Mental Health Inequality in Chiapas, Mexico

This is the room where a man has been incarcerated for five years, without ever leaving.  I don't call him a patient because I didn't meet him personally, but his story churns my stomach.  He is somewhere around 60 years old, and developed schizophrenia when he was 18.  He was odd but functional for many years, but in later years grew increasingly aggressive and threatening both to his family and to people in the community.  He had one psychiatric hospitalization, where they used injection medications that aren't available in the community.  Once he was discharged back home, he refused to take oral medications.  After he attacked his family, they decided he needed to be locked up, for the safety of everyone.  It took eight men to restrain him and secure him in the above room and he hadn't left this room in five years.  

Note the rope that is tied to the metal door... That is to keep it locked.  There is a hole where they pass him food and he uses the floor to go to the bathroom.  No shower, no grooming in five years.  As we walked near the house, it smelled of filth.  He yelled for his mother repeatedly and said that he wanted us to go away, whoever we were.  I don't know if he meant us or voices he was hearing, although we're the most likely culprits.

We were there to try and convince the family to let Compañeros en Salud try and get an injectable antipsychotic in the community that lasts for a month, in the hopes that it will make him calm enough to be able to come out of his locked room.  The proposal was that we get the police and lots of back up, open the door, sedate him, clean him and bathe him, give him the medication and return him to the room after it has been cleaned.  The hope is that he may be able to be calmed enough that he won't have to stay a prisoner for the rest of his life. 

His family was hesitant; they'd had lots of doctors try to fix him, and all of them had demanded large sums of money.  They also didn't want to be hurt.  Another big concern...  We would need to destroy the metal door, which had been solderd shut and they didn't have money for a new door.  But the seed has been planted, and hopefully they will make it happen.

The situation makes me feel physically ill. There is nothing humane about what is being done to him, which I say even as I understand why his family is doing it.  There simply are not places for people like this man to go in the long term in rural Mexico.   With only one psychiatric hospital, there are long wait times for a place in the hospital, and there are no discharge locations where patients who need interim care can go. While his family was trying to mitigate the harm he could cause, I can't imagine a more terrifying situation for a paranoid patient than to be locked in solitary confinement, essentially forever.  People of sound mind go crazy under those circumstances, let alone people with his degree of illness.  

I say this with deep respect for each of the individual players, who are doing their best in a terrible situation.  And yet the horrific inequality of how impotent we were in the face of this awfulness shows how large the problem looms.  And it is a hard measure of how well they are able to take care of the mentally ill, some of society's most vulnerable.

-Sarah Kimball, PGY-3

Internal Medicine, Brigham and Women's Hospital

Thoughts on two weeks of rural primary care in Mexico

Update: I go to Jaltenango today enroute to Refoma, the second community that I am working in.  From what I understand, it is both more rural and yet closer to Jaltenango.  It is apparently also a community of many Jehovah's Witnesses.  

My last night in Laguna was marked by an after-dark walk to the pantheon/cemetary to try and get phone reception in order to talk to the main office about a case.  All the lights are gone, which is unsurprising after the three days of gloomy cold rain.  It also means that I haven't showered in two days because it is too cold to envision an icy bucket bath.

I've learned a tremendous amount about how I have (mostly subconsciously) learned to practice medicine by being here.  Today, we had a female patient who has a history of gallstones and who clinically seems to have progressed to pancreatitis.  As usual, the question arises of whether she is safe to stay here in the community until Monday, when her family can take her to the local hospital with surgical capabilities.  And the answer as to whether she is safe, as with so many things here, is that I haven't a clue.  I know how to risk-stratify pancreatitis in a hospital, where I can get labs and imaging.  I can fearlessly quote mortality statistics.  Here, I'm fairly certain of our diagnosis, but without the laboratory confirmation that I've learned to rely on, I feel paralyzed with doubt on how to treat people.  My pasante is so much more fearless, having gotten used to trusting her instinct without needing multiple (or any) forms of confirmation of her clinical instinct.  Somewhere in the middle is probably best for patients.

How can I tell how likely it is that our patient's chest pain is angina without ever getting an EKG, or lipids?  What is the pretest probability in a rural Mexican farmer who has never smoked but who probably inhaled tons of smoke in an indoor kitchen?  How do I treat him without access to a stress test?  How applicable is the Framingham Risk Score (or pick your favorite) to him?

I've learned that, in the absence of the screening tests that the majority of my patients get, I tend to suspect cancer at every turn.  I blame this in part on three years at BWH, with all our Dana Farber patients.  But in every abdominal pain in an older man, I see colon cancer and I fret about every woman with pelvic pain having cervical cancer.  I hadn't realized how much comfort I personally take in having an easily accessible screening panel.

