Malnutrition Work for the Clinic: Patient Education

As my work in Xela is coming to end, I am trying to wrap up my projects and share the things I have learned with the clinic community. I am also going to try to train the medical students in primary care treatment and screening of Grade 1 and Grade 2 malnutrition.

One of the parts of my treatment plan is a strong educational component for the patients and families. I made up food pyramids with some more nutritional info for the patients to take home, and some to keep in the clinic for quick reference. I'm also including some basic malnutrition info, and a couple of forms of keeping track of weights and lab values both for the clinic and the families.

Here's what the food pyramid looks like:


I printed paperwork for 150 charts, and double-sided handouts for the same number of patients. I am hoping this is a good way to get things started. We're still working in finding enough money to support the protocol (which includes tests for anemia, tests for parasites, treatment for any GI infections, appetite stimulants when needed, multivitamins, possible iron supplementation, and monthly weight checks). But in the meantime I'm trying to get things going with whatever resources we have.

Hopefully after tomorrow's class and getting the papers in place at the clinic I can start focusing on the ORS project this weekend, to get that set into place.

Calle del Arco, Antigua

I found this photo on my camera, and thought it was beautiful. This is one of the main streets off of the plaza/park in the center of Antigua. The arch, or bridge, was apparently built to allow nuns to cross the street from the convent without being seen. Through the arch you can see the Merced Church.

Lots of Transitions

The Primeros Pasos Clinic is always bustling with change (forgive the cliche, but it's true). The medical director has generally been a one year post, and the administrative people are shifting in and out. International volunteers may come for as little as a week or a month, though few stay for longer. The most influential group of transitioning people is the medical students from the local university. They rotate about every 2 months, and each time they change we have to train a new group of people. The med students get this as their family medicine rotation, which comes before their pediatric rotation. Our clinic sees mostly pediatric patients, so this leaves them with a lot of catching up! This means that they have been spending the last week learning dosage calculations, and what ages you can start using certain medications. After getting used to the previous group of students, it feels like a difficult transition to start all over again teaching the same things. But it's exciting to see when they pick things up, and start to remember the things we have gone over before. Since there is little orientation for people coming into the clinic, there is a lot of peer-peer teaching.

Working with people through all of these transitions, and coming into what seems like a lot of abruptly finished projects, it seems like there is little continuity. Not just in terms of protocol and procedures, but in terms of knowledge. If I have learned what a particular rash is, or what medications are not well tolerated my the population, then I leave with that knowledge and leave others to figure it out. But if I find a way to transition out, leaving information for people who will come in the future, I can use some of that information for the grater good. This is one of the things that I have been working on.

I started a list of medications to share with foreigners, and all newcomers to the clinic. As healthcare providers, sometimes it doesn't matter to us what particular medication from a group we use, as long as it's from that group, and safe for the patient. If a patient goes to the pharmacy and can't find a particular medication, there is often some flexibility, but the decision must be made carefully. At home, CVS or whatever pharmacy may call the person who prescribed it, but that doesn't happen here. When there is no dialogue after the one-time visit, there's no way we can adapt our choice of medications. Needless to say, we have to be very careful about what we write on a prescription. So I am writing a list of meds that can be prescribed for some relatively common conditions that are rare enough that we don't stock the meds in the clinic. This includes certain allergy medications, antbiotics, laxatives, asthma meds, and eczema meds. When I first got here, I had to make guesses on EVERY one of these drugs, hoping they happened to stock that kind here. Now that I have scoped it out, I can share that with future volunteers, and even post it in the pharmacy for easy access!

I am also going to work on sharing my protocol information for children with malnutrition. I am starting to write up a curriculum to review with the students soon.

The clinic has some protocol in place to make these sorts of transitions easier, but there's always room for improvement. I think that the only way to keep this consistency going is to have strong leadership and communication between the people in the environment. That's what I'm trying to help out with!

Asthma without ICS

One of the mainstays of asthma treatment at home is the use of inhaled corticosteroids (ICS). They are so effective that we even branch out to using them for asthma-like symptoms on infants and toddlers during the cold season. We use them in nebulizers in the office, and prescribe them for use at home. Once kids are needing a lot of albuterol this is how we can treat asthma and breathing problems from another direction. Used short term, or in low doses, there aren't a whole lot of side effects to worry about, making them a much safer choice than systemic steroids, which can have a whole bunch of nasty adverse reactions.

In school and in practice we are taught that when a person is having a certain number of exacerbations, and needing albuterol at certain intervals, we need to bump them up to the use of ICS. From there we can manage the dose, and get them on any combination or taper necessary.

But what do you do when the pharmacy only carries albuterol and Advair (a combination, not first line)? And not just in inhaler form, there seems to be nothing but saline and albuterol for the neb, too.

Twice in the last week I have seen two children who I would consider using ICS for, but I had nothing to offer. So today I went to two pharmacies after clinic to fully research the options. This is something that I try to do every once in a while, because I need to be able to accurately tell my patients what to buy, and how to get it cheapest. Many of the families are unable to afford an expensive medication, but when I find that a pharmacy sells the old generic (CFC containing) version of albuterol, I send them there where it costs about 2/3 of the price at the other pharmacies.

