Blog 26

Blog 26: 10/30/08

My second day at Hospital ISSSTE was tough. In the ICU, being aggressive takes a lot of energy, and after a while I couldn't keep asking the doctors and med school students to explain every little thing. To really learn in that environment, you need to have the requisite knowledge they teach you in medical school. So I decided I'm going to switch to cirugia(surgery) tomorrow, or at least gynecology. Overall, it was a pretty relaxed day. One thing that I don't like about ISSSTE is how hard it is to move from one department to the other. I have to go to the administrative department and get permission (which is contingent on if the lady is even there that day) in order to move from ICU to surgery.

On a side note, one thing I noticed about Hospital ISSSTE is that it's pretty well funded. They have pretty good landscaping, and the hospital is relatively well taken care of, especially in comparison to Hospital Civil.

So far, my favorite rotation has been through the surgery department of Hospital Civil. It's very easy to switch rooms or departments to find what I wanted to see. And most days there were tons of interesting surgeries going on. I'm trying to get Hospital Civil to be my last rotation on this trip, but it's extremely sought after by the other students, so the only thing I can really do is pray. I'll definitely start going on the weekends to see surgeries, being that I don't have many more chances to be there, before and after Puerto Escondido. Also, there's a ton of work to do before this quarter ends. I have a 10 page individual research paper, a 10 page group research paper, and a final paper....YIKES. I've got to jump on that horse quick or else it's not going to get done.

Comida was good today. At Becari, many home-stays made tamales, and luckily there was manteca-free tamales for me to eat. It was really good, and I was pretty satisfied. Dia de los muertos (Day of the Dead) is coming up, and there were little kids dressed up as skeletons and zombies. They performed a dance for our group, which was pretty cute. Dia de los muertos are actually two days in Mexican culture. The two days are dedicated to honoring dead children and adult family members once a year, by making them altars. In Mexico, they actually celebrate the dead instead of mourning them, which is really interesting. The rituals and customs are derived from pre-Spanish cultures, and combined with Catholicism. It's going to be on Friday and Saturday, so I'll definitely take pictures and keep everyone posted. I'll also keep everyone posted about my surgery experiences tomorrow. Salamz.

Blog 25

Blog 25: 10/29/08

It was my first day at Hospital ISSSTE, which is a hospital dedicated to serving government employees such as public school teachers, administrators, etc. It's a very nice hospital, located only a few blocks away from Hospital Civil (General Hospital of Oaxaca). My first rotation was in the emergency department/Intensive care.
Unfortunately, by the time we got there, all the patients were stabilized and referred to their relative departments. There wasn't much to do. Rotating through the ER is very different than through the O.R. or primary care units.

ER has a lot more stress associated with it. A lot of patients come in with unknown problems, and need to be stabilized immediately. Because today wasn't such a busy day, the residents were using it to really relax; they looked really worn out, probably because most of them were on a 36 hour rotation. It was a really interesting and valuable rotation for me because I learned a lot about myself, and how I would need to change in order to take what I wanted from the experience.

Unlike in the other departments, it was much harder to learn in emergency care. Everything is fast-paced and people don't have the time or energy to stop and teach. It was really frustrating because I was having a hard time getting what I wanted out of the situation. I was used to having doctors taking the time to really explain the patient's problems, and answer questions that I asked. Many times In surgeries, doctors explained to me what was going on, many times without me even asking questions. Due to time and attention constraints present in the ER, I really had to change my strategy to learn. In order to learn, I realized I would have to be more proactive and persistent. The residents weren't just going to wait for me follow them around and ask questions. I would have to be more aggressive. So, I changed my approach and tagged along with any residents I could find. I didn't wait around for them to notice that I had questions, instead I asked questions as they were working and walking around. Any free time they had, I would swoop in with questions that I needed answered. The residents didn't mind my approach at all, and were really willing to explain things when I took the initiative to ask. Many times they didn't fully answer my questions, so I would just ask the person later, or ask someone else.

I learned a lot from the experience because it forced me to learn adaption skills for that environment. In this particular environment, where there's no time and a lot of stress, the only way to benefit is to be proactive and go after what you want. No one has the time to notice what you want or need. Hopefully, I step it up a notch tommorrow and get even more out of the ER. I want to practice my new found skills. However, I also realize that being this aggressive may not fair well in other contexts, such as in the O.R.; instead it might be interpreted as something else, and serve as a great annoyance to surgeons and surgical residents. The lesson I took away from this experience is that it's important to adapt one's approach to learning, based on the context of their environment. Being proactive takes energy, but I'm really looking foreword to my rotation tomorrow!

Blog 24

Blog 24: 10/24/08

he surgeries I saw today have topped all of the other surgeries I have seen on this trip so far. God was looking out for me because the line up today was ALL orthopedic; as opposed to the last two days where I didn't have any. I was pumped on adrenaline all day. I'm pretty sure found my calling. I've never been so excited about watching anything in my life. I HAVE to be!!....no, I'm GOING to be an orthopedic surgeon!

In the operating room, my obsession must have been apparent because the residents where taking extra measures to let me see what was going on. They moved me near the surgical table and let me look over their shoulders while they hammered away. I'm sure they could see my enthusiasm by my constant facial expression of astonishment (I would've screamed if I could). In that room, I felt, what I like to call, a "surgical high" (I'm a dork I know). I was in a complete state of euphoria, and I could've stayed in that room for another 9 hours. Alexa and I, asked the attending surgeon (Dr.Zapien) questions after the first surgery and he invited us to other his surgeries of the day. We were really lucky. A lot of props go to Alexa because she really helped me understand what was going on in the first two surgeries.

The first operation was on a 7 month old girl. The tendons and ligaments in her feet were congenitally abnormal, causing her feet to be tilted to their sides and pointed downwards. To correct this, they had to cut her tendons and ligaments, and re-stitch them in a way which reoriented her feet into their proper orientations. The surgeon was going to specifically cut the tendon from the posterior tibia. They also removed the extra membrane which was around her tendons and ligaments (not sure why?)This was probably the most focus intensive surgery of the day. I could tell the surgeons were under great pressure because children are extremely hard to operate on because their tissues are small and look different compared to adults. Operations requires more precise cutting, time-constraints are different, and vitals are more essential. Complications can have negative developmental effects on the child, and even death.

The second surgery, which was a much simpler procedure, was a fractured elbow. The patient was a 10-12 year old boy, who probably fractured his elbow through some physical activity. The surgeon made a cavity into his elbow, and reoriented his bones into their proper positions. Thereafter, the surgeon (which was actually a resident) drilled two screws through the elbow (my guess is to keep the bones in their proper positions while they heal). Lastly, he re-stitched the elbow, and the surgery was done. It was really simple.
I don't think there was an attending present for that surgery. It seemed like one resident was teaching another. They kept taking out the clavias(screws) and re-drilling them into the same part of the arm. My guess was the resident's first time doing the operation, and he was having a bit of trouble getting the screws into the right spots. In fact, they kept calling a senior resident as a reference. But, I suppose that's how you learn to do surgery!