In addition, so much of my practice at home is based on not missing anything.  We will get chest x-rays and labs for the lowest probability events.  So often, we use the language of 'ruling something out.'  Here, as testing is so hard to come by, you have to be pretty darn sure that you need something before you make someone travel.  

In my last day, we had two children who clinically looked like they had hepatitis A (one of whom's mom actually said, "his urine looks like coca-cola and his eyes are yellow."). How many kids in the past two weeks with diarrhea and abdominal pain actually had hepatitis?  Are we sitting on an outbreak?  Do you need the serological confirmation?  All these questions are new ground for me.

On an unrelated note, here's my pasante, myself, our neighbor's daughter and one of a thousand local dogs.

-Sarah Kimball, MD

Health related graffiti in Jaltenango, Mexico

I'm a total sucker for health-related graffiti.  There seems to be an HIV educational campaign in Jaltenango, which makes for some amusing artwork.

"HIV/AIDS.  Bring me, look for me, use me!"

"HIV/AIDS can only be aquired by means of sex and blood.  And a mother can transmit the virus to her child during pregnancy, delivery and breast feeding."

And my personal favorite:

"If you want to have sex, you should protect yourself with a condom."

-Sarah Kimball, MD

Primary Care in Chiapas, Mexico

Some of these posts are backdated, due to poor internet access in Chiapas.  But in short, thanks to funding from the Partners Center of Excellence, I'll be spending the next month in rural primary care clinics in Chiapas, Mexico with Compañeros en Salud, the Mexican arm of Partners in Health.  While I work on my Spanish (starting from a place of fumbling with many years out of practice), I'm hoping to get a sense of how primary care is practiced in a place where routine health exams are not the norm, and where people come without good access to the health care system.

My role here is as a medical consultant to the Mexican pas antes who are stationed here for a year.  They do six years of schooling, including a year of hospital training.  As a payback to their community (because medical school is paid for by the government), all pasantes do a year of community service.  My first post is in Laguna de Cofre, high up in the mountains of Chiapas, and about two hours from Jaltenango.  We have a small house next to the clinic where my pasante and her nurse live along with anyone else who comes along and needs a place to crash, like me.

On our first day, we left Jaltenango at 7am and headed straight for clinic, as the line was already getting long by the time we arrived at 9:30  From what I understood from my broken, aching Spanish, today's clinic included (in semi-medical speak)

Pts 1-4: pregnant mother and there kids, there for HIV testing.  Kids negative, mother positive.  Presumably from father, who travels back and forth to Tiajuana for work, as HIV rates are quite low here. 

Pt 5: well pregnancy check

Pt 6:  woman with pain in multiple parts of body, likely from stress.  IUD placed. 

Pt 7: woman with RA, who was getting dexamethasone injections and developed Cushings Syndrome and diabetes.  Now off steroids, but in lots of pain.  No clear other medication options available.

Pt 8: 60 yo man with exertional chest pain. No EKG or stress test easily available.  No clear idea of protest probabilities without lipid testing. Opted for nitrate trial diagnostically.  

Pt 9: 70 y.o. man with hypertension and vision changes.  As a side note, he was as tall standing as I am sitting.  

Pt 10: 70 y.o M with hemorrhoids and hearing issues.  Clearly no colonoscopy, but they have hydrocortisone suppositories with lidocaine in them.  Brilliant!

Pt 11: hypertension and sore throat

Pt 12:  well pregnancy check.  23 year old with three other children

Pt 13: sick kid (eeek! I don't know what to do with kids!) with diarrhea.  Fortunately, the wonderful

Pasante that I am working with knows kids may better.

Pt 14: teenaged boy with facial dermatitis

Pt 15: urosepsis in a 70 y.o. man with a permanent supracatheter.  Looked bad.  IV fluids, abx, monitored, no labs.  Will see tonight and tomorrow (he lives across the street) to make sure he doesn't need to be shipped to a local hospital (which he almost certainly does, but it is such an issue here to make happen)

Pt 16: told by a naturalist doc that he had bladder inflammation that he healed.  Wanted to talk to someone else, which is good because the story didn't make sense.

Pt 17: young girl with diarrhea

Pt 18: very depressed 15 y.o. girl who walked 2 hours to get to clinic.  Her problem is, in short, that she is a female in a a village in Chiapas without the ability to get out.  Not something sertaline will help, but that was what we had,

Pt 19: 19 y.o. lady with constipation

Pt 20: 15 y.o who was pregnant.  Wanted an abortion, but it is illegal in this state.  More about that later, which I find baffling and angering.

Off to this spot, which is my bed for the next ten days.

And our kitchen, which is barely functional but doesn't really need to be.