Today's pharmacy results:
Albuterol inhalers cost about $6, which is expensive, but not entirely unreasonable.
Pulmocort is available in nebulized form, but costs $3 per dose, which adds up fast!
There's one combination ICS with albuterol, pretty pricey at around $18 per inhaler. Other combos with LABAs like Advair are well over $20.
Spacers w/ and w/o masks cost about $15
There's no inhaled ICS in inhaler form that is not combined with anything.



My new ideas are that it's possible to consider that one combination ICS if really truly needed, and prescriber a spacer, too, for the young ones. I checked out the pharmacies so that I can recommend the right places to go, and wrote it all out on a list to share with the clinic. If someone really needs pulmocort it's possible that we could have them come into the clinic 5 days a week, and they could buy it and bring it to put in the nebulizer we have. But I'm going to try to pursue routes of asking for donations from the US to both fund purchases here, and bring us some goods from home that are not being used.

A baby's funeral

This week has brought many challenges, from big to small. But one of the most striking events this week happened yesterday, on Thursday. A young Guatemalan woman who works at the clinic has been absent for the past week, having her first baby, at the age of 18. We were all excited to hear the news, as when she approached her due date we all half-expected her not to show up anymore, thinking maybe that was the day she'd gone into labor! Her sisters and mom brought the baby into the clinic to be checked out when he was just 1 day old. The doc examined him and gave the report that all was well. The grandmother was full of smiles, and so proud of the little guy that when I missed my chance to hold him, she ran outside to grab them for me. I held the little guy, wrapped in a bundle of a half dozen blankets.

Somehow things changed in the next 48 hours, because on Thursday morning (yesterday) the young mom woke up and the baby had died, at just 3 days old, and with no warning. The news traveled fast, and within a couple of hours, when the clinic was scheduled to open, everyone knew. The whole day at the clinic was affected by it, from our speculations to the cause of the baby's death to the fact that the woman who cleans and opens the clinic every day is the grandmother of this baby, and therefore was not there. We all asked what we could to to help, and it seemed that the only request was money--for the burial, and whatever other expenses were necessary. At the end of the day, we were all invited to the burial at the city cemetery.

There were few questions asked about the cause of the baby's death among the non-medical community, or at least that we heard. There was no discussion of an autopsy, and I heard no one try to place blame on anyone. Of course we all wondered was it some sort of hemorrhage, was it a cardiac problem, was it SIDS? But the overwhelming emotion everywhere was sadness.

The burial was intense. We waited outside in the cold for the procession of people down from the rural area (one of the communities where we did mobile clinics). 4 pick-ups trucks packed full of people passed by, and the 50 of us who were waiting on the steps stumbled over to join. The first truck carried the baby-sized coffin. From what I could see from the short distance, it was a white, ruffly, padded box, rectangular. It looked more like an ornate accessory than a coffin. It was propped on a stand made of metal rods. A group of men carried the coffin as pallbearers would, though it was small enough to be carried by just one.

As soon as they pulled into the cemetery one woman started to sob. Loudly. Like nothing I have ever heard before. It was pure anguish. There was no holding back. Occasionally she would shout out some term of endearment, or flail her arms and body toward the coffin, and her companions would hold her back. As she fell to the ground only a few yards into the cemetery, and stayed back for a while with two younger women, I learned that she had been drinking. When she rejoined the rest of the group, she continued with her sobs.

There was a fascinating contrast between the numerous children, the women selling candy and snacks at the burial, and the pure, honest grief in peoples' faces, posture, and sounds. About 25 of the 150 people present were wearing strips of white cloth--tied over babies on their backs, on their heads, as ties around their necks. These were to signify that they were family members. Most of the women were in indigenous dress, except for a few younger folks, and the 2 foreign women. Then men were mainly in jeans and a jacket, though a few were in suits, and almost half had cowboy hats. I heard that white was the chosen color, because it was a baby who had died, not an adult. White is the color of angels, which is what he was said to have been--a little angel called back to God.

There was little order to the process. As we walked to the far end of the cemetery (beyond the fancy monuments and such, to where space is given to people free of charge), we turned off to the right, then stopped while some men discussed the location, and we all turned around and walked to the left. We stood in the narrow spaces between the graves. There was a space already dug in the ground when we arrived. I'm not sure who dug it and when. A man in street clothes and dark sunglasses held his hat in his hands, and said a few religious words, and the entire crowd--minus the 4 foreigners there--crossed themselves. The speech focused on the idea of a little angel being returned to God.

After a moment, the coffin was lowered carefully into the ground, and the sobs became louder. The coffin wasn't just set into the earth, with a ceremonial placement of a shovel-full of dirt. The coffin was actually buried. Shovel-after-shovel-full, the crowd watched as two men took turns shoveling. They only stopped when there was a mound of dirt over the grave, and they had dug holes for four cut-off soda bottles to hold the white calla lilies they had brought. The grave was adorned in white flowers, and tiny plastic cups of soda were distributed to the crowd. Some of the women bought snacks for their kids, from the vendors who followed us to the grave sites.

Two of the women had almost identical cries in the crowd. The other woman was the grandmother. These women were in the throes of grief, they weren't burying it deep inside. Neither were the men who freely letting tears pour down their faces. Psychologists say that people have to experience grief, or the pent-up emption will cause some sort of explosion or harm later on. But many people struggle with how they should grieve, in a culture where displays of extreme emotions are not considered acceptable, especially in public. These women have a skill that is not often found, at least not back home. There were no negative repercussions for their sobs. I would imagine there may have been a quiet whisper about the woman drinking so much, but I heard none, and saw no disapproval.

The baby's mother did not attend the burial, because she was unwell, her face swollen, likely from so much crying, but possibly more. This is a place where temperature plays a significant role in health, and the family thought it would be harmful for her to be out in the cold, so she stayed home. She missed her own son's burial, but the baby's father shed some tears for her, standing right over the grave.

At the end of the burial, a group of us 3 foreigners walked away together. I thought we wouldn't say a word, because we were all so deep in our heads about what we had just witnessed. But it took surprisingly little time to cross over into conversation--sharing the observations, and questions that we had. It was surreal for me to imagine that within the span of 24 hours the mother probably spent 10 hours comforting and feeding a crying child, put him to sleep, woke up a couple of hours to find him dead, call her family, call the clinic, get arrangements made, hold a funeral and a burial, and have him in the ground 12 hours from the time she had woken up thinking he was ready to feed again. And after all that, after the day she had, and all of her family, we were going to go home to the comfort of our homes where no sobs were being let out, and have a peaceful evening.

Cough Syrup

One of the things we struggle with upon occasion is the idea that patients expect to receive something when the come into the clinic--basically, they expect medicine even when they do not need it. This doesn't happen much, because most of the kids we see are genuinely pretty ill, but we see our share of common colds, too. Now the desire to leave the clinic with something in hand is not the most absurd of ideas. I think patients do it at home, too, expecting a prescription to make the visit worth it. Every provider has her own way to deal with this issue. I have decided that this is the purpose of the cough syrup at the clinic. It's not an antitussive, but rather we have 3 different liquid formulations of expectorants. The families become accustomed to receiving a bottle each time the child is sick with even the slightest and driest of coughs. This has become the culture at the clinic (and perhaps in the greater area).

Lately there have been a few occasions when I have sent the family home with a bottle of tylenol for fever, and instructions that the child's cold should pass in a week or so, and warning signs for a more serious illness. As they are leaving, I've heard something like "Excuse me, you didn't give me anything for his cough." Even when I explain that an expectorant does nothing for an occasional dry cough, they insist. I go back and forth about what to do in these situations. Is it a belief that the syrup will truly cure a cough? Or does it just feel better to go home with SOMETHING in these visits? And what happens when they already have something, but still want something specifically for the cough?

I was pleased to see that the mom of one of my patients today seems to have caught on that guayacolate doesn't do much to get rid of a cough. But she's been the first one to admit this to me. Some moms smile and nod, and seem to accept my explanation as to why I am the only one who won't give them the stuff. But many outright disagree, because every other doc here gives it out like candy whenever there's a cough.

This comes in light of learning that because of certain budget restrictions, we are short on important supplies (like vitamins for malnourished children). I look at the wasted expectorants, and wonder why we're really spending all that money on something that doesn't do much anyway. There's a time and a place for expectorants, certainly, but is this it?

But despite the preference for prescribing expectorants, I'm going to take matters into my own hands for my last couple of weeks here, and I think I'm going to start giving out bars of soap to these kids instead...

Antigua

This is an image of one of the churches seen on the side of the road. There's no sign explaining the history, but it is quite an understated beauty. It's just one of many such sites in Antigua.

When Luis came to visit I figured it was cruel to make him do too much traveling on his only "vacation" of his semester, so I had us stop for a couple of days in Antigua, the colonial city in Guatemala. I wrote briefly about Antigua when I went with Jean. Luis and I spent a little more time relaxing there, and went into some more historical sites (and did less shopping). It seems like every street corner has an old broken down church, or some interesting ruin. Most things are religious in nature (convents, churches, etc.).

One of my favorite places was the Colegio de San Geronimo, which was once used as a religious school, then attacked by indigenous protestors, taken away due to lack of authorization by the Spanish crown, and then used as a royal customs house. It was gorgeous, and reasonably well-taken care of, with grass and gardens and public trash cans, all available for a small fee, just off the side of the road and market. You can climb up and see the volcanoes, though we went on a rather cloudy day.


Another famous site in the area is the Merced church. One cool thing about it is that there are some images of the gods prominent in the local religion, mixing the indigenous with the colonial. After being destroyed in 2 earthquakes it has been restored to this pale yellow beauty.