The last, and most EPIC, AMAZING, and INGENIOUS surgery to EVER take place (at least for me), was a femoral reconstruction surgery. A 22 year old girl had a motorcycle accident that resulted in a major fracture of her femur; her bone was broken into 2 main pieces and the area of trauma was shattered like glass They hung her leg up to a pole, and at the fracture site it bended 45 degrees, when normally that area of the leg shouldn't bend at all...crazy stuff.
The surgeon started by entering the site of her fracture, using cauterizer (similar to in radical surgeries, but on her leg). It was weird to see a huge bone like the femur to exist in pieces within the leg. The surgeon, separated the pieces of bone to reveal the interior of the femur. He took a unique hand-drill, and started removing the interior of the bone. Another incision was made at the top of the hip where they drilled another hole through the femur. Eventually, there was a hole that ran from the fracture site all the way to top of the hip. The surgeon inserted a long metal tube that ran through the tunnel made through the medulla of the femur (there was a lot of hammering for this part). Thereafter, the metal tube was visible at the end of the femur where the fracture was, as well as the end where the hip incision was made. The surgeons then took the pieces of fractured bone and pieced them together around the visible part of the metal tube (located at the trauma site), and used a metal tie-rod to hold the pieces together. After that, they drilled screws through the surface of her femur longitudinally so it permeated the metal tube and exited on the other-side of the bone. The longitudinal screws were meant to hold the metal-bone construct together. The surgery was indescribably amazing
She reminded me of a super-hero named Wolverine from the comic book series X-Men because this character had a metal skeleton.

I had a really amazing experience. It was my favorite rotation in Oaxaca thus far, and it's hard for me to believe I'll see anything cooler. However, I have yet to see an open heart surgery and a neurosurgery, so I'll keep my mind open. I have a feeling that neurosurgeries are also an amazing experience. One thing I know for sure though, is that surgery is definitely my path.

I still can't believe that I saw three orthopedic surgeries in one day, I could not have lucked out more. A real benefit was that I was able to watch two of the surgeries, with the same set of surgeons, and due to the fact that they've seen me before (yesterday, and the day before) they're pretty relaxed about letting me get close. They also gave me their e-mails, so I could e-mail them pictures of the surgeries and ask questions about anything I didn't understand. I talked to the attending surgeon at the end of the surgery, Dr. Zapien, he was really friendly and willing to answer my questions. Definitely a great experience. When I get back to the bay area, I'm interested in finding research that exposes me to surgical methods and techniques, and other aspects of the process also.

Blog 23 - Competition

Blog Entry 23: 10/23/08

I learned a really important lesson today. I've defined what competition means to me, and how I can use it to my advantage. I think it really improved my opinion of certain people I used to look down on, and me realize goals through their perspective. By integrating my morals, what I want, and how other's perceive competition, I've created my own definition, which I think will serve me extremely well on my way medical school, and throughout the rest of my life.
Competition was a concept that I've only recently come to address. And until now, I've never consciously identified what it means to me. What I found was that I subconsciously defined it as process of defeating everyone else by any means necessary to achieve a goal. Motivation to compete would come from hopes and efforts in the failure of others; it also meant having hatred and jealousy when witnessing the success of others. This internal definition kept me away from competing in many things because it went against my values and morals. However, I changed my perspective by observing some students on this program.
Initially, I saw some other students spending disproportionate amounts of time with the professor, as well as going on some really awesome rotations. I framed their actions in the context of my old definition of competition, which built resentment in my heart. I felt that their intentions were to step on others to get what they want. I viewed them as my cold, heartless, and selfish; people that I have to beat. However, I was able to identify the condition of my heart, and I didn't like what I saw.
Our perceptions are colored by our beliefs and principles (Thank you emotional intelligence lectures!). It turned out my perceptions of these students were a result of my flawed belief of competition. I found that a little part of me wanted to have all the cool rotations to myself, and that others shouldn't benefit as much I should. I really didn't like thinking that at all, and it wasn't something I wanted to exist as a part of my personality. So, I thought about it in a different way, in other words I reframed it so that I could understand the perspective of these proactive students.
By reframing and putting myself in their shoes (Thanks again emotional intelligence lectures!!), I began to understand and respect them. In fact, I ended up respecting them a lot. I noticed that these are students who were motivated enough to take the initiative to try obtain what they were interested and passionate about. They weren't going to wait around for something amazing to fall into their lap. That's also something I've come to realize about life in general, things aren't going to come to you, you have to go proactively find it. I think I trace my old perspective to the way I was raised. Everything was pretty much handed to me, and I never had to proactively seek much of anything. When I didn't see amazing stuff falling into my lap as usual, I became stressed out. I saw other students benefitting, by being proactive... something I didn't understand at first. This program actually taught me otherwise, which is what makes the experience priceless. It's an essential life skill for anything one wants to accomplish.
I realized that it wasn't the intent of these students to take something away from me, instead it was to seek out something they wanted. My new definition of competition incorporates that. If everyone benefits that's great, but the reality of life is that there are goals that many people may have, but only a few people can obtain them. These goals are obtained by people who take the initiative to go seek it out. Their intent isn't to prevent others from getting to the goal, in fact, they're unconcerned with that. It's more of an internal struggle with yourself to go and get what you want because you realize it's not going to just be given to you. And people who proactively seek things out, deserve the rewards of that. I respect people like that, and they've really motivated me to do the same. By this definition, the success of others should inspire one to strive and learn from the success of others. It should build respect for those you see succeed and obtain a certain goal. At least, that's what it has done for me.

Blog Entry 22

Blog Entry 22: 10/22/08

In this post, I'll be going over my second day of Hospital Civil, which took place last week. I rotated through the operating room with Samantha. It was pretty fun.

I was able to watch my first orthopedic surgery, and I must say... IT WAS AWESOMEEEEEE!!!!!!

The patient was a male, who had an open fracture of the tibia as a result of trauma. The orthopedic surgeons were operating on his leg, 36 hours from the time the trauma took place. The patient wasn't fully anesthetized for the procedure, due to the fact that it was a regionalized procedure.
It started out with the anesthesiologist numbing the skin around the patient's L4 vertebra with litocane. Then he inserted a negative pressure injection/catheter through the muscle, into the spinal cord. If we saw the catheter fall out, it meant they weren't in the right area. The anesthesiologist inserted a thin needle to penetrate the spinal tissue (similar to a spinal tap). He drew out some spinal fluid, and put in the anesthesia. The process is a general process of anesthesia for most of the surgeries that I've seen.
After the patient was anesthetized, the orthopedic resident was using a needle to find the joint in the ankle. He inserted 2 screws, one in his tibia and one in his joint. At the end of the surgery there were 5 screws total around the ankle and in the tibia. They drilled the screws, above and below the fracture in order to line up the fractured areas of the tibia. They lined up the screws on both sides of the fracture, with other metal bits. The whole contraption was extremely rigid, and it managed to line up both parts of the fractured tibia, so that they would heal symmetrically. It was LITERALLY the coolest surgery I have ever seen!!!!!!!!!!!!
I loved this surgery because it was very technical. It was amazing that they used a simple power drill, to drill screws into the tibia. The procedure stimulated my mind spatially; in my head, I could see the different parts of the bone lining up when the screws were lined together. It's just amazing to me that we could fix the body using screws and power-drills. I've decided I want to be an orthopedic surgeon. Orthopedic surgery forces the surgeon to use their spatial intelligence, ingenuity and knowledge of the bones and leverage, in order to design different mechanical structures to fix fractures. It' extremely creative because every fracture is unique, and there are an infinite number of ways a fracture can act and look. It was a simple surgery, but I LOVED IT. I HAVE TO BE AN ORTHOPEDIC SURGEON!!!!!!!!!!!! If a kid breaks his arm playing football, I want to be the guy to fix it :).

