And we're baaaccck!

6.18.09
Andy- After losing three days to an amazing stomach illness I picked up in a remote village outside Sucre, I was finally heading back to the hospital. I cannot remember being that sick for a long time, and even today I was a little shaky. I went and got a Whopper last night from Burger King, since I am still a little wary of Bolivian food. The Burger King is an anomaly in and of itself, while the prices are the same as home and the burgers are much the same. The only problem with that picture is that it’s fairly crowded and those prices will buy you a very nice steak dinner here with multiple courses and a stiff drink or two. Why anyone would choose Burger King over that is beyond me, unless of course you are an American just looking for a little of the familiar fare.
But I’ve severely digressed; as I said, I was on my way to the clinic. I missed the last days of my Ped’s rotations being sick, something that really disappointed me. But Celia was starting her Pediatric rotation so I took her into the Pediatric ER to introduce her to the residents there who helped me around. After some issues with a particularly grumpy attending, we went upstairs to the Pediatric Intensive Care Unit (or PIC-U if you want to sound intelligent), so I could introduce Celia to the doctors up there. Dr. Monroy was there, who speaks perfect English and is an all around great guy- even if he never smiles. He quickly went over each of the patients in the room, giving us their condition and prognosis. One thing that was interesting though was that though many of the ICU children were there with the traditional pneumonia or sepsis, Dr. Monroy explained that their larger problem was the traditional medicines many of the Quechua and Amarya families use which very frequently cause liver and renal failure. He invited us on rounds of the patients with the medical students. I stayed for two of the patients, regretting more now that I had been sick for the remainder of my Peds block, before excusing myself and heading back to the burn center where I was about to begin my rotation there, albeit a day late.
When I got there, Dr. Ramero was already in surgery. He was working on debrieding a little girl’s face that had badly gotten burned. The next day he was planning a partial thickness skin graft, but today was just cleaning off all of the scabs and dead skin that had collected. The next case was a child who was severely burned on her bottom. She had third degree burns on the bottom of her thigh and the back of her calf. She was burned because the local Quechua believe that if you have diarrhea, then going over a hot stone will cure it. Dr. Romero was cutting away the necrotic tissue, again preparing for a partial thickness skin graft sometime later that week. After that case, an emergency case came in, and they had to clean burned tissue of the face of this little girl. They used a razor blade to scrape the dead skin off her scalp. Also, they had two residents trying to put in I.V. in the femoral vein using the cut down method. However, the girl was so young and the vein so small, that they could not get the catheter tube into the vein. When I left that day, they had given up on the left leg and moved to the right leg with Dr. Ramero’s help, where they were still having trouble.
Later that night we went to watch Night at the Museum 2. The movie theatre here in town caught in an identity crisis with the rest of the country, which is the only reason I mention it here. A modern building, rising several stories above the surrounding neighborhood that contains an amazing movie theatre, a very American-esq food court, an arcade, and several upscale shops. It’s like an island of consumerism, and it’s all very American. On our way back, we passed the Municipal Band of Cochabamba, a brass outfit, playing outside of a small building with a great deal of gusto. I started marching by, and a lady came by and invited us in. Not sure what we were getting ourselves into but using the ‘Nothing ventured, nothing gained’ argument, we went in. It turned out to be a cultural celebration of Cochabamba put on by a local arts group, which was really interesting. There were a number of displays, including a display of the local herbal treatments for various maladies, and I found myself wondering which of these had brought their users to the ICU that I had seen earlier. There were a number of local politicians and arts patrons and we were severely underdressed in our t-shirts. So, after we finished a glass of very good wine out of a Dixie cup, no less, and at least pretended to listen to a speech by the nationally famous Zulma Yogar, who is apparently quite a big deal, we headed off for home.


Jen- Today was my first day of OB rotation. I was in the Maternal ER where pregnant women who are having problems (pre-term labor, bleeding, regular labor) go before heading up to the labor and delivery floor. It was a fairly quiet day with women coming in with contractions and then being sent upstairs. I followed some of the medical students around while they removed stitches from C-sections, drew blood, and did exams on pregnant bellies. I counted the fetal heart beat and saw how uteruses were measured to see how well the baby is growing. All in all it was a fairly calm day. Hopefully tomorrow I will be able to help out a bit more.

