Disease. This disease causes a problem with the intestines where a certain segment of the intestines fail to relax leading to obstruction . Normally during fetal development, a certain cell type called the ‘neural crest’ cells migrate to the intestines and form nerves to help regulate relaxation of the intestinal muscles. When these nerves fail to develop, certain sections of the intestines can’t relax leading to obstruction and the parts of the intestine that comes before this ‘squeezed’ or tightened area becomes super big (megacolon). Typically, the section that lacks the nerves is removed and the intestines are reconnected.

The one month old we saw will have his surgery at a later time, but we saw the surgeon, Dr. Galindo, put a central line in him. At first, he tried putting in the line using the right subclavian vein, which is pretty typical. But it just wouldn’t work. He tried the left side without success. Finally, he went for the right saphenous vein which finally allowed him to get the line in. That was interesting to see because I’ve never seen that being done on a baby before.

The following case was a young boy about 7 years old whom Erica and I had seen last week during our time on the infectious disease floor. The patient had a history of a serious fall about a month ago and he later presented with difficulty breathing. When they did imaging on him, he was found to have what looked like a large area of abscess near his liver and lungs. He had a chest tube put in which drained a good amount of fluid, but there wasn’t a whole lot of improvement. So he was scheduled for surgery and it was amazing to see that they were able to remove several pus pockets (sorry to those with weak stomachs…).

While we didn’t stay long for these next couple cases, we were able to get the gist of what happened: a teenaged boy suffered trauma to the left side of his head close to his eye due to a bicycle accident. The cut was very deep and very close to his eye, but the surgeon said there were no concerns about his vision because neither the nerve nor the actual eyeball was damaged; there was also a little girl who was involved in an explosion and her face, hands and parts of her back were burned.

Today, we saw an orchiopexy on a two and a half year old. We then went to surgery clinic with Dr. Galindo. A mom came in with her 7 month old baby who has Down Syndrome and gallstones. While we typically think of gallstones being due to cholesterol, in this baby’s case it was due to hemolysis, as evidenced by her abnormal bloodwork. The mom was asking about surgery, but Dr. Galindo explained that because she’s so small and so young unless she starts becoming symptomatic (like becoming jaundiced), he won’t operate yet.

There was also another baby only a couple months old who has an imperforate anus (there’s no opening for feces to come out). She already had a colostomy put in (an opening in the side of the abdomen that allows feces to come out) and surgery is set for when she turns 6 months or weighs 7 kilos (about 15 pounds).

These past couple days have been filled with new learning and also refreshers which is great! We’re ending the week with a trip to Salar de Uyuni! More on that on the next blog 🙂

Highlights: getting to see some awesome cases; understanding Spanish better; Bible study last night; upcoming weekend trip!

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New Week, New Adventures

On Monday, we started Pediatric surgery. We met the surgeon who we’ll be working with this week, and I could tell he will be great to work with and learn from. He is a far cry from the ‘typical’ surgeon: he’s very kind, patient, and humble.

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General Surgery floor

The surgery we saw was an orchiopexy, a procedure done to correct an undescended testicle. This correction is very important because if not fixed, there is a higher risk of testicular cancer later in life.

I was pleasantly surprised that much of the OR here is pretty similar to the ones in the US, from the instruments and techniques they used down to the music in the room! (except it was Bolivian music). Erica pointed out to me the coca cola bottle that stood right next to the bottles of povidine… and I also remember seeing a resident drinking coke while typing notes. More evidence that coke is as common as soil in Bolivia 🙂

Later in the afternoon, we had Spanish class where we’re practicing the preterite (past) tense and the imperfect tense. It can be tricky, but speaking it out helps. I’ve come to the realization that I won’t learn Spanish perfectly in 4 weeks, but I’ll put in a good effort 🙂

Going back home after class was an adventure. It took us about 15 minutes to find transportation that had room for three (Erica, Amina [another student in the program and our roommate], and myself). We went up the street, down the street and finally across the street before finally finding a bus to get on. It was very full and people were standing in the middle of the aisle and even on the steps of the bus! That could be pretty scary since the door remains opened while the bus is being driven… and the most surprising thing was watching people literally jumping into the moving bus if they really wanted a ride. It was very theatrical. I couldn’t help but think that I would never see that happen in the US. While I do appreciate how organized the US is, I’ve come to appreciate how ‘laid back’ the culture of Bolivia is…

Unless there’s a strike. In a previous blog, I talked about how strikes are frequent here amongst the medical community. I experienced a little bit of that today. We arrived at the hospital and the main entrance doors were locked, only the ER doors were opened. There was a sign on the door that more or less stated ‘what would the hospital be like without doctors, anesthesiologists, or other specialties?’ Only the ER was functioning. We came across the surgeon we were working with yesterday. He explained to us that there was a strike today and he would not be performing any surgeries, but will resume tomorrow. Hopefully their message gets across.