-Sarah Kimball, MD

Healthcare for All at Hospital San Carlos, Altamirano, Chiapas, Mexico

With the incredible nuns of Hospital San Carlos.

The evening prior to my departure from Altamirano, the Hospital San Carlos nuns invited me to join them for dinner in their community.  As I mentioned in my prior entry, they are a truly incredible group of women.  Each has unique and important responsibilities in the daily functions of the hospital.  Among them include: Sor Rosario, determined hospital director and fearless leader; Sor Edith, wise clinical supervisor and xray technician; Sor Genoveva, director of nursing and nursing education; Sor Paz, pharmacist; Sor Consuelo, near to my heart, head pediatric nurse; Sor Rosaura, head medicine nurse; and Sor Anita, the most senior of the group, tireless nurse anesthetist.  Though each came to Catholic sisterhood through distinct paths, they all share a deeply religious and loving dedication to the poor and marginalized.  A story they shared that evening highlights the irreplaceable role that they and the Hospital play in providing care to so many families throughout Chiapas amidst a sea of barriers:

During a weekend when I had taken a respite to visit the Mayan ruins in Palenque, a gravely ill five year old girl was carried through the doors of the hospital by her parents in the middle of the night.  She was in severe respiratory distress, with a fever, and a concerning murmur, likely decompensating from pneumonia superimposed on a previously undiagnosed congenital heart disease.  Francisco, one of the several new physicians spending his year of social service at the Hospital, immediately called Carlos, an outstanding family medicine physician from Spain who has served as the hospital pediatrician for several years. The patient was rapidly stabilized and survived the 3-4 hour long journey to the pediatric subspecialty hospital in Tuxtla Gutierrez, where she was intubated and placed on a ventilator. Francisco formed a special bond with the family, who, like him, spoke the indigenous language of Tzotzil.  Later the following week, he received a phone call from the parents, informing him that their daughter had died after several days of medical care. They had been profoundly impacted and upset by a question that a Tuxtla provider had asked them, “Why did you take so long to bring your daughter to the hospital?”  Perhaps a sign of a provider having trouble coping with the injustice of losing a young life, or perhaps willful ignorance with regards to daily injustices, including poverty and discrimination, faced by the indigenous communities of Chiapas.

Hospital San Carlos serves as a safe, accessible, and culturally sensitive and acceptable provider of inpatient, outpatient, medical, surgical, pediatric, and OB/GYN care for indigenous as well as autonomous communities throughout much of the state of Chiapas.  Of course, resources are limited.  Plain films and basic labs (which do not include cultures) are available during the day as well as at night in the case of emergencies. Bedside ultrasound skills are acquired by some of the physicians over time.  Outpatient subspecialty referrals can be challenging, whether due to lack of patient resources or long wait lists.  Inpatient transfers, such as for neonates who may need CPAP or intubation, are at times refused by the referral hospital due to lack of beds. 

One segment of the infant and toddler's unit.

Caring for patients in both the inpatient and outpatient pediatric units was truly an excellent clinical experience.  In addition to a handful of newborns, we typically had somewhere between 3 and 7 inpatient pediatric patients.  Admission diagnosis were reflective of two the top five killers of children under five globally, acute respiratory tract infection and acute diarrheal illness.  Probably about a third of infants and toddlers were admitted with bronchiolitis, pneumonia, and a surprisingly high proportion of bronchodilator-responsive bronchospasm, perhaps secondary to indoor air pollution from firewood use.  Another third were admitted with dehydration in the setting of viral gastroenteritis, dysentery, and parasitosis.  These diagnoses certainly have parallels with those that most commonly lead to admission to MGHfC; however, the superimposed stunting and/or wasting among most of the patients clearly demonstrated how chronic and acute malnutrition might contribute to 50% of under-five mortality around the world. 

I learned a number of infectious disease-related clinical pearls during my month: one should assume that all children with severe acute malnutrition have a severe bacterial infection whether or not they have signs or symptoms such as fever; iron repletion for anemia should be deferred until treatment of bacterial infections (e.g. infectious enteritis, see: BMJ 2002;325:1142) has been completed, as there is a theoretical risk of worsened infection; congenital tuberculosis exists (see: N Engl J Med 1994; 330:1051-1054); and the management of fever without a source in well-appearing newborns/infants in the absence of culture data can rely significantly on clinical suspicion. 

