Wednesday, March 27, 2019

Access to Care in Rural Mexico

Anna Ruman, MD
Resident in Pediatrics at Massachusetts General Hospital 

I’ve just finished the first half of my global health elective with Partners in Health/Compañeros en Salud in Chiapas, Mexico and am very excited to report back. To briefly introduce myself, I am a second year pediatrics resident at MGH. I’m very interested in global and community health and hope to work with predominantly Spanish speaking communities in the US and abroad after residency. I decided to do my first of hopefully two international electives during residency to learn more about working in low resource settings, managing tropical diseases, teaching and learning from international colleagues, and of course understanding the Mexican healthcare system.
CES Clinic Matazano

As a bit of an orientation to my work, Partners In Health (PIH) is an international organization committed to improving the health of the poor by partnering with communities to delivery high quality health care. PIH’s Mexican partner organization, Compañeros en Salud (CES), operates out of 10 rural clinics in Chiapas, Mexico. As Resident Mentor with CES, my primary responsibility during the month long elective is to provide full-time bedside teaching for social service year physicians (pasantes) working in these rural sites. In addition, I plan to spend time at the Casa Materna, a house staffed by clinical providers in the larger city of Jaltenango. Essentially, women can come down from parts of the Sierra where there’s little access to obstetric care and spend 1-2 weeks prior to their due date at the Casa Materna to await their delivery, which would also occur in the Casa itself assuming it remains low risk. Overall, I’ll be spending about 90% of my time “in community” and the remainder at the Casa Materna or on various research or capacity building projects.

After arriving in Chiapas the first week of March, my first community assignment was Matazano, a community of approximately 600 people in the Sierra Madre. After an approximately 5-hour drive on mostly dirt roads, we arrived, and I met my colleague Doris, Matazano’s pasante, for the first time. For the next two weeks, we saw patients together Monday-Friday 8 AM-5 PM and Saturdays 8 AM-1 PM, although there were frequently emergencies in the evenings that kept us in clinic sometimes as late as 9 PM. Approximately 40% of all visits were children, which is of course where I had the most to offer in terms of teaching. With respect to the overall patient population, the most common reasons for visit included acute illness (respiratory, gastrointestinal), maintenance of chronic disease (asthma, diabetes, hypertension, mental health), routine obstetric visits, or urgent/emergency cases, mostly minor to moderate trauma. The pediatric cases trended more towards cough (allergic vs. postviral vs. asthma), acute vs. chronic diarrhea, fever (mostly viral illnesses), failure to thrive/malnutrition, adolescent mental and sexual health, routine newborn care, and minor to moderate trauma.

To step back for a moment – why does Compañeros en Salud work in Chiapas specifically, and why would a pediatrician be interested in working there? Well, I knew coming in that infant and maternal mortality in the Sierra region of Mexico had been identified to be much higher than the national average. Most female patients who I met had lost at least one child, often during infancy. The tradition in many rural communities in Chiapas is to leave a child unnamed until around the age of six months, that is to call them simply “niño” or “niña,” due to the reasonable possibility that the child would pass away. Similarly, new mothers don’t typically leave the home until 40 days postpartum due to fear of complications. This means that a provider doesn’t see a newborn until after one month of age, especially if they are born at home (a terrifying thought to most providers who care for infants). And lastly, children are rarely brought to physicians unless an acute care need arises due to the incredible difficulty and expense of transportation and overall poverty in the Sierra.

With these barriers in mind, Doris and I learned a lot together about neonatal fever, how critical congenital cardiac disease presents, which bronchiolitis baby is not like the other, when to start inhaled steroids in a dusty town with indoor wood burning stoves for cooking, how to use the nutritional supplements and rehydration solutions typically available in Mexico, when to clinically suspect varicella vs. measles vs. other red rashes of childhood, how to diagnose and manage UTIs without the availability of urinalysis, how often to suspect pediatric rheumatological diagnoses, how to clinically evaluate for fracture, and many other topics of discussion related to the patients that we saw. Incredibly busy, incredibly fulfilling, and just overall hard to describe.

Dona Mari's Tortillas
Of course, there was more than being in community than seeing patients. Each day, we ate two meals with Doña Mari. Fruit and vegetables are very hard to find in Matazano due to lack of reliable transport from the larger city, Jaltenango. However, Doña Mari always made amazing food with very limited ingredients. A typical breakfast included fresh eggs from her hens, black beans, hand made tortillas, and often a mild red sauce made from a local variety of tomato. We also always drank coffee prepared from the family’s coffee trees. For lunch, Doña Mari surprised us with a lot of treats, but probably the most unique was a crab and shrimp soup. Someone from the coast had driven up fresh seafood (about a 6-7 hour drive minimum) to sell in the community, and Doña Mari was so excited to have these ingredients to use. My favorite dish of all was a very traditional preparation of lentils from the Chiapas region in which fried plantains are mixed in. And the best part was learning about the community’s past and present from Doña Mari herself. Amazing!

