White Coat Underground

Notes from Honduras III

In 1999, during my intern year, Hurricane Mitch struck Central America. As stated below, I wanted to become involved. The program director of my residency was kind enough to view this as a worthwhile educational experience. This is my diary from the trip. Part II is here.

Zopilotepe; the Clinic

We loaded our supplies and our tired but excited selves into a jeep and headed out to the highway. Shortly after leaving town we turned down an unremarkable dirt road that threaded through bean and corn fields. The rough-hewn wooden fences were covered with purple and pink morning glories. As we wound down the road our elevation dropped slowly and we were gradually surrounded by more and more red mud, uprooted trees, tractors, and other wreckage that indicated we were nearing a river. After about a mile of wasteland the river appeared, with red, fast-running waters and a gravely shore. Trucks lined the river as some people bathed and others sifted gravel, selling it for repairing roads and bridges, and using the discarded sand to make cinder blocks to rebuild houses.

We crossed the narrow span of the recently-built bridge and a young man stood collecting tolls at the other end. We refused to pay the five limpira toll until a few days later when the young men laughingly offered to destroy our tires with machetes if we continued our deadbeat ways. In a country where everyone carries a gun, we felt we got off easy.

The next river we crossed was shallow enough to drive through. We shared the crossing with cattle and young men drinking and cooling off in the waters. Several large grain trucks were stuck in the mud on either side, but our jeep climbed the bank easily. The road began next to wind though villages of rough shacks with pigs, roosters, and banana trees in their yards. People came out and stared as we drove by. Passing ox-carts and young boys with machetes heading out to the fields on horseback, we came to our last river crossing, five logs thrown across a ravine with gravel fill in the interstices. Each day the bridge looked just a little bit smaller.

After turning down a few more small dirt roads, we came across a few houses along the road surrounded by fields, and a white concrete building with crowds of people milling around the yard, some having set up food stalls, mothers combing children’s hair, dogs and chickens wandering between legs. People moved aside (slowly) as we pulled up and unloaded our gear into the local health clinic. The building had three rooms; a large anteroom and two small clinic rooms. It also had a bathroom whose toilet was flushed by pouring in a bucket of river water at the end of the day. No running water was available, and the water that was available was quite unreliable. I am still not sure if we had electricity.

We had no idea what to expect, but from the look of the crowd already gathered, it was clear that we would be busy. Fifty percent of the Honduran population is under fifteen years old, so it was no surprise to us that many of our future patients standing in the yard were children. We had been trained very well to treat adult patients in the US. Without a thought, any of us at home would order a CT scan for a dizzy elderly woman, or an EKG for a grandfather with chest pain. Here our patients were mostly kids, and our laboratory was our hands and our stethoscopes. It took about an hour for us to organize into a system that worked. Interestingly, all the groups that went out ended up organizing along very similar lines. Kim Marie became our pharmacist. Meghan was nurse and translator, Ty the physician in the main exam room/pharmacy. I set up a second consultation/exam room in the next room with my interpreter. Magda spoke perfect Spanish. My English was more than adequate. Unfortunately neither of us was bilingual. In between patients, however, we conjugated verbs and compared adjectives until we developed a system of communicating rather effectively.

Most of the people came in for unremarkable problems: headaches, backaches, diarrhea, heartburn. Unfortunately, the closest pharmacy was in Juticalpa, until recently unreachable, and in the best of times about a four hour ride by ox-cart, two hours on horseback. We dispensed a lot of Tylenol and aspirin.

Many patients came in complaining of parasites. It took us quite a while to learn how to best approach the problem. At first I took detailed histories, inquiring how their food was prepared, if they owned livestock, used clean water, without getting closer to actually diagnosing a problem. Finally, a mother came in complaining that her child had worms around his anus. I put him up on the table, pulled down his shorts, and sure enough, there was the little white Enterobius worm squirming away. I began to itch. From then on I took their word for it. It was just a matter of learning the village lingo (which we probably got wrong) and finding out whether they had the little white worms (bichas) or the long reddish worms (lumbrices; Ascarias).