Before we left for the day, we went back to the infectious disease unit and read the chart of the boy with suspected Well’s Syndrome. A new differential was added: Melkersson- Rosenthal syndrome (or cheilitis granulomatosa). I’ve never heard of this condition before. It’s a rare disorder that can cause swelling of the face and lips. The swelling can occur on and off for several years and can become permanent, unfortunately.

Highlights: learning about Melkersson- Rosenthal syndrome; having light hours today 🙂

 

Easter Weekend

And the wonderful weekend continues! On Saturday, our host mom took us downtown where there are many old style homes as well as markets and tons of art galleries. She also took us to Plaza Murillo, which is the political hub of La Paz and the location of the Presidential Palace.

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Down the street of an older section of town

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Downtown

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Market

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‘Calle Jaen’ (pronounced Ca-ye Ha-yen) is a colonial street with several museums and art galleries

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A beautiful courtyard

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Plaza Murillo

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A clown 🙂 He was acting like he was undressing and he said ‘call me!’… Silly clown

Today, we went to our host mom’s church for Easter service. It was a wonderful church called Ekklesia. She told us that there are only a handful of Protestant churches around; the majority of people here are Catholic and many others practice “Pachamama” (a reverence for Mother Earth). I was able to pick up a good amount of what was being said, but the energy and joy that was in the sanctuary was unmistakeable! image

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I was happy this song had some English in it 🙂

After church, we went to a shop that sells ‘salteñas’, which is a meat filled pastry. It is so good! It’s very popular here and it’s usually served in the mornings to early afternoons. There is a technique to eating it though- it’s really juicy so what the locals usually do is bite the top corner of it and drink the juices, or else there will be a big mess!

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Salteñas

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I had a chicken salteña. Other varieties include beef, pork, or vegetarian.

Highlights: Easter service; eating salteña; enjoying a relaxing Sunday afternoon

It’s A Beautiful Day in the Neighborhood!

Wow, what a day! Good Friday represents the day Jesus Christ was crucified and died for humanity. It was also a good Friday today because of the blue skies, fluffy white clouds, warm weather and fun outings! Here in Bolivia, Friday to Sunday are observed as holidays in preparation for ‘Pascua’ (Easter) and shops, banks and schools are closed. Some places closed as early as Thursday! So Erica and I had the day off from clinic and we took full advantage of that 🙂 To begin, we walked down the street to  check out the market. Every year around the time of Easter, the indigenous people of Bolivia come to La Paz to sell their goods. Items for sale range from pottery and Barbie dolls to Biblical movies and jewelry.

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This lady was preaching the gospel in Aymara (another language spoken here). You can also see the pottery they sell too.

image After walking through the market, we then rode on the ‘Teleférico’, which are cable cars in the sky used as an important way of getting around in La Paz. Currently, there are 3 lines- red, yellow, and green. We rode the yellow and green lines because they were close to our homestay and it’s really cheap- a one way trip is 2.50 Bolivianos which is about .50 cents! I was nervous, but thank goodness Erica had enough courage for the both of us 🙂

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This is the Teleférico from my bedroom window

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Oh my gosh! We’re about to get on!

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Here we go!

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The view was spectacular

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Some of the buildings had paintings on the roof

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Nervous smile…

After riding the yellow line, we rode the green line to the ‘Megacenter’ which is a mall/arcade/car dealership place- there were many things in that one location. Our Spanish teacher had to cancel class yesterday, and to make up for the time she took us to ‘Valle de la Luna’ (Valley of the Moon). It has breathtaking landscape, unique rock formations and trails for days. I’m not much of a hiker, and Erica may or may not have had to hold my hand a time or two, but it was a great time! image image image image image We went back to our homestay and had our evening tea and shared our day with our host mom. All of a sudden we heard music playing out in the street. We rushed to the window to see what was going on. Our host mom told us that every Easter, there’s a procession that takes place by the parishioners in the neighborhood. It’s like a parade with floats that are carried by several men, there are hundreds of people walking in front of and behind the floats holding candles. There were men, women, children and even pets (last time we visited the church there was a section for dogs… muy interesante…) image Highlights: the whole day!

Another Day At Hospital Del Niño

Today we were back on the Infectious Disease floor. There were 14 patients. On my previous blog, I talked about a 13 year old boy who may have Well’s Syndrome. Today, the doctors were concerned that it could be a possible tumor. They discussed at length why his condition would cause such swelling from the neck up and no other place on his body. There seemed to be two main areas of swelling near his jaw on both sides and his lips were about 3X the normal size. They felt the areas underneath his jaw and on his neck to get a better idea of any obstruction. The patient is still able to drink and communicate so at least it is opened for now. The plan they came up with was to start him on steroids to help with inflammation and get imaging on Monday, since Friday is a holiday (Good Friday) and imaging will not be available till then.