Blog Entry 21

Blog entry 21: 10/21/08

Sorry, I haven't posted a while. Midterms just ended, and I was enjoying the week. Dra. Adela left on Sunday, I'm going to miss her because she's really easy to get along with and was always willing to hang out. One thing that I respect (it also kind of scares me) about Adela is that she's SUPER perceptive. For any future students of hers, DO NOT think she's oblivious to anything; I guarantee she can read you like a book. I'm sure she read me like a book, YIKES. But these qualities make her a good professor who can recognize potential... hopefully she saw some in me. I'm just hoping, I didn't do anything stupid in front of her without noticing (probably did :P). As of now, Dra. Melnikow is taking her place.
I was able to talk to Dra. Melnikow about the medical school process, and she has some really awesome perspectives. She really helped me understand certain pathways I could take in applying for medical school. She's a real asset to this program
I'm going to talk about my first rotation at Hospital Civil, which started last week.
So far, Hospital Civil is my favorite rotation. I'm probably going to come back here for my last 2 weeks. The first day started out in Pediatrics. I'll talk about all of the cases.
The first case was a three year old boy who had fractures through his humerus, ulna and radius. In Mexico, three years of age is the most common age for fractures. However in the U.S., we see the most fractures occur in ages 16 years and up. The contrast exists because car accidents cause the most bone injuries in the U.S.; Why? because most people are able to afford a car, and can start driving at 16. On the other hand, in Mexico, we see fractures mostly in children, occurring from sports and physical activity. Adults tend to walk instead. It was interesting to see the boy's x-rays. His humerus was completely fractured through and displaced. He didn't have a cast, and his arm was suspended by a system of pullies which served to reorient his bones into their proper positions. Luckily, the boy didn't suffer from medial nerve or muscle damage, and we knew that because he was able to move his hands and fingers.
Side note: We rotated with Dr. Jacobo Lopez Garcia. This Doctor LOVED my group (Me, Nick, and Alexa). He oriented the rotation as if we were real medical students. We weren't told what conditions the kids had. Instead, the doctor would give us symptoms and clues, and expected us to figure out what was wrong. After we figured out what was wrong, he would explain the conditions in depth. We would go over pathology, risk factors, and treatments. It was AWESOME. It really helped that he was able to speak a lot of English.
Our second case was a 14 year old boy who contracted Pneumonia. The boy was brought in by a resident who thought it was asthma. After running tests, the doctor found out the boy's problem wasn't asthma at all, it was pneumonia. Pneumonia is characterized by fever, cough, and respiratory weezing. Dr. Garcia showed us different x-ray angles, which indicated a mucous obstruction (called atelectasia) in the boy's bronchii. The doctor said that if the atelectasias are really bad, a surgeon might have to endoscopically wash the brochii with sterile water. Fortunately, the boy didn't need an endoscopy, and recovered with Penicillin. However, if after 3 days, they didn't see a recovery, the antibiotic is changed to another one.
Dr. Jacobo gave us some public health information on the usage of Penicillin to treat local strains of Pneumonia. Due to the over-usage and availibility of antibiotics in Mexico, 30% of Pneumonia is resistant to Penicillin (very high) as opposed to 10% in the U.S.
The third case we saw was a 3-4 year old boy with a brain tumor. The tumor was a cyst, which is a soft-tissue type of tumor. Doctor's knew the boy had a brain tumor because he suffered from headaches, vomiting and dizziness; these symptoms indicate problems in the brain. There was a lack of fever, and other symptoms traditionally associated with infections. The surgeons removed the cyst, however the boy still had headaches and vomiting, which indicated another problem. We found out that complications in the surgery resulted in the contraction of meningitis. This explained the residual symptoms. The boy had to be put into isolation, so the other children didn't get exposed to meningitis. Apparently, surgically complicated infections were quite common in the hospital.
Dr. Jacobo asked me what types of antibiotics should be used to treat the infection. Initially, I said ciproflaxin (which I assumed to be a powerful antibiotic). He said we could'nt use ciproflaxin because it acts as a growth plate inhibitor in children, using it would result in developmental complications. Then I said Amoxycilin, but he corrected me again. Amoxycilin is unable to penetrate to the meninges, due to the inflammation. The antibiotic we could use, was called cefalosperinas (and vancomycin) because it could penetrate the meninges with no developmental side-effects.
Dr. Jacobo said, In Mexico, for kids 5 yrs or less pneumonococcus can cause meningitis because patients cannot afford to buy the vaccine that would prevent it. In the case of this boy, pneumonococcus caused the secondary infection in his meninges. Other major symptoms after the surgery included: Edema of the brain in the surgical area, and an abscess(a collection of puss); together, these symptoms caused thrombosis (blockage of veins and arteries). The child was at serious risk for brain damage!!!
The fourth case, was a 5 yr old boy. He came in with headaches, vomiting, and couldn't swallow. These symptoms were a result of a tumor occurring in his mesencaphalon. Unlike a cyst, this was a solid mass of tissue. The mass of tissue caused hydrocephaly by blocking the drainage of of the C.S.F. in the ventricles. We saw that the ventricular cavity became larger, due to the build-up of C.S.F., resulting in intercranial hypertension. Due to the compression of the brain, from C.S.F. build-up, the patient could no longer talk. His gloseopharyngeal nerves were affected by the tumor, which is why couldn't swallow; these nerves innervate the muscles responsible for swallowing in the mouth. The boy is in need of surgery. Surgical intervention would include a shunt, which would drain extra C.S.F to the gut, in order to eliminate hydrocephaly; they would also remove the tumor.
The fifth case, was really interesting. A 13 yr olds girl had two unrelated problems. Her head was proportionately bigger than the rest of her body, due to congenital hydrocephaly. She also had a frontal fracture in her cranium from trauma. There was a hemorrhage lesion due to to the trauma of the fracture. Compared to the last case, the congenital hydrocephaly had less of an effect on this girl. The girl had hydrocephaly since she was born, and her cranium was extended in response to the larger ventricular lakes. Due to her larger cranium, her brain was not compressed, which is why she was relatively asymptomatic compared to our last case.
The sixth case (the most interesting case of the day) was a 6 year old male with an inflamed kidney. The doctor made the boy drink a phase-contrast solution in order to highlight the problem associated with his kidneys. We saw what was wrong by examining the boy's x-rays. He had a congenital valve failure in his bladder. Due to the faulty valves, the bladder was unable seal the ureters, and urine would go back and build up in the ureters and kidneys. Doctors were able to diagnose the problem due to the frequency of urinary tract infections. The boy had problems with valves associated with both kidneys. One kidney was severly damaged, and would only function at 25%, which the doctor termed as hydronephrosis or acute kidney failure. The second kidney was still functioning, however, in a short period of time would have also gone into failure. On the x-ray, we saw one of the kidneys taking up the phase-contast solution (it was bright), while the other failed kidney could not reabsorb the solution (it was dark). The functioning ureter and kidney, were both very inflamed. The boy required surgical intervention.
Surgical intervention would shunt the ureter to the gut, and the extra urine would be excreted from his gut. Also, the boy's valves would be replaced with plastic valves. With this procedure, the failed kidney should return to 75% functioning capacity, while the other kidney would remain at 100%. It was an extremely interesting case.
The last case of the day (I loved this case because Dr. Jacobo gave me the unofficial title of doctor, for my ability to diagnose it on my own). It was an 8 yr old girl, with dark bruises/spots all over her legs and arms. She didn't have a fever or any symptoms associated with an infection. I concluded, that the only reason she would bruise is due to a problem with her platelets (platelets bind together to form clots, and unexplained bruising or internal bleeding indicates a problem with platelets). I assumed it was some type of autoimmune disease... turned out I was right. There are two possible problems associated with platelets. One type is associated with abnormal platelet aggregation (function), while the other is a low count. A normal platelet count in the blood is 200k-400k, this girl had 7000-8000. The doctor told me that her immune system was attacking her platelets, which would explain the low counts. The repercussions are serious. The girl could eventually have hemorrhaging in her brain, GI tract, and Urinal tract, which together is called idiopathic trombocitopenica aguda (trying saying it fast). Platelets are produced in the medulla osea (bone marrow), along with RBCs (red blood cells), and WBCs (white blood cells). I thought the problem could be a form of leukemia, but Dr. Jacobo told me that Leukemia affects only RBCs and WBCs.
The girl was going to be treated with Prednisone, a cortico-steriod (can diffuse through plasma membranes) that acts as an immunosuppresor (the doctor said it also stimulates platelet formation from the bone marrow). The side-effects are more hair growth, psychosis, cataract formation, osteopenia( precursor to osteoporosis), and osteoporosis. What's more interesting is that the treatment is a permanent cure. Apparently, when the body cells are exposed to higher levels of platelets, over time, they start to recognize them. Therefore, autoimmune response goes down permanently. That's really intense!
Reflections...
This rotation was the best I've had yet, mainly due to the doctor. Dr. Jacobo Garcia was an amazing guy, who had the interest and patience to teach Me, Nick, and Alexa. In fact, he wanted us to comeback, and I really want to. So far, this is the most I've learned about diseases and treatment in comparison to all the other rotations I've done. Dr. Jacobo is like a walking medical textbook. I still don't know WHY he liked us so much, but I'm glad he did. Pediatrics seems really interesting, but I feel really bad for a lot of these kids. I saw some kids in a great deal of pain (especially the boy with meningitis), and it really hit me emotionally. Serving children is extremely important because they deserve the chance to experience a long and healthy life. They deserve the chance to find themselves and reach their potential.
Pediatrics, as in other primary care fields, is based in problem solving. That's probably why it's so interesting. I think it's more fulfilling than other fields because you're helping children improve their quality of life.

