Carnaval

May 25th, 2015 by Garrett Hooker
Posted in Uncategorized|

I was on call last Thursday and had to go into the ED at 1am for basically a follow up on one of the kids I had seen in clinic. I think he’s about 1 month old now, but was still having URI symptoms…like I said he would for probably another week. Had been eating well and vitals were normal, so I told them to come back in the morning if his symptoms worsened. They never ended up coming back in. I also had another lady come in at around 3:30 am with sudden onset LLQ abd pain. I was only able to obtain a limited number of labs, but I’m thinking she either has a kidney stone or ovarian/adnexal torsion. I sent her for an ultrasound in La Ceiba and told her to come back Monday morning when she can get some other labs done, rather than the middle of the night.

The other patients I saw in clinic Friday were as follows:

– 24 yo F with GERD
– 40 yo M with R inguinal hernia; sent for surgical consult
– 5 month old here for follow up from yesterday. Has a viral URI, is feeling better, and appears well hydrated
– 7 yo F with viral pharyngitis, molar coming in, and numerous caries. Set her up with dentist who won’t be here for at least the next month.
– 44 yo F with lipoma on back and lumbar back strain
– 32 yo F here for follow up on R otitis externa. Still painful and draining after two weeks of antifungal tx
– 7 yo F daughter of one of the lab techs who has a temp to 102.1 F and cough x 1 d. Looks like pneuomnia on CXR. Tx with Amox, Doxy, Tylenol
– 9 d old F here for newborn check
– 5 yo M with pruritic rash that started out on face and has spread to extremities and trunk. I’m not really sure what’s going on but it sort of sounds like tinea versicolor so I treated him with a topical antifungal.
– 74 year old F with uncontrolled DM and atypical CP. Changed her insulin up a bit because she keeps having hypoglycemic episodes and also checked an EKG on her.
– 62 yo M with arthritis in knees
– 24 yo F with UTI and yeast infection

I should also mention that Oscar, a Honduran guy who acts as one of the chaplains here, invited me to his house in La Ceiba for Carnaval. Apparently it’s a huge deal in La Ceiba, so I thought that would be an excellent way to spend the day. Unfortunately I would have to come back before the parade actually started because I would be on call the next morning and there are only a limited number of buses that come out to the hospital.

So, after clinic we headed down to the front gate and waited around for a long time for the bus. When it arrived, it was already full of people, I assume mostly headed to La Ceiba for Carnaval.

Maybe the bus is just always full, but either way I spent the next two hours standing in the very back trying to not get bucked out the back door.

I should also mention that around this time, Oscar informed me that he loved taking pictures and would be happy to take my phone to help snap a few….so buckle up, there are a lot of pictures ahead.

When we arrived at Jutiapa a bunch more people hopped on board to sell food.

Countryside view from the bus

While we were walking from the bus stop to Oscar’s house, I saw this awesome old Toyota and felt compelled to take a picture of it.

Oscar’s house. When he’s not working at the hospital, he spends the weekends here. His mom, sister, brother, and family friend all stay here as well. There were I think 4-5 bedrooms, one 3/4 bath, a kitchen, dining room, and small living area.

Distrito Toronjal, where Oscar’s house is located. It used to be covered by fields of grapefruit trees, hence the name “grapefruit distict”. You can also see Pico Bonito in the background, which lies just south of the city.

Pretty much right after we arrived, we had to head to Oscar’s church, where he leads a bible study or something. While he was doing that, I kind of explored the church grounds and took this pic from out the window of the unfinished second story.

Surrounding the cementerio municipal is a long wall covered in murals that illustrates the history of the city.

Mas mural

They even have the Zipper here.

While this guy was picking his nose, I was busy laying down some serious fire. In my younger days, I discovered all manner of ways to torture GI Joes…this being a favorite.

I won this necklace with a clip thing on it, and it only cost me the equivalent of $1…no idea what it will be used for, but definitely a steal.

As with all fair food, there are certain risks. This was an especially bold move given the fact that within 18 hours, I’d be going on a non-stop, bumpy, two hour long bus ride back to the hospital…but the carne asada was excelente.

Getting set up for the parade the next day. Right before this, Oscar and I went to Pizza Hut and I was reminded of how awesome pizza is.

Me and Olvin, Oscar’s family friend.

Oscar and Olvin admiring a painting at a galeria de arte we happened upon.

I think this is a school of some sort…I just kind of liked the building.

This magical tree and its rainbow of bark colors

This was apparently the first train in La Ceiba. I also really like that tall weird palm tree.

Acting like a five year old

All of these park pictures were taken in Swinford Park.

Caminando

Verde

Flamencos

Weird roots

More weird roots

Really old tree

There’s a restaurant called Cafeto in this building I ate at last week when I came to town with Steve and his family.

Dia de Carnaval

Mucha gente

Somehow Oscar got the phone switched over to black and white mode, just to add a little more artistry to his already keen photographic eye.

City market

I think this guy was hauling some plantains if I remember correctly

Oscar and Olvin taking a break from the heat

Down by the beach a bunch of people were getting their horses ready for the parade

Caballos a la playa

This one is hungry

Mas caballos

Muelle nuevo dentro de los ultimos 2 meses

Olvin y Oscar

Mostly just