Another patient I saw was a boy about 3 years old. He has an abscess on the right side of his jaw (which seems to be a pretty common ailment here) and he was getting it drained by the maxillofacial doctor. There is a separate room in the Infectious Disease unit that is used for simple procedures such as draining abscesses. He always has a huge smile on his face whenever I see him. But today, when it came time to remove his bandages and lance the abscess, he cried and cried. He was calling out for his mom, and I couldn’t stand there and watch anymore for fear I’d be reduced to a puddle of tears. I left the room and visited another patient, a little girl who went through quite a lot herself as Erica and I found out by reading her chart. Her history includes septic shock, thrombocytopenia (low platelets), and now a distended belly. She was in bed with her mom by her side feeding her an apple. She was so happy when I handed her a small, sparkly pink purse, a tiny token to brighten her mood.

We also saw a 10 year old girl who has Ascaris, a type of parasitic infection; a little girl with status epilepticus (a severe seizure disorder); a boy with complicated appendicitis that lead to peritonitis; and a little girl with glomerulonephritis (a condition that causes the kidneys to leak out important things it’s not supposed to such as protein). Many different interesting cases today.

When we got back home, our host mom prepared a delicious soup for us and the three of us chatted about our day and upcoming weekend plans.

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A typical lunch consists of soup and bread. This particular soup is quinoa soup with ‘queso fresco’ (fresh cheese)

Highlights: seeing the little girl happy with her purse; taking a nice walk with Erica; having the day off tomorrow 🙂

A Blessed Day

Our host mom is so knowledgeable about the people and history of Bolivia. She tells us stories of how the current president, Evo Morales, worked to incorporate indigenous people into Bolivia’s society; she shared with us their struggles and pain as they seek to be recognized in modern- day society. She shares with us how school systems function here and how businesses operate. But my favorite conversation with her is her viewpoint on the spiritual needs of La Paz and Bolivia in general. I was happy to find out that she, too, is a believer in Jesus Christ as well as Erica and myself. She offered to bring us along to a Bible study she attends and we were most excited to accept this wonderful invitation! More on that later…

Erica and I get up and get ready to make it to the hospital by 9 am. We eat breakfast and catch a ‘trufi’ that will get us to the hospital in about 15 minutes.

Typical breakfast: tea or coffee, bread with butter/ jelly

Typical breakfast: tea or coffee, bread with butter/ jelly

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Our transportation

Wednesday morning was grand rounds at the hospital. It’s a time where a clinical case is presented and afterwards doctors, residents, and medical students ask questions and discuss the topic at hand. The topic today was urinary tract infections.

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The auditorium would soon be filled with medical students and doctors

Afterwards, we met with Dr. Salete. She is the pediatrician we are working with this week, and we had clinic with her the rest of the morning. She is truly an amazing doctor and human being, so patient and kind is she. The first patient was a young boy who came in because he had several itchy areas on his scalp and body. When we walked into the room, there was another doctor present who was examining the boy, and she is a dermatologist. An interesting note: if there is a patient that requires a specialist for their chief complaint, Dr. Salete can just call them up and one miraculously appears for a consult very quickly. The dermatologist spoke with the mother of the boy and explained that he needs to be seen in a Derm clinic and Dr. Salete set that up for them.

The second patient we saw was a 17 month old baby with Down Syndrome. His mom brought him in for a cough he’s had, but the mother had no idea of the condition of her baby. When Dr. Salete asked her if her baby has ever been diagnosed with Down Syndrome, she said she didn’t know. In the short time this precious baby has been alive he’d already had a colostomy bag put in because he had an imperforate anus (there was no opening in the anal canal) and one undescended testicle. The amount of work-up that needed to be done for him was overwhelming: an ultrasound of the heart, blood work to check for TSH and T4 levels to check the functioning of his thyroid, a hearing and vision exam, making sure he’s up to date on his vaccines. Dr. Salete took her time to educate the mom on what Down Syndrome is and made sure the mom had all the appropriate information.

The third patient was a 15 year old boy who came in with his mom. A year ago, he fell and hurt his right knee and now there is a lump on the medial side. He denied pain, but it does cause him some discomfort. His mom also pointed out that he has a lump on the right clavicle that was not initiated by any kind of trauma. After some questioning, Dr. Salete called the orthopedist and bam! About a minute later he walks in and examines the boy. He had the patient lay supine (on his back) and performed various tests to check for any meniscal or ligament problems. Not too much later he had his diagnosis: osteochondroma. This is a benign tumor that occurs near the growth plates of long bones. Together with this tumor on his knee and the apparent growth on his right clavicle, the orthopedic doctor suggested ‘sindrome de Ollier’ which is characterized by predominantly unilateral, multiple cartilaginous tumors. He was then sent for an X-ray, but we have not seen the results of it yet.