Blog 20

Blog entry 15: 10/14/08

I couldn't have started off the week in a better way than by watching a surgery. At 8:30pm in Hospital Carmen, I watched a radical hysterectomy, and it was EPIC. It's very invasive and it takes about 2.5-3 hours to complete. It's analogous to a radical prostectomy, however, instead of removing the prostate of a man, we remove the uterus of a woman. The surgeon this time around was Dr. Banos, who was really friendly and let me watch the surgery right at the surgical table. I had the same viewing angle as I did in the radical prostectomy, so I could see pretty much everything that was going on inside the body, and this made the experience AMAZING.
Oh, and as a side note, I watched a cesarian a few days ago, but didn't have time to write about it. iA I'll try to make a post for it this week. Midterms are killer.
I'm really getting used to surgeries now. As the surgeon enters the body, I'm starting to identify and differentiate between tissues. For example, today I was able to identify lymphatic ganglion, the iliac arteries and veins, mucles, fascia, and fat. Also, I pretty much know most, if not all, of the functions of the techniques the surgeon uses in surgery. Considering the amount I'm learning by watching these surgeries, as well as the having the ability to talk to surgeons on a regular basis, this program is priceless. I'm able to go into the O.R. so much, that the surgical nursing staff knows who I am! There are no programs that offer such a comprehensive medical experience, especially for undergrads, and I'm experiencing medicine in a way I know most people won't even be able to imagine. I don't think I realize the extent of how lucky I am. Now, I'll go into the specifics of this surgery. I'll also contrast the radical prostectomy to the hysterectomy, as a way to compare the individual operative styles between surgeons.
The surgeon operating was Dr. Banos, he wanted to be more fast-paced in comparison to the last surgeon we had, mainly because it was a night surgery, and he wanted to get done before it became late. However, 5 min into it, he changed his mind and decided to spend more time teaching Me and Yadira about the procedures and process... We got really lucky.
The patient was a 64 year old woman. She had cervical cancer, which is generally detected through a papsmear(if the lesion is not visible), or a biopsy (if the lesion is visible). In this case, I think it was a papsmear because the surgeon told us we wouldn't be able to see the lesion. Dr. Banos preferred that the patient was fully anesthatized and intibitated to prevent her from moving around. I noticed that Dr. Flores from the radical prostectomy preferred his patient to be half-awake. The surgeon entered the body with a cauderizing tool. This woman was extremely skinny, and to get to the abdominal rectus we didn't cut through much fat at all. It was interesting when the surgeon stitched edges of the first 2-3 tissue layers in the incision to these large towels so that we would have better access to the cavity. The towels held the cavity open in a way which we could only see the innermost tissue layers. Then he checked the abdominal cavity with his hand for cancerous tissue. Inside the cavity, he cauderized blood vessels to prevent bleeding, as well as tying off certain tissues. As we went in, he showed me her large intestines. It was CRAZY when he pulled some of it out of her abdominal cavity to show us how it looks. Analogous to the prostectomy, the surgeon pulled off the lymphatic ganglion that runs next to the iliac vein/artery bundle and inferior to the obdurator nerve. He pulled off the tissue carefully so as not to tear into the artery or vein; if he did tear into the artery or vein, there would've been a lot of bleeding, mainly because they're HUGE. He also pinched the obdurator nerve, and we saw a leg twitch in response, which was really cool. The surgeon also repeated the procedure on the other side of the body, where he showed us the nerve that innervates the genitalia.
Then, he cut down 1/3 of the way into the vagina region to make sure there was no cancerous tissue left. Thereafter he cut the ligaments that hold up the infundibulum part of the uterus. To remove the uterus he cauterized all the way through the neck of the cervix.
After he removed the uterus along with the ovaries and uterus associated lymphatic tissue, he stitched the inner end of the vagina in order to seal it. In the pelvic cavity, he reconnected the ligaments that hold up the vagina. Before the entire cavity was closed, he inserted 2 "sondas", which are tubes that run from the inside of the cavity to a drainage pouch. The sondas are used to drain out residual bodily fluids. However, in the prostectomy, there was only 1 "sondas."
Reflecting back, the surgery was very similar to the radical prostectomy, but it was interesting to note the anatomical differences between men and women, as well as differences in surgical styles; even the stitching styles were different. This particular surgeon also felt around much less with his hands. It was way easier to see her iliac vascular bundle than it was for the man. I was able to really identify tissue differences, which was really a big deal for me. Last time it all just looked the same. Again, we were lucky because the doctors were all really nice. When I first pointed the vagina out, I didn't know what it was because of how it looked inside the pelvic cavity, and the entire surgical staff laughed for about 4 min.s straight. They called me chicitito, which is an endearing term for innocent little kids, and said I would find out what it was soon enough...LOL. I think I lightened the mood, which was good.