In summary, I am so thankful for the learning and teaching experience I have had over the past few weeks. This week, I will be heading to another community, Soledad, to continue my teaching role with the pasante stationed there. In my next post, I’ll be describing both Soledad as well as my overall takeaways from this global health experience. Wish me luck!

Tuesday, March 26, 2019

Directly Observed Therapy for Tuberculosis in the Navajo Reservation

Akash Gupta, MD
Resident in Medicine/Pediatrics at Massachusetts General Hospital

March 21, 2019

As mentioned on my previous post, I have been on a month-long immersive clinical elective at Northern Navajo Medical Center, a small community hospital run by the Indian Health Service in Shiprock, New Mexico. As a future infectious disease fellow, I have a strong interest in tuberculosis, and was lucky enough to spend the day with the TB community outreach nurse, Dorothy.

Every day, Dorothy performs home visits to administer anti-TB medications under Directly Observed Therapy (DOT). She serves patients in a large catchment in the Four Corners region, and sometimes drives up to 2 hours to patients’ homes. On the particularly day I joined her, Dorothy had 3 patients who needed DOT: two had pulmonary TB, one had spinal TB or Pott’s disease.  I joined her for visits for two of these patients.

The patient’s lived quite far from each other, and in varied settings. One was an elderly woman living with her husband in a small trailer home in a very small town about 1.5 hours from Shiprock. She had severe rheumatic arthritis (a surprisingly common disease among the Navajo) and had recently been started on immunosuppression by a rheumatologist in Salt Lake City (some 3-4 hours drive from her home!). The suspicion was that she may have reactivated in the setting of immunosuppression. She and her husband were quite old, and appeared frail (her husband was on home oxygen). As a result of recent snow-melt, her driveway was extremely muddy. Their apartment was very cluttered, and was heated by a small central wood stove. They said that while the husband was able to drive, it was hard for either of them to do many of the manual tasks required around the house, and they were getting limited help from their children. They unfortunately also had some money stolen recently, and were very worried about both finances and their ability to manage their daily needs. Dorothy spent time discussing this with them, which she did almost daily.

The other patient was a middle-aged woman who had likely acquired TB while taking care of her mother, who had pulmonary TB several years earlier. Interestingly, this patient had taken a full course of isoniazid prophylaxis after caring for her mother, but still ultimately developed active TB. She lived in a beautiful home on a property overlooking mountains, and was active and robust.  The home was neat, well-decorated, and with many books. She had multiple other small buildings, dogs, and a lovely garden. It was a stark difference to the prior home visit.

The last patient also had pulmonary tuberculosis, but lived in the city of Farmington, which is the closest city to Shiprock. While I did not join for this visit, I believe the patient had a case of typical pulmonary tuberculosis.

Given the far distances, Dorothy and I spent a long time in the car together, driving across beautiful landscapes. She was a lively, animated, and extremely chatty woman. She could keep the conversation going for hours, narrating to me the history of various elements on the countryside, and telling me details of her patient’s lives. She also told me about her own life story and family, which was an incredible epic. I recommended she write a memoir one day, and she laughed. One of the beautiful sites she showed me was of a mountain of the neighboring Ute tribe, and a small building that used to serve as a jail cell, and is now preserved for history.

Late Presentations to Care on the Navajo Reservation in Shiprock

Akash Gupta, MD
Resident in Medicine/Pediatrics at Massachusetts General Hospital

March 21, 2019

I just completed a 4-week immersive clinical elective at Northern Navajo Medical Center, a small community hospital run by the Indian Health Service in Shiprock, New Mexico. Shiprock is a small town on the Navajo Reservation, named for the nearby beautiful rock formation with sacred significance for the Navajo. I was able to visit the rock formation at sunset early in my rotation, pictured below

The facility serves about 53,000 members of the Navajo Nation. It has 55 inpatient beds, a small 5-bed ICU, and attached outpatient clinics. Represented specialties include Internal Medicine, Pediatrics, Family Medicine, General Surgery, Orthopedics, Ob/Gyn, Podiatry, Audiology, PT/OT, and Radiology.