Interestingly, we had a number of people come in complaining of enuresis (bed-wetting) and insomnia. My first thought was that it was a response to the stress of disaster. However, I was reading up on worms the next night and found that both are very common symptoms of pinworms (bichas). From then on we treated both problems with our standard Mebendazole de-worming regimen.

Our tools were very simple out of necessity. We knew intellectually that 80 percent of diagnosis should come from the history and physical, but here we were practicing it. In fact, most of out diagnosis was based on history. My hematocrit was a glance at the conjunctivae. At no extra cost, I could simultaneously look at the sclerae to assess the bilirubin. If a woman gave a good history for it, we treated her and her husband for Trichomonas infection without the benefit of a microscope. Urinalysis was replaced by very careful questioning. Thick and thin blood smears for malaria were replaced by “┬┐Tiene malaria?”

Flavio, our driver, was supposed to have been our guide for the first day, just until we learned the way to the clinic. His talent was too useful to give up, so we recruited him to be clinic manager. In addition to registering people and giving them numbers, he would seek out the very sick ones and bring them to the front. We saw between 150-200 patients per day. On the first or second day, he came running in with a eight or nine year old child with a piece of cloth tied around his foot. I took off the soiled cloth, revealing a four inch machete wound, with deep subcutaneous tissue dehiscing through the irregular gash. I cleaned the would and attempted to anesthetize it with lidocaine, but it became apparent that with the materials I had on hand I would not be able to suture it well enough. I stopped the bleeding, dressed it, gave him a tetanus shot, and sent him into the city.

Fungal infections were universal. Tinea versicolor, which causes white patches on the otherwise sun-darkened skin of the campesinos, was the most common, followed closely by tinea pedis (athlete’s foot). One grizzled man in a cowboy hat came in complaining of a foot fungus. He removed his shoe revealing a large violet-colored patch covering his toes. My first thought was to turn to my Tropical Medicine text to find out what horrible creeping crud causes the foot to turn purple. Then my interpreter explained to me that this was the folk remedy for tinea; paint the foot with violet dye.

The extent of an illness depended largely on the level of poverty of the patient. Most showed up in their Sunday best, the little girls in beautiful dresses, the boys with clean shirts and hair combed. However some were too poor for even that. A mother brought in her child because of foot fungus. I brushed away the dirt covering her foot and found large open wounds teeming with small flies. I asked her if she had shoes and she stared at the floor shaking her head “no”. I gave her soap and antifungal cream, but in my heart I knew that before long, maggots would begin to debride the wound.

Our patients were universally welcoming and kind. One brought me a bag of oranges, which in Honduras should really be called “greens”, but their flavor is quite good. Each of the six oranges had been carefully peeled and the tops sliced for easy eating.

A note on food: our host, the bishop, insisted as noted above, on having traditional American food. The cook at the church made us sandwiches of ham and American cheese for lunch every day. Flavio overheard us express the desire to eat some more indigenous food, and made some inquiries. The second morning of clinic a plate arrived on my desk with two thick, potato-filled flautas garnished with fresh cabbage, salsa, and queso fresco. I greedily devoured the warm, crisp tortillas, then moved in on the cabbage. It was as I was taking the last bite of cabbage that I realized that I was eating the same cabbage, in the same village, watered by the same river, and picked by the same hands as the people who came to me complaining of parasitas. I dropped the plate and somewhat irrationally ingested a gram of Mebendazole. This was only the first of my dietary indiscretions. After the first day at the clinic, Flavio ensured that we were supplied with generous portions of (well-cooked) red beans, rice, cheese, and corn tortillas for lunch. We later realized that all the various versions of queso fresco that we had been enjoying were made from unpasteurized milk. After that initial shock I took a real chance and started to brush my teeth with tap water. Fortunately, after 600 patients I am quite familiar with the remedies for the various creeping nasties that may cause me future distress.

While we enjoyed the novelty of beans and rice at lunch, Magda, our translator, made it known through subtle expressions that she missed the ham and cheese sandwiches. It turned out that she eats the same dish every day, three meals a day. It is always prepared the same way, without change in spices, presentation, or ingredients. It seemed only humane after that to leave her to her sandwich while we enjoyed our Honduran lunch.

Next: After Hours…