Blog 19

Sorry I haven't posted in a while. I have 3 essays to get don within the week, so I really haven't had the time to reflect and post. But when these essays are done, I'll definitely talk about the cesarean I saw, as well as ethnography, cultural humility and competence!!! Thanks all. Salamz

Day 17 and 18

Blog Entry 14 and 15: 10/07/08-10/08/08

The past two days have been very reflective. After seeing surgeries and some primary care, I definitely have a feeling of what I'm more interested in, which as my blog posts show is surgery. Also, another large realization I had these past two days allowed me to conceptualize why I wanted to become a doctor... I'll explain
There are MANY ways to help others improve their quality of life. You can be a public health administrator involved in health policy and planning, and in turn affect health care programs and ultimately the health status of more people than an individual doctor could. Policemen also improve people's quality of life by keeping us safe, and giving us the security of knowing that our lives aren't in danger (well they do most of the time). Also, Psychologists improve the quality of life for many patients by focusing on mental health. Improving the quality of life is a goal of many professions, and I don't feel that's it can serve as a sole explanation for why someone want to specifically be a doctor; it's a part of a collection of reasons that lead one to become a health professional. After my conversation with Dr. De La Torre, I realized that I want to be a doctor because I like the medicine itself.
What interests me most in the field of medicine is the science behind it. I like knowing the functions of lymphatic pathways, vascular innervations, and neural pathways, and how they interact. I like learning about the mechanisms that viruses use to infect the patient, and what are the outcomes on the biological level. I get a rush while I'm in surgery because it involves deep knowledge of the physiology, pathology, and anatomy of the body. I really liked primary care, not just because I could form meaning relationships with my patients, but also because it required deep knowledge of bodily physiology to figure out the specific pathologies of their condition (well on a basic level for me, I'm not a doctor yet :P).
The science and methods involved in surgery are what gave me that excitement, passion and motivation to pursue particularly the surgical profession as a life goal. To see someone operating on someone else, with such a high level of expertise, fascinated me on a level that's still very hard for me to describe to you. I think that's just how my personality type is; I'm amazed by form, function, and mechanism, and how our knowledge of medicine can allow us to manipulate the body to solve problems. I just love it.
So to summarize, I think improving people's lives should be the basis for any profession. However, one should choose a profession that helps people in a way that most interests him/herself. If you're not interested in what you do, then that means you wont be using 100 percent of your potential for the benefit of those you serve; if your not using all of your potential then you're wasting your time because the outcome of your fruition won't be the best possible outcome. Personally, If I'm not interested in something, it's very hard to put the effort and commitment required by any type of work to create any worthwhile outcome, and there really is no point in half-assing something you're going to be doing for the rest of your life, especially in the case of health, where the repercussions decide the future of people lives.
Also to note, I think the intricacy of the body is a testament and sign of how amazing God really is.

Day 16

Blog Entry 13: 12/06/08

First day of the new week started off pretty well. I wasn't as well rested as I could've been due to the incessant buzzing of mosquitos around my head, which lasted all night. It's becoming hotter here during the day, and I'm noticing more mosquitos around that are also larger in size. However, the learning experience of the day was good.
Dr. Tenorio's lecture today was about the communicable disease found in Mexico. The disease that interested me the most was tuberculosis. Tuberculosis is mostly an issue in underdeveloped countries, and it's pretty hard to combat in general. The disease itself isn't caused by a virus or bacteria, but micobacteria, which is why its so hard to kill it with antibiotics. The micobacterium also has a fast rate of mutation and exists in 60 different strains, which complicates things even more. Tuberculosis can occur in ANY organ of the body, and has a variety of unique symptoms depending on the organ and the person in which it infects. What made tuberculosis more of an epidemic is the modernization of travel, people now use plains and can transfer their regional strain of T.B. to other areas of the world, which in turn allows for a diverse array of stains to exist in one location. I remembered, in centro de salud, the endoscopy of the woman who had advanced T.B., and the symptoms aren't fun to look at (granula in the respiratory tract). Most countries now use a antibiotic cocktail to deal with T.B., and if detected early enough their is a good chance of survival. But in developing countries such as Mexico, early detection is uncommon.
Dra. De La Torre, talked about the health care platforms of both candidates in the upcoming U.S. presidential election, and the bottom line was that both platforms aren't dealing with the main problem. The main problem that both parties are failing to address is the existence of the current health insurance oligopoly. The oligopoly controls the health care industry by setting prices for procedures in the private sector. So even though Obama wants to set up a federal exchange program that would allow affordable insurance to anyone due to funding by the federal government, patient's still do not have control over how much the procedures will cost in the private sector, and therefore control what procedures the patients have access to. McCain on the other hand wants to retain the current industry of health, and offer tax incentives to lower income families in order to make insurance more affordable, which in reality won't do much if we look at the logistics involved. The tax break is too small to make any meaningful difference, and in fact may be worse because it potentially eliminates employer-based insurance coverage. The nation needs to deal with the phenomenon of a few healthcare insurance companies that control the entire market, meaning that it's expensive due to lack of competition. Not to mention the money that goes into malpractice litigation, and administrative health costs. Bottom line is that our healthcare is system is super inefficient, and that our dollars are lost in administrative costs, corporate health profiteering, and litigation, hopefully the problem gets solved, but neither candidate it willing to do it...sigh.
Reflections...the repercussions of our collapsing health industry, and subsidization from the government results in what's now occurring in our collapsing banking system. In the future, income for doctors will be quite different than it is today. Doctor's today are well off because the system of health worked well in the 1960s-1970s when it was designed, but new economic factors have changed the dynamics of our health industry. Bottom line, being a doctor in the future will definitely not be for the money, which doesn't really change my plans, but it really sucks to know that the reason patients and doctors aren't benefitting from money earned and spent in healthcare can be attributed to the inefficient system of health perpetuated by the greed of these conglomerates.

Weekend 2

Blog Entry 12: 10/04/0 FORGIVE ME FOR GRAMMATICAL MISTAKES ILL GO BACK and correct it later.