Celia – Ah, PEDS. I’ve been looking forward to this rotation the most. Andy took me to the PEDS-ER and started introducing me to all the interns and residents. They were all huddled up in a group, pre-gaming before the onslaught of the day. Lastly I was introduced to Carlos who Andy followed around the majority of the time. He let Andy practice a physical exam, duly noted. As we were introducing and laughing (at my inability to remember names probably), I felt someone watching me and turned to see a very sour face indeed, that of the attending. The interns explained to her about our presence but she insisted that we called Dr. Montano who is to call the head of the PEDs who is to talk to her before I do anything. We agreed and marched off to PICU upstairs to meet Dr. Monroy. He introduced us to five patients, most of who were there for pneumonia and sepsis. There was a child in the isolation room for an intra-hospital infection. Two at the end of the PICU were there for ‘intoxiccion folkaloricas’ which Andy explained. Andy left after rounds and the rest of us went upstairs for a presentation by an intern on acute respiratory distress syndrome. I felt like I understood the majority of it (PEEP!) and nearly laughed when I saw the ventilation-perfusion equation. Afterwards we returned and a resident who spoke a little English directed me to different procedures. I saw an arterial stick on this beautiful Quechuan boy with possibly the longest lashes on earth. He was one of the poor kids who have intoxiccion folkaloricas (liver failure, kidney failure, respiratory acidosis) when his mother attempted to cure him of a fever. I also saw a catheter put in through the abdomen on another child. Looked up and the time flew so I didn’t have a chance to check out the PEDS-ER. But I will tomorrow!


6.19.09
Jen- Today was the best day by far of this trip! I was in maternal ER again, but this time the doctor on call was my favorite doctor so far, Dr. Farrell. Things started out fast from the moment I walked in with a 22 year old woman who ended up having a partial abortion. I am not sure if it was natural or induced, but either way it was the first time I have ever seen anything like that. After she went upstairs to the labor and delivery floor another woman came in. Dr. Farrell did her pelvic exam and apparently she was quite dilated and we literally put her in a wheel chair and RAN to the elevator and onto the labor and delivery floor. I followed Dr. Farrell most of the morning and I ended up doing my fair share of pelvic exams on pregnant women. It took me about 5 before I was able to actually feel what I was supposed to. Hopefully with more practice I will get better! Regardless of whether I was doing it right or not, it was quite an experience! After a morning of patients, Dr. Farrell took me out to a quick lunch of saltenas before the group’s Friday afternoon meeting with Dr. Montano. In the afternoon we when to CRIN, which is the area for malnourished kids. It was very cool. I got to feed a premature baby boy. After about ten minutes of being afraid that he was choking on the milk I finally got comfortable with him. I burped him and right after setting him back in his crib he threw up on EVERYTHING. Needless to say, I don't know how much actual milk he was able to keep in him. This afternoon I went to labor and delivery and saw 4 vaginal births and 2 c-sections. I even got to carry the new babies to the newborn nursery and clean, weigh, measure, and dress them! It was really cool. I met a really nice doctor named Dr. Samuel in the new born nursery area. He graciously took the time to explain APGAR scores and some methods to help newborns breath when they are having difficulty. I feel like I am finding my niche in OB/GYN. We will see if it continues when I get back to the US.