Abnormal L5

The remaining one third of admissions encompassed an interesting mix of subspecialty issues. These included: a 12 year old boy with anasarca, ascities, pericardial effusion, and pleural effusions secondary to nephrotic syndrome; a 3 year old girl with >50% partial and full thickness second degree scald burns, one week out from injury, who was transferred AMA from government hospital; a 7 month old boy with tachypnea since birth and failure to thrive, without murmur, but certainly with a yet undetermined congenital heart defect, admitted with worsened respiratory distress; a 3 month old girl with severe stunting, presenting with vomiting since birth, found to have hemoglobin of 4 and guaiac positive stools; an 18 year old boy admitted after intentional ingestion of Gramaxone (aka Paraquat), an almost universally fatal herbicide without effective treatment nor antidote; and a full term, newborn boy with perinatal asphyxia, low apgars, who developed clinical seizures on day two of life, requiring phenobarbital.  I also encountered a good deal of developmental delay, including a 2 year old boy who presented to clinical with a URI and who apparently could not walk, stand, nor really sit appropriately.  He had bilateral ankle clonus, lower extremity spasticity, bilateral Babinski, and these apparent findings on physical exam and plain film:

Violaceous mass over lower lumbar spine.

Hospital de Especialidades Pediatricas - Tuxtla, Gutierrez

I was frequently left with the desire to teleconsult my MGHfC attendings and fellows and, in fact, did speak with one of our wonderful cardiologists, Dr. Manuella Lahoud-Rahme regarding one of our CHD patients.  Wait times for consultations with subspecialists at Hospital de Especialidades Pediatricas are often prolonged, and the prospect of enduring the costs and opportunity costs of travel make the trip all the way to Tuxtla Gutierrez prohibitively expensive for many families.  Performing an echocardiogram while Dr. Lahoud-Rahme watches via Skype, is just one example of the potential for telemedicine to advance access to subspecialty pediatric care at Hospital San Carlos.

Helping Babies Breathe - Workshop 1

In addition to the clinical and community-oriented aspects to my trip, I spent some time working in the realm of formal medical education and quality improvement.  I gave a chalk-talk on a variety of neonatal health issues for the physicians during one of the biweekly morning conferences.  This was perhaps more of a learning experience for me, as my audience helped me grasp the many adaptations necessary to take care of newborns in a low resource setting. Continuing with the theme of neonatal health, Dr. Jennifer Kasper and I prepared an abbreviated Helping Babies Breathe^© training for nurses, nursing students, and auxiliary staff at Hospital San Carlos, in collaboration with Sor Genoveva. 

Nursing students at their capping ceremony.

There were 42 participants who attended one of two, two-hour sessions that focused on the Golden Minute of life and practicing scenarios with NeoNatalie newborn mannequins. About 3 weeks later, I was able to schedule a follow-up refresher session, and while this landed at the tail end of vacation week for the nursing students, 31 learners participated in the workshop, including 10 new participants.  While I had intended to perform OSCEs to evaluate effectiveness of the first workshop measuring retention of knowledge and skills, this was ultimately not feasible in light of time and resource constraints.  Subjectively, the students expressed that they very much appreciated the opportunity to reinforce and practice their skills.  I could see that many were more prepared to revive their mock newborn patients, and to do so within the first minute of life.  The second session also gave me the opportunity to fine-tuning practices that I had observed in the delivery room during my month, for example: not delaying bag mask ventilation to attach oxygen to the self-inflating ambu bag and acting upon an emergency plan (i.e. calling Carlos) at the first sign of trouble, whether fetal distress or difficulty with ventilation. 

Carlos (pediatrician in-charge) and I.

Lastly, I worked with one of the hospital administrators and Carlos to create a self-evaluation tool for the pediatrics unit that could be used to highlight and select priority issues for quality improvement.  Drawing from hospital standards from the WHO, the Mexican General Health Council, and other resources, the tool asks doctors and nurses to respond to questions relating to seven themes using Likert scales: professional communication, medications and errors, rights of the hospitalized child, involvement and education of families, evaluation and treatment of pain, hygiene and prevention of infection, personnel and equipment, and trainees and continuing medical education.

I truly hope that I will have an opportunity to return to Chiapas and to Hospital San Carlos.  My upcoming fellowship program in pediatric emergency medicine is affiliated with two hospitals, UCSF and Highland, who send attendings and residents to San Carlos.  Now that I’ve had a chance to reflect on my trip, it’s time to get busy thinking of next steps.  Next steps in strengthening the Hospital’s referral capabilities, perhaps via telemedicine … next steps in ongoing capacity-building in skills such as neonatal resuscitation and pediatric ultrasound.  I’m so grateful to all my new, amazing colleagues in Chiapas, the sisters of Hospital San Carlos, Dr. Jennifer Kasper, Dr. Juan Manuel Canales, and Doctors for Global Health, who together made this experience as enriching as it was.  Many thanks as well to MGHfC Pediatric Residency Program and the Partners Center of Expertise in Global and Humanitarian Health without which this incredible experience would not have been possible.

Ashkon Shaahinfar, MD, MPH
MassGeneral Hospital for Children
Pediatrics, PGY3