This was probably the best day that I've had in Oaxaca so far. I observed a radical prostatectomy, which was the MOST invasive surgery I've ever seen. The only thing I could image to be more epic would be a open-heart surgery or a neurosurgery. I was there with my friend Yadira (or as Me and Nick call her Yadidaaaa!). She was a huge help because fluency in Spanish allowed me to understand what was going on in the surgery. This particular surgery was special because Hospital Carmen had to bring in this surgeon from Mexico City to teach the other surgeons at the hospital how to do this particular prostate removal. The teaching surgeon, Dr. Flores (A surgeon specialized in Oncology), did very beautiful work, and it was easy to see that he was an expert as well as a seasoned veteran. The other doctors were complimenting him on his work. Another reason the surgery was such an invaluable experience was due to the fact that the doctors in the room were so friendly, especially the head surgeon (Dr. Flores), and were willing to explain what was going even WHILE they were operating. They even let me take videos and pictures, which I'm definitely going to post. We were standing RIGHT next to the surgeons as they did the surgery, which made the observation an AMAZING learning experience; there was literally no way anyone could've gotten closer to observing than we did. To put it in perspective, I was as close as the surgeons were to the patient, but a little off to the side. In the U.S. they probably would've made us observe from behind glass in another room, which is also another reason why Oaxaca is such a priceless experience. I have trouble believing that any experience after this would be able to top the one I just had today...but maybe a neurosurgery or open heart might top it :P. Now I'll go to explain the specifics of the surgery.
We walked into the room with the patient already under the influence of anesthesia. His legs were wrapped and was given anticoagulants to prevent clotting anywhere in his body. Before the patient was operated on, doctors (I'm assuming his oncologist or primary care physician) already did a biopsy which revealed the presence of a very high antigen count, which usually indicates the presence of a tumor. Before any cutting, for about 5 minutes, the doctors would pinch the patient's abdomen to see if he would moan; moaning would indicate that he's still feeling pain and the painkillers still required more time to come into effect.
They started cutting his lower abdominal area, right above his penis, by using a very unique (at least it's unique to me) electrical burning tool. The first layer under the skin, was this thick layer of fat. It was REALLY weird that as the burning tool made its way through the layer of fat, it smelled like someone was frying something in cooking oil....very eerie. After the layer of fat, the surgeon stopped using the burning tool and instead started moving through the body by conventionally cutting connective tissue with different types of surgical tools. Throughout the surgery, the surgeons had tied off many parts of tissues with these interesting black ties (might be sutures), I need to find out what their function is, but I assumed it was seal bodily fluids from entering the cavity during surgery. As we made our way to the prostate gland, the surgeon was cutting out rectal lymphatic ganglion because these ganglion can serve as a pathway (which started in the iliac and ended in the prostate) for the malignant tumor to travel and spread to other areas of the body, such as in the case of metastasis. The lymphatic tissue was collected, and would later be sent to the pathologist for analysis to make sure that cancer didn't already spread along the lymphatic pathway; however, this was just a safety precaution, and Dr. Flores highly doubted that metastasis occurred.
Also, throughout the surgery, Dr. Flores put his hand fully into the cavity and felt around. He told me that a good surgeon must be able to visualize the cavity and viscera through tactile knowledge, surgical tools and visual knowledge were not enough. It looked SO CRAZY so someone put his whole hand and part of his arm into the gut of another man, but i thought it was cool.
Dr. Flores also said that this particular radical prostatectomy, saved 5-7 liters of blood over the older method; looking at how much blood came out, I would say this surgery MAYBE resulted in 1-2 liters of blood loss. There was bleeding when the surgeon cut into the pelvic fascia (visceral tissue), but the benefit of this was that we could see perfectly into the pelvic cavity, and therefore the bladder and prostate. What really blew my mind was when the surgeon cut the urethra, and separated it completely from the bladder and prostate gland (gland is located between the bladder and urethra), and we saw the catheter connecting the bladder to the separated urethra INSIDE cavity, I have pictures of this. Dr. Flores then identified the neck of the prostate gland, and started using the burning tool to separate it from the bladder. Once he separated the prostate gland from the bladder, he cut the catheter at both ends and used it to lift out the prostate gland.
Before reconnecting the bladder and urethra, Dr. Flores stitched the outer and inner membranes of both the bladder and urethra (my guess to promote membrane fusion). He reconnected the urethra to the bladder by passing a new catheter through the urinary pathway, and then stitching the bladder to the urethra, with only 4 stitches; his method of stitching was beautiful work, and all the other doctors were super-impressed. The cavity was resealed with stitches, by individually stitching together 3 layers of tissue. There was also a tube, that lead from inside of the cavity to outside of the body, into a bag that collected any extra bodily fluids that needed to be drained from the cavity. The surgery was over after that, and the patient was wheeled into recovery.
Some extra things I wanted to add about the surgery. The surgery was conducted in a way where the patient theoretically retained 100 percent of his voluntary bladder control, due to the fact that the surgeons where able to avoid damaging the neurovascular innervations that were located in the surrounding bladder control muscles. 15 percent of voluntary urinary control is located in the tissue surrounding bladder, and 85 percent was located around the urethra near the penis. The tissue was undamaged, and was joined together after the prostate gland was removed. Also, at points during the surgery, the patient was awake and making some jokes, even though there was a hole in his abdomen almost a foot deep, which was REALLY bizarre. If it wasn't for the visual divider, the patient would've FREAKED out seeing his own surgery, guaranteed. Dr. Flores let me feel the removed prostate, and we could see how enlarged it really was. The prostate weighted about 80 grams, while a normal prostate weights about 20 grams. Also, one side of the prostate was more enlarged than the other, indicating where the tumor was.
Now, I know this has probably been my longest post, but here are my reflections...
After watching this surgery, I am CERTAIN I want to be a surgeon. It was amazing in so many ways. It requires high levels of visual and physiological knowledge, and a level of intricacy and skill that can only be gained through lots of experience and talent. You have to be able to know the human body on an instinctive level, using intuitive knowledge to navigate the viscera as if it were the back of your hand. Surgery is an AMAZING art and it seems to require the usage of the left and right brain, which I think is the best way to stimulate the mind. I love it because it's a high level skill set, which makes the field really special, it's not something everyone can do. I think I fit into this field because I'm a very visual-spatial thinker and it's a field really based on using that sort of talent to develop it into an expertise. The surgery was 4.5 hours, which felt like 30 minutes; and I guarantee, I would've been glued even if it went on another 10 hours.