As a Medicine/Pediatrics resident, I was able to rotate on both the internal medicine and pediatrics services. Internal medicine had a very interesting practice, where providers saw patients in continuity clinics, walk-in clinics, and specialty clinics through the day. However, they also admitted and followed any of their primary care patients, even if they were in the ICU. This meant that they were able to practice across the spectrum of their training, which is very fulfilling. One morning for me consisted of rounding and presenting two ICU patients in the morning to hospital-wide ICU rounds, then going to HIV clinic in the morning. I would be bouncing back and forth between counseling patients on HIV Pre-exposure Prophylaxis, and having a family meeting with an ICU patient. In the afternoon I did walk-in clinic, from which I admitted a patient and continued to round on him the next day. It very much suited my personality, as I enjoy variations!

A lot of the morbidity I encountered was similar to what I would find in Boston: diabetes, hypertension, COPD, pneumonias, cirrhosis, skin infections. However, some of the patients presented significantly later in the course of their illness than I was accustomed to. For instance, one middle-aged man came to a walk-in clinic complaining that his toe was red. What he actually had on exam was an ulcerated, necrotic, gangrenous large toe that had developed over about 10 days. He had been on a work job in Utah, and had been trying to manage at home with topical creams and bandages. He had gone to an urgent care about a week earlier and started on oral antibiotics, but when the toe started ulcerating he had not re-presented to care for several days. He ultimately required emergent debridement, and will likely require amputation. I encountered other stories similar to his, where late presentations appeared to be related to long-distance travel for work, as occupational opportunities were minimal in the immediate surrounding area. It’s interesting to think about how to optimize a health system to meet this issue!

All in all, it was a highly educational 4-weeks at Shiprock!

Internal Medicine rotation in Rural health clinics in Chiapas, Mexico Part 2

David A. Cardona Estrada, M.D.
Internal Medicine Resident, North Shore Medical Center
PGY- 3

March 18, 2019

During medical training, we often develop a superficial sense of control over the natural course of disease processes. There is such an overwhelming emphasis on data, diagnostics, and evidence-based practice, that we often lose our humanistic perspective. We forget that having a disease, whether chronic or acute, is just a small part of our patient’s lives, particularly in our most vulnerable patients and populations.

While providing medical care in Chiapas, Mexico, I quickly realized just how impactful socio-economic factors are in determining a person’s health and wellbeing, as well as access to basic medical care. In a resource-limited environment, the challenges encountered when making diagnostic and therapeutic decisions can be quite complex and challenging, to say the least. Lack of resources combined with a population that lives well below the poverty line creates a unique medical and moral challenge that is rarely encountered in well-developed countries

These challenges were exemplified with one particular scenario that I encountered during my time in Chiapas.  “Mrs. V” was a 40-year-old female, who presented to the clinic with a two-day history of persistent, intense right upper quadrant pain. She had a history of similar pain in the preceding weeks, which was triggered by heavy meals, though the pain had previously remitted spontaneously. On exam, she was afebrile though tachycardic. She appeared non-toxic but her abdominal exam was concerning; guarding, significant tenderness to palpation, and a blatantly positive Murphy’s sign. Our immediate concern was evolving acute cholecystitis. 

Community of Laguna del Cofre,
Sierra Madre Chiapas Mexico
“Mrs. V” had been evaluated earlier that week by another physician who had performed an abdominal ultrasound. The physician had advised surgery; presumably a cholecystectomy. She also was prescribed a medication, which she unfortunately could not recall the name of, and was unsure if it was an antibiotic. To further complicate matters, “Mrs. V” did not bring the report of the ultrasound nor did she have the ability to read the report anyhow. Her clinical picture was concerning.  In the ideal setting, she would have basic labs, right upper quadrant ultrasound, and a surgical consult.  In this scenario, the nearest medical facility with basic ultrasound capability was 2 hours away, and the only means of transportation would require pay-out-of-pocket, which was an unrealistic option for her. 

Herein lies the dilemma:  If she did in fact have cholecystitis, she would have to travel to the capital city, which would require a 5-hour trek through mountainous terrain with unpaved roads.  The logistics are well beyond the scope of what Mrs. V and her family could coordinate, not to mention afford.  Food and housing for family members, transportation, and payment for services received while in the hospital were just a few of the foreseeable obstacles.  Unfortunately, she was from one of the poorest families in her village.

As I began to discuss my impression and potential plan with her, I explained the importance of an ultrasound which would cost her ~$20 US.  She promptly expressed that it was the coffee harvest season and that if her husband took her to the ER, they simply would not have money to feed their family.  I was stuck between a rock and a hard place. Do I recommend traveling to the nearest hospital for an ultrasound, with the possibility of this being only biliary cholic at the risk of not being able to feed her family? Should I sit tight and watch things evolve? What if she decompensates?  If that happened, then we would have to emergently send her to the closest city, which again would be a dangerous and expensive 5-hour drive. 