After the orthopedic doctor left the room, Dr. Salete went to take care of something and Erica and I were left in the room with the patient and his mom. We talked about the different things he likes to do and his mom explained he only likes to play video games all day (League of Legends for any gamers out there). Through some more conversations, she told us she preaches the gospel in Brazil and we ended up talking about our similar faith in Christ. It was awesome to see that language was not a barrier in talking about the grace of God.

Once clinic was over, the three of us went to the cafeteria for some tea (tea is very popular here, so is Coca Cola). We chatted about the day and had other light conversation. We then met a cute little girl and her puppy.

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Me, Dr. Salete, Erica and our new little friend

Me, Dr. Salete, Erica and our new little friend

After we were done, Erica and I had our first Spanish class, much like our own personal tutor. I find that I understand Spanish better than I speak it so these sessions are greatly welcomed!

We then went to Bible study with our host mom. The people there were very warm and welcoming and they were happy to have us there. At the beginning of this trip I was praying that I would find fellowship with other believers and today God answered those prayers. What was even more interesting was the fact that the teacher of the Bible study was going to teach from Isaiah 43: 6 and 7 that states loosely ‘bring my sons and daughters from afar whom I created for my glory’. They were fascinated that we came from the US and ended up at their Bible study. Coincidence? I think not 🙂

Highlights: learning about Ollier’s syndrome; the wonderful conversation with the mom; having our first Spanish lesson; eating a wholesome dinner that cost a little over $3; Bible study!

Different, But the Same

Monday night was a great night. We met with Dr. Uribe, a Pediatrician, who gave us our first lecture. She spoke about the structure of the healthcare system here. Overall, there is a universal healthcare model- any employed citizen of Bolivia receives free healthcare and it covers pregnant mothers and infants, the elderly, those with disability, and various programs to cover specific illnesses such as HIV and TB.

There are different tiers to the system- the first tier is primary care visits and maternal/ OB-GYN care; the second tier includes hospital visits. Those who are unemployed (such as street vendors) can also receive free medical care if they become sick or injured, provided they first see a primary care provider (PCP) first; the third tier involves medical care by specialists. As with many other health systems around the world, none is truly perfect.

When I asked what kind of problems there are with this system, the doctor responded ‘muchos problemas!’ For one, many people flood the ERs and urgent cares when they become ill (particularly those who are unemployed and skip the first tier of seeing a PCP, and a fee would be required if they go to the hospital without first seeing a PCP). Secondly, doctors go on strike because of unfair pay. There was an instance a couple years ago where doctors went on strike for 54 days: they are required to work 6 hours a day, but don’t get compensated for working nights and weekends, while other workers of other occupations work 8 hours a day and get compensated for working nights and weekends. Since that strike, doctors are now compensated for extra hours, but are still required to work 6. Another interesting fact is that no matter the specialty, all doctors receive a similar salary, which in the US would seem unfathomable.

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Tuesday was our first day on the in-patient infectious disease floor. Much of how the medical education is conducted is the same as the US: residents are always on the move and busily typing notes (however here there are paper charts and notes are typed on a typewriter); rounds are in the morning and there were at least 15 people congregated in front of the rooms (including nurses, medical students, nursing students and a nutritionist); residents are pimped just as hard (for my non-medical readers, to be ‘pimped’ is to be asked a bunch of questions back to back about a patient or medical topic, with everyone staring at you, and doctors looking at you with judgmental eyes); and residents give presentations. The presentation was on ‘tos ferina’ (whooping cough). Erica and I did our best to understand what the resident was saying during patient presentations, but most of our understanding of the cases came from reading the charts since a lot of the medical words are similar (i.e. ‘hiporexia’, [we figured that was ‘anorexia’/not eating]).

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There were about 15 patients, ranging between the ages of one month to 8 or so years old. A boy about 3 years old with swelling on his right lower jaw was diagnosed with chronic osteomyelitis suppurativa. There was a one month old who we saw in clinic on Monday who was admitted for bronchiolitis. There were several others with abscesses. One patient had Well’s Syndrome which is an uncommon eosinophilic cellulitis (an ‘eosinophil’ is a type of white blood cell that works its way into the skin and causes itching and swelling). I wasn’t familiar with it, but I remember seeing the face of the little boy swollen up. A bite or sting or a viral infection can lead to this hypersensitive reaction.

Infectious Disease floor

Infectious Disease floor

Highlights: understanding more Spanish!; learning about Well’s Syndrome; visiting Plaza Murillo; trying out a highly recommended pizza place