Day 13

Blog Entry 11: 10/03/08

This is the third day of my rotation, and I'm slowly starting to like it more and more. For the past two days, it was getting pretty boring, but I realized that was mainly because it was hard for me to understand Spanish, and in turn Dra. Ana Maria. Today, I was able to understand much more, and therefore the experience became immediately more enjoyable. It's interesting how fast I was able to understand her because it only took me 2 prior days of 4 hour sessions to really start deciphering her diagnoses. At this rate, I should be able to fluently understand, and hopefully speak Spanish within a few weeks, at least for medical Spanish. Also, the cases themselves were more exciting than yesterday.
The first patient of the day was a middle aged woman, who was 45-50 years old, with scoliosis. Although the lady looked pretty normal, the x-ray really showed how distorted her spinal column really was. By tracing the spinal column from top to bottom it made this very apparent S-shape, and I was surprised that it didn't really manifest itself in her posture; however, maybe if we looked at her much closer we could've noticed it superficially. Dra. did not recommend surgical intervention to fix the problem, so she prescribed painkillers (analgesics) for the patient. Looking back, I think the main reason the patient would not be able to get surgical intervention with scholeosis can be attributed to the fact that her insurance coverage is Seguro Popular, or the state's social security program. Due to expense, my guess is that surgeries are reserved for life-threatening conditions. Although, she said that if the scoliosis did get worse, in terms of pain, they would consider surgery as an option, but I doubt that being that it's classified as a cometic surgery. It was odd to see an older woman with, what looked like a bad case (looking at factors of pain, and the obvious distortions in the x-ray) of scholeosis. In the U.S., they had free programs in my elementary school to check for scholeosis, before it becomes harder to correct. I'm interested in finding out whether there are programs in Mexico in observing the presence of scholeosis during child development.
I also wanted to comment on something cool I learned today. I was carrying a certain opinion that was critical of prescription practices of doctors at the clinic. My opinion was that they over prescribed antibiotics in dealing with bacterial infections, being that every other prescription I wrote for Dra. Ana Maria was one for Amoxycilin. I still somewhat have this opinion, but I'm glad there's some counter evidence to it. It turns out that she prescribes Loratadina, which is antihistamine (for symptom control), instead of an antibiotic, for minor infections that are relatively asymptomatic in terms of fever and inflammation. This then makes the cold more manageable for the patient, and just allows the body's immune system to fight off the cold on it's own. I was a bit afraid that antibiotics were prescribed for all infections regardless of intensity, but this wasn't necessarily the case. Don't get me wrong though, there is an overuse, and over-access of antibiotics in the community due to the fact that there isn't a need for prescriptions for Amoxycilin at a lot of pharmacies (something I found out from Dr. De La Torre); which results in patients taking them erratically, or for every small problem, and developing antibiotic-resistant strains of common bacteria.
Also, I'm finally able to interpret lab test results relating to the presence of diabetes mellitus and bacterial infections. For bacterial infections, I look for elevated levels of leucocytes and nitritis(nitrates?), which indicate possible infection. It makes sense to see elevated leucocytes because they're responsible in developing a response to pathogens. For diabetes mellitus, I look for high levels of blood glucose, triglycerides, and blood pressure. Pretty cool stuff.
One case that I was able to deduce on my own (Yes, I'm proud of myself!!), was a case of rheumatoid arthritis. A thirty-one year old woman came in complaining of pain in the joints of her legs, and said that she's had this pain for about 8 yrs. Right off the bat I guessed that it was either osteoarthritis or rheumatoid. What gave it away, was that she also complained of pain in her wrist and neck, which have been occurring for a years also. Due to the fact that rheumatoid arthritis is an autoimmune disease, in which antibodies attack the joints (specifically the synovial membrane, I think), people get pain in ALL, or most, of their joints.
Those were just a few of the cool cases that came in today. There was a kid who we figured out had a parasitic amoeba within his intestine, due the pain in the intestinal area when we were pressing his abdomen. I was also able to see cataracts in some patients eyes, which was really interesting also. But tomorrow, I'm pretty psyched about seeing another surgery at 9:30!!!!!
Reflections for the day... After somewhat overcoming the language barrier, I was starting to understand and enjoy the rotation. Knowing about various identification factors that allow you to deduce diseases and conditions makes primary care analogous to being a detective, which is why it's so interesting. I realized that not all factors are biological indicators, and that a doctor also needs to be aware of people lying about their conditions, which adds another extremely hard dynamic to diagnosis. I definitely can see why people want to be primary care physicians, but I still don't know if it's for me. My heart is still in surgery.
Also, I also wanted to note how amazing Dra. Ana Maria is. She's really patient with me while I'm learning. Student's on other rotations told me how impatient and apathetic some doctors were to them, and it just made me realize how lucky I was to get paired with her. Even through I yawn and slouch, she never seems to get annoyed or offended, when most doctors would! Many times, when a patient is on the bench, she lets me examine them with her, telling me what to look for. She also spends the time during, in the middle of the appointment, explaining the patient's condition to me, even through at times she knows I have no clue what she's saying. My lack of understanding never frustrates her, and she's always glad to see me the next day. I really got lucky, she's awesome and I'm glad I was able to learn from her.

Day 12

Blog Entry Day 12: 10/02/08

My second day at the clinic was interesting in terms of finding out about things that I like and I don't like. I found out that I definitely do want to help people, but I'm not sure primary care is the way for me. Now granted, I also need to factor in the language barrier into my experience, in that I am limited in asking questions and receiving information on the cases that we see. Also, it might just be this particular rotation, or day, in which I don't see that much. So, I won't judge this as my deciding experience on whether I want to do primary care or not. But I noticed that it does get quite repetitive at times, and most of the procedures involve looking for infections by examining the throat, the ear, or the body in a basic set of ways. Though, one case in particular really excited me today.
A girl the age of 16 came in. Initially, I couldn't tell what was wrong with her, but the doctor told me to follow her into this mini-operating room. The girl took her sweater off only to reveal a ridiculously large stab wound, and when I mean large I mean LARGE. It was stitched up, but the wound itself traced down at least half of her arm. She took off her bandage and we checked for areas that secreted puss. Most of the stab wound was healed; but the area we looked at, which also looked like bullet hole due to its odd circular shape (I'm not sure if that actually happened, i suppose a knife could've been twisted in a circle, as another possbility), was still very wet with blood and puss. So, we wiped that part of the arm down with swabs soaked in iodine and alcohol, and then squeezed it, so that the puss came out. Once the puss came out, we cleaned it, then reapplied alcohol and iodine, and re-bandaged her wound. An interesting thing I noticed was that there was three dots tattooed on to her hand, and I think that means she's part of a Mexican gang, so I wouldn't be surprised if her wound occurred due to some extremely shady situation. I was just glad I got to assist by providing iodine and alcohol soaked swabs, as well as being able to get a really good look at the wound. It was really sad to see this young girl in that sort of condition because it was extremely painful, and the experience of getting that wound was probably pretty traumatic.
Reflecting back, the most exciting rotation I've had so far has been my first surgery rotation, which was the arthroscopy. I felt that it was more hands on and involved, and for some reason I just like to see blood, tissue and everything inside the body. But, I still think that I'm not giving primary care a fair chance, mainly because I can't understand what Dra. Ana Maria is saying, and I'm guessing if I was able to, I would be hearing really interesting conditions and problems. Again, I have to give her a lot of kudos for going through as many patients as she doest without any breaks; she goes 5 hours at a time with 12-15 patients in that time period. I didn't really get a chance to take pictures of me doing anything, but I'll ask when I'm comfortable enough with her to bring it up.