There was no “right answer”. We did what we could, with what we had, in the given moment. Our organization had arranged for a general surgeon (with ultrasound capabilities) to visit the town closest to us, though this would be in two days time. We gave her oral antibiotics, analgesics, and urged her to return in 2 days for a cost-free surgical consultation.  My decision weighed heavy on my conscience and I could not sleep that night. I was troubled by fact that someone has to decide between paying for basic medical care and feeding her family. The outcome was favorable and Mrs V. had no complications. She eventually had her ultrasound which showed gall stones without cholecystitis.

Internal Medicine rotation in Rural health clinics in Chiapas, Mexico Part 1

David A. Cardona Estrada, M.D.
Internal Medicine Resident, North Shore Medical Center
PGY- 3

March 05, 2019

“To cure sometimes, to relieve often, to comfort always”

I have known this expression since I started medical school, but it has never been so present in my mind until I arrived to the Sierra Madre region of Chiapas, Mexico a couple of weeks ago.
I was trained in Mexico and I knew before coming to this rotation what it was like to practice medicine in a low-resource setting. I remembered that you had to do as much as you could with whatever you had, even if it was not the gold standard for treatment. What I forgot during my last 2 years of training as an internal medicine resident in the United States, were the feelings of powerlessness, frustration and sadness that arise whenever you know that you could cure someone, but because the resources, environment and social determinants of health you are not able to do so.
They were several days that I asked myself: what am I doing here?, Am I really helping?, What does being a doctor really mean?. I was having an internal crisis, until I was asked by the palliative care team to evaluate one of their patients.

She was a 30-year-old women with liver cancer with lung metastasis.  She was initially treated with palliative chemotherapy, but due to the lack of response, adverse effects and economic burden, she decided to stop her treatment a year ago. Unfortunately, during the last month, her hepatomegaly has been increasing and causing more pain, so she had to be started on morphine for pain control. She has been losing weight and developing lower extremity edema. She started wondering, if it would l be worth traveling l to the closest city (4 hours away) to be re-evaluated by oncology.

Image of Laguna del Cofre, one of the 10 communities where
Partners in Health has community health clinics 
We went to evaluate her on a Friday night. When I entered her small house, I found a very frail and emaciated woman sitting down in bed, surrounded by several family members. After my 2 colleagues introduced me to her, I asked how she was feeling. She said her pain was better controlled with the morphine, but her appetite was gone and she started having fevers 3 days ago. On physical exam, she was so emaciated  that she could not close her eyes anymore due to the lack of peri-orbital fat and I could see her heart beating through her chest. Her liver occupied the right half of her abdomen and right hemithorax. She had lower extremity edema up to her thighs, more in the left leg than in the right. A DVT as the cause of her fever, was my highest differential on the list. We asked her if we could come back the next morning to evaluate her legs with our ultrasound and to have a family meeting.

The next morning as we arrived, she told us that she had an episode of bloody emesis. Instantly, I felt my heart racing as I thought she may have esophageal varices and she would decompensate in any moment. Her vital signs and physical exam were stable. She told us that she has been using NSAIDs for more than a month, which gave me a sensation of false reassurance as I thought she may have a gastritis or a peptic ulcer. We performed the lower extremity doppler ultrasound and found a left femoral DVT. Oh my God, can this poor woman catch a break?

My colleagues and I stepped outside. We all knew her prognosis was grim and traveling 4 hours to the city was not feasible. We also could not anticoagulate her because her hematemesis. We agreed that to continue the palliative care route was the most appropriate plan. Now we just had to talk to her and her family.

We sat down with the patient and her family to tell them the bad news. She said, “I do not want to go to the city, it will be too much for me”. We told her that unfortunately she was going to die from her cancer. After the bad news, I sat down by her side and grabbed her hand in silence. While grabbing her hand, I looked up and saw her husband and family crying, and near the doorway I noticed her 3-year old beautiful daughter hiding from us. My heart broke as I thought: she is my age and is going to leave 4 children. I have never felt so useless. I apologized to her for not being able to offer her better news. We all promised her to do as much as we could to alleviate her symptoms and to help her enjoy her family during the time to come. She looked at me with her eyes covered in tears and smiled with one of the most beautiful smiles I have ever seen.

Do you have any questions?, I asked at the end of our conversation. “No doctor”, she said. “I just want to thank you all for taking care of me”. There are not enough words to explain how grateful I am, because you have come to my house to see me, because you worry so much about me and my family.” At that moment, everything became clear. That’s what being a doctor its all about: the purest human connection with our patients. We were not able to offer a treatment for her disease – in fact, we only had bad news for her that morning. What we were able to do was to sit down in her house surrounded by her loved ones, grab her hand, look her in the eyes and promise her to do as much as we could to alleviate her symptoms and comfort her at the end of her days.

Because that’s what being a doctor is really about: “To cure sometimes, to relieve often, to comfort always”