Barra de Colotepec

This past week I worked with Dra. Antonia and Dra. Yazmin (Dra. is the abbreviation for doctora-the term for doctors who are women) in their Centro de Salud in the village of Barra de Colotepec. It is a coastal village a couple of miles distant from Puerto Escondido. Many who live in Barra have jobs in Puerto Escondido. It has schools through eighth grade, a city hall and a smattering of shops and restaurants.

Dra. Antonia was my assigned doctor, but I worked with Dr. Yazmin on Monday. She is in her forties, has been working as a doctor for some time and was quite comfortable in her role although clearly very tired of all the required paperwork. One great surprise was that she had an air conditioned office. I found the time with her a great respite from the heat. It is so muggy sometimes, I work up a sweat just sitting still if there is no wind or fan. She did a couple of pap smears and I was surprised by the little differences in technique. Nothing that would change any results, just a different routine.

Monday, Dra. Antonia did not come to work. Wedsnesday, Thursday and Friday the nurse did not come to work and then Friday Dra. Yazmin did not come to work. Both Doctors were gone on Thursday for meetings at the Health Dept. Headquarters. Ericka, the nurses assistant, who was there everyday said she did not know why they did not come to work and that she thought they would be at work. This ongoing stress of adapting to the staffing situation provided me with an interesting week, but certainly not any routine.

In addition to these four women, there was a psychology intern doing his year of service named Guillermo. In Mexico, if you are admitted to to a professional program there is no cost to attend, but each graduate does a year of service at the end of their education. This is true for those in clinical professions like nursing, medicine and psych counseling at least. So, Guillermo lives in a room with a bed, a refridgerator and a camp stove on the grounds of the Centro de Salud. He has appointed himself caretaker in addition to providing what little psych counseling the local people are willing to accept. Thursday, while the Doctors were at the meeting, he and I returned to the school to distribute liquid multi vitamins to all of those over the age of ten. This was a part of the National Week of Health which was all of last week.

Dra. Antonia is around 30 years old and has quite abit of confidence in her manner with patients. She is building herself a house nearby the clinic and as director of the clinic has plans for expanding services provided from there. Right now, she lives with her parents.
I saw some interesting cases this week. On Tuesday, we saw a 8 year old child presented with classic symptoms of appendicitis. He was referred to the local hospital and had surgery, confirming that he did have appendicitis. His mother was quite distressed especially because this child has an older brother who had appedicitis and an appendectomy just over a year ago. The mother wanted to know if she had done something wrong for both her children to have appedicitis. Dra. Antonia was quite reassuring and said that there is no specific prevention for appendicitis. I saw the grandmother on both Wednesday and Friday and was informed that he is doing fine and home from the hospital.

The nurse assistant, Ericka, encouraged a woman to bring in her child who was clearly quite ill. The family is very poor (they looked poorer than anyone else I saw) and transient, homeless, I guess. They had spent the night next door to Ericka and all the neighbors were kept awake by the cries of this baby. Then, before lunch the baby started crying again and blood started coming out of her right ear. When the baby (10 months old) was examined there was an obvious superficial skin infection all around the right ear extending into the scalp. Dra. Yazmin, cleaned the area and then began to rinse out the ear canal. This caused the baby a lot of pain. We were concerned that there might be an object or a bug in the ear. Nothing was seen, but it was not normal. Dra. Yazmin wanted the family to take the baby to the hospital for a better examination of the ear and IV antibiotics. The family refused due to lack of funds for the bus trip and previous bad experiences at that hospital. So, she provided the mother with an oral antibiotic and tylenol. Dra. Yazmin was going to also give the mother an antiseptic soap to use, but decided against it as she was concerned that the illitierate mother would mix up the soap with the antibiotic and give the child soap to drink by mistake. The next day Ericka reported that a couple of hours after the clinic visit one or two dark worms or larvae craweled out of the ear. All at the clinic assured me that this was not a typical event and none had had an experience such as this before. Good news is that this child received the care she did in the clinic even though the family had not enrolled in the government sponsored insurance program for low income people and the family was not charged anything for the service they did receive. The family left Barra de Colotopec the next day, so there was no way to follow up on the child.

Dr. Antonia saw a woman and her one year old daughter for well checks. Participants in a program called Opportunidades are required to receive periodic check ups and health screenings. After establishing that both the mother and daughter were doing well, the doctor asked why the mother had not come in for her monthly birth control medication for several months. The mother related that she did not need birth control now as her husband had left to seek work in Kentucky several months ago. He has not yet found any, but she is hopeful he will soon. She related that they had discussed leaving their child with the grandparents and both going to Kentucky in search of work, but this mother did not feel she could leave her baby and instead chose to live separately from her husband. She hopes to be able to join him with their daughter in a year or so. She went on to discuss the stress she was experiencing related to this separation and not knowing how he was doing day to day. She has support in Barra de Colotopec from her family and is not overwhelmed by local responsibilities. The doctor was very sympathetic and encouraged the mother to take some time for herself, taking a walk daily, going to visit a girlfriend without her daughter, something. I found it interesting to hear the other side of the story. I have had women as patients in Missouri who were suffering greatly because their children were in their native country with their grandparents and they were trying to manage the behavior or health problems of the child over the telephone.

Then, on Friday, Dra. Antonia had planned to give a talk to all the participants in the program Opportunidades, which is a government sponsored program that pays a stipend to families in whose children are up to date on their immunizations, requres all family members have well check ups and health screenings and to attend clinic sponsored talks about issues of health and well being. She was very busy in clinic as both doctors were gone Thursday and had shortened a clinic to distribute antiparasitic medications to all the school children in town on Wednesday.
Just as Dra. Antonia was done with the last patient, and was headed to the large tree shaded area with about 100 mothers and their children waiting, a mother came up and asked the doctor to refer her baby to the hospital as his diarrhea continued even though she had given him the medicine for three days. Dra. Antonia tried to explain to the mother that one does not go to the hospital when diarrhea is the only complaint, but rather gives rehydration solution deligently at home. The mother was quite insistent that her child be evaluated and insisted that Dra. Antonia talk with her husband by cell phone, who also felt the child needed hospitalization. The husband must have said something, because the attitude of the doctor totally changed halfway through the call and she headed into the exam room with the mother and baby. Meanwhile, there are still 100 or so waiting for her talk outside in the shade with threats of rain.

The baby, about 8 months, was sleeping peacefully, had easy respirations, good skin color and tone. I did not see anything to worry about and wondered what the father had said to convince her to evaluate this child. Dra. Antonia had a worksheet for determining what to do with babies with diarrhea and vomiting. The sheet had a check list and points assigned to different symptoms depending on the worrisome nature. As this child had no fever, no vomiting, no signs of dehydration based on this scale, he did not need to go to the hospital, but rather needed close observation and fluids at home. The mother was insistant that the child should be referred. So, Dra. Antonia started the referral form, which is really quite detailed with lots of slots for various information and a central area requiring a two to three paragraph clinical history. When the form was almost completly filled out, Ericka entered to say it was starting to rain and could the 100 people still waiting outside please come and seek shelter in the waiting room. Dra. Antonia agreed.

As the one mother was leaving with her one baby here came another 60 or so with their babies and the snacks they had brought to share. Really quite a sight. I left just then because I needed to get to my Spanish class.

I am learning from and enjoying this experience. Next week we will spend with the public health brigades that work on reducing the presence of mosquitoes and other insects that can spread disease. It seems incredibly relevant as the wet season is just now starting, so there will soon be new places for mosquitoes to prosper. I have have been assured there is no slogging through crocodile ridden swamps, but in any case, wish me luck.