Day 11

Blog Entry day 11: 10/01/08

Today was the first day of my rotations, and it turned out to be great. Nick (housemate) and I, took the bus to the municipality of Volcanes, which is where our centro de salud (center of health) was. We arrived at about 7:30 AM, but were notified that Dra. Consuelo, the doctor we had to meet with, was going to arrive at 10:30. So instead we chose to be reassigned to another doctor who already there. The first doctor, me and Nick were with, was Dr. Victor Lopez; he was a really easy going and fun doctor, something that I really liked. The first case of the day was a boy, about 5 yrs., old came in with trouble breathing. After, checking his chest with a stethoscope the doctor concluded it was bronchitis, an infection I would find out later in the day that is all too common with kids around the area. After the patient, I was transferred to another doctor, Dra. Ana Maria, to keep the ratio more one to one. The transfer turned out to really benefit my learning experience, both in medicine and in Spanish.
Throughout the 4 hours I was there, we went through a least 12 patients. I honestly don't know where she gets the energy to keep examining patients and diagnosing problems one after the other, I suppose you get used to it after doing it so much. Due to the fact that she didn't know english, my main challenge was trying to understand what she was saying. When I started to pay more attention to names of diseases, while looking at the parts of the body she spend most of her attention on, as well as the types of medications she was prescribing, I started picking up where the problems most likely occurred and what types of sicknesses the patients had. I really liked my rotation because she let me do stuff during the examination. I was able to look for inflammation and infection in peoples throat and ears, as well as listening to what wheezing sounds like when someone has a respiratory infection. I'll go over a few interesting cases that came in.
The most interesting case that I saw was this 1 year old girl with a secondary secretory bacterial infection (after doing some research might have been fungal). She had these strange green secretions on her skin, in different parts of the body. The girl had a primary infection that she probably caught from her older brother, who was 3 years of age. The doctor said that because the girl would scratch and itch herself after wiping her nose with her hand, the infection spread to places where she scratched, causing a secondary bacterial infection. She was prescribed an oral antibiotics (Dicloxacilina suspension, Lortadina Jarabe) as well what I assume to be an antibiotic topical creme (clioquinol creme, which turns our to be an antifungal).
I was also able to look at pictures of an endoscopy of a woman who came in with tuberculosis. She had many lesions and granulosa in her respiratory tract. I felt really bad because she was in a lot pain and was on the verge of crying. It seemed like the T.B. was really accelerated, possibly due to late assessment and treatment. I derived that it was bad, based on the expression and tone the doctor; in this case, she seemed really disturbed and had a really grim expression on her face.
I think the most common types of cases, are those relating to chronic diseases such as hypertension and diabetes. There were a few men we saw who's ages ranged from 50-75, who didn't exhibit any infections, but instead we paid close attention to blood glucose levels and blood pressure; which, luckily, were pretty well under control.
Most of the kids who came in exhibited bronchitis or rhinopharyngitis, which seem to be the common infections in the area. For most bacterial infections Dra. Ana Maria prescribed Amoxycilin, in other oral tablet or liquid form. The way I learned to identitfy infections was to look at the back of the throat, color of phlegm, secretions in the ear, and the presence of a fever.
Due to the lack of technology in these clinics, doctors rely much more on their senses and intuition. For instance, Dra. Ana Maria would feel the abdominal area of her patients to check for where there was pain, and what types of pain the patients felt. For pregnant patients who came in she felt the abdomen and listened with her stethoscope to get information on the timing of contractions and information on the baby, rarely was there a sonogram included in the chart. What was pretty cool was that she let me listen to the baby and contractions through the stethoscope, which was something I've never done before, and to be honest I don't know how she was able to get information on the baby from that, but she did. It was a bunch of random sounds to me, and I had trouble distinguishing the sounds from the ambient noise.
Being at this clinic has shown me a little bit about primary care, and I know I'l learn a lot more in the next two weeks of this rotation. From what I could see from my first day, primary care is really exciting because you never know what's coming through your door next. People could have any variety of problems, ranging from any field of medicine, and the primary care physician must be ever vigilant in diagnosing these issues, which any times can reveal greater hidden problems. The job seems to be mostly based on finding and diagnosing problems based on any current symptoms supplemented with information you can get the patient's medical history. You never know what your going to see next, you have to have knowledge of all fields, and nothing is repetitive because every patient is unique in the problems and issues they bring to the clinic, which is what I think keeps primary care interesting and fresh.
Reflecting back on the first day, I really liked the experience. There is an immense amount of joy in helping people increase their quality of life, there's no doubt in my mind about that. One aspect of being a doctor, which in my opinion makes it completely worth it, is that people literally trust the doctor with everything that's really important to them, which is their quality of life, life itself, and their trust. The way I think about it is, if someone trusted me with their life, which is their one of if their most important assets, then it would become my responsibility to help that person save or improve the quality of that asset with everything that I can, due to the fact that it's entrusting it to me and no one else, which is a great honor in itself. Likewise, if I were to go to a doctor, I'm trusting him/her with the my ability function and enjoy life, which aside from my religion and family is my most important asset. I would expect that doctor to guard and take care of my life with the utmost care and compassion. I truly believe that I can be a great doctor because I care about people and I would to improve their quality of life and make that difference by taking caring the things most important to them. Today, I was able to feel the joy of seeing patients feel relief when the doctor found out what was wrong with their either themselves, or their kids. Knowing that the doctor was able to provide a solution really brought satisfaction to a lot of these patients, which makes the entire profession worth it. It's a very good feeling, a sense of fulfillment hard to describe.
However, I realize that its not all a walk in the park, and that there are unsatisfied patients and unsolvable problems, but that's how life goes, and we can only do the best we can.

Days 9 and 10

We had our first days of classes, and we were on the topic of emotional intelligence and Insurance systems in the U.S. and Mexico. In class, what I found most interesting were all the constraints that doctors must work with to deliver care in the U.S., due to an inefficient system of health care. Private health care, which is limited to the rich or corporately employed has limited access to the general population, and public systems such as Medicaid are contingent on the federal and state definitions of poverty and eligibility status. The problem is most serious for the Mexican-origin population of the U.S., due to the fact that they are concentrated in lower socioeconomic levels and occupational locations. They work in industries where the employer does not offer insurance, yet they make enough money to lose eligibility for Medicaid, making them a class of uninsured known as the "working poor". The problems with improper health care due to low economic status translates to patients waiting for problems to get big enough that they need emergency services, not filling prescriptions due to cost, and lack of regular health care services, which turns out to be ultimately more expensive for the patient.
I never realized that there was so much beauracracy within our system of health. What's scary is that the current national debate over the future of our healthcare system will affect the way I practice as a doctor. I never realized it's so important to know the issues. Due to the fact that insurance is so privatized, doctors have no bargaining power in procedural costs, therefore insurance companies set all the prices, which will put more constraints on the types of tests doctors will run on their patients. In my opinion, there needs to be a movement for a national health care system that offers a beneficiary package of basic health care services, and optional supplementary insurance (public or private) for patients who want more coverage. Our health care system, today, is not a vertical system, due to the fact that the private sector deals with ALL the direct medical care of the patient, and public programs like Medicaid only provide funding (no actual health services) for procedures done in the private sector (which cost way more than medicaid can fund, which why many doctors are unwilling to take medicaid alone). The government should provide fully vertical programs that integrate funding and resources all the way down to direct medical care, through the existence of vertical public systems, for at least basic health care needs and services.
Another important concept emerging in quality care and effectiveness of treatment comes in the form of a doctor's ability to be culturally competent. A doctor must understand his patient's perceptions and emotions in order to deliver care. Factors for treating an illness don't only lie in the pathology of the illness but also the cultural and belief factors that the patient has regarding the advice the doctor may give. For instance, a patient may not take medication the doctor prescribes because their culture or belief system dictates otherwise, and a doctor must be able influence patient perceptions to alter behavior or figure our a way to treat the illness in another way. Emotional Intelligence is something the doctor must have in order to fully understand his/her patient's behaviors and provide an environment where he/she can effectively give care to the patient.