Andy-
Friday, man it came fast, and like that it’s already been two weeks. Of course when you spend the first three days of the week in bed, the rest of it does tend to get by quite fast. I was in the burn clinic again today. I started out the day playing with the children in the patient rooms. I played for a while with a girl named Josephine. She was 10 years old and attempting to hoard all the stuffed animals in the entire clinic in her bed and she enlisted me as her gullible accomplice. I kept bringing her more until I found out she had Eva in on the racket too, and I told her I was no longer her partner in crime. She broke my heart a minute later though when she called me over and pulled out a coloring book that she kept stashed in the drawer next to her. Hidden inside the coloring book was a picture of her two sisters, and her incredibly ugly puppy, and herself- before she was burned and had long brown hair instead of her now bald and burned head. She told me about her sisters and her puppy and I decided maybe she might need a few more stuffed animals after-all.
The first surgery of the morning was the girl whose face we had cleaned up the day before. Her face was burned about four to five weeks prior, and though it was mostly healed, she had no pigmentation on her face, whereas the rest of her skin was quite dark. Using a dermatome, they cut a paper thin layer of skin off her thigh and spread it over a few spots on her face. It only helped her a little, and I wasn’t sure if more procedures would be necessary or if the small grafts would grow. I made a mental note to find out when I got home.
The next case was a little boy who was two years old and had been in a car accident. I had seen him earlier, with his head covered in a large bandage and not known what happened to him. As they took off his bandage, Dr. Ramero explained that he had lost a part of his scalp and his skull was exposed. We would need to drill holes in the skull to provide nutrients for the skin before they could do a skin flap to close the hole. As the bandages came off, I finally saw the hole; it was about 2.5 inches in diameter and the rest of his scalp looked like it had been patched back together. Dr. Ramero pointed to the hole and told me to scrub- which I did immediately. When I finished scrubbing in, they were just finishing putting in an I.V. in the femoral vein, again using the cut down method, only this time it went much more smoothly than yesterday. After the catheter was set, they asked me to close the hole in the thigh, while Dr. Ramero and the resident went to work on the hole in the head. I threw in a couple of stitches, maybe a little too close together, but definitely much better than the last time I had tried. When I was done, I took a look at the scalp, and what had been a red hole was now white bone, laid bare, with a fracture running through the middle of it. Using a surgical drill and a run of the mill drill bit Dr. Ramero proceeded to drill a series of very small shallow holes in the exposed skull. I sewed shut another part of the scalp while they worked on that. We then rinsed out the bone to remove the fragments, and I helped bandage the wound back up leaving it open. Dr. Ramero scheduled another surgery for five days later to finally close the rest of the hole up which I hope to make it in for.
While I was watching the anesthesiologist wake the patient up, Dr. Ramero called me out into the hall and showed me a little four year old girl. She was one of the sweetest girls I have met so far, just a bundle of smiling energy, except of course, every time I tried to take a picture. Dr. Ramero indicated the girl’s thigh, and I felt down there noticing she had an expander down there. An expander is a silicone bag that is implanted beneath the skin and slowly filled with saline over the course of about a month. Once the skin has been stretched out, the scar tissue is cut out and the new skin is used to stretch over the resulting gap. I thought she was the next case, not really catching all of Dr. Ramero’s Spanish, until a nurse handed me a syringe and I realized what it was he had wanted me to do. I had never given a shot before, but I had seen an expander put in last time I was down here in April so I knew what the port looked like and what to do and I figured it was pretty much point and shoot. I felt for the port, finding it about two inches below her hip and just underneath her skin. I was nervous though, and I probably stopped to check my placement ten times before I inserted the syringe into her leg and slowly injected 10 cc’s of saline into her expander. She didn’t even cry- what an amazing first patient! Then the nurse handed me a second syringe, telling me they were putting another 10 cc’s in. When she saw the second syringe she started crying, but once the needle was in the port she was all smiles again. She even talked to me after it was all over as I helped her get dressed. As I left, Josephine, the compulsive stuffed animal hoarder, called me over and gave me a great big hug and asked me if I was coming back tomorrow. I told her no, and I think she said that she was going home over the weekend, so though I won’t see her anymore, I was happy for her.
All in all it was an amazing day. But there was still a little more in store for us. At this point, I was about half an hour later for a meeting with the rest of our group just down the hall. After just catching the last few seconds of the meeting (perfect timing!), Dr. Montono took us to the CERN ward of the hospital, where the malnourished babies were. The children ranged in age from just a month to 11 months, so they were very young, and two were very premature. It was a great experience as we all got to feed the children bottles and burp them, something I had actually never done, and play with them for about an hour before we left for lunch.

Celia – I decided to go to PICU first before PEDS-ER because I didn’t want to miss rounds. Instead of rounds we had another presentation, this time on intoxiccion folkaloricas. There are a variety of plants used to treat a variety of health problems, used not just small villages but also in big cities and all across South America. From what I gathered, one of these herbs is also used in Red Bull. Hm. I asked the doctor about how often they see patients with this intoxication and he said about thirty a year, and those were just the severe cases. Wow, this is just the pediatric population. Afterwards, we went down and I found that the poor child in isolation died and the beautiful boy who was getting an arterial stick was brain dead (cerebral muerte?). The resident went through his checklist. He did a cold water nystagmus test and checked his pupils for brain activity. The poor child didn’t make it and he is going to be on a respirator until all his organs die. In Bolivia, you can’t “pull the plug” as it goes against their medical board of ethics. The mother was called. I took one last look at him before heading to the PEDS-ER. Carlos was there with his face covered. He has a cold. I followed him around and he insisted I do a few physical exams. I listened for heart sounds, to lungs and around the abdomen. I checked the eyes, ears, skin, nose, etc all the way down. One child was so scared he started peeing all over the floor! Hahaha. Anyways, most of the children had colds or fevers and those with fevers were treated to fifteen minute bath to drop their temperature. A little girl was crying the whole time we were there and I found out why. She was throwing up and had diarrhea from something she ate. Oh how I can relate. Dr. Montano took us to the CRIN and I found this cute little girl who demanded my attention. So I took her out and played with her, changed her cloth diaper (a first) and just fell in love with her. If she ends up missing somehow in the next few weeks, I’m not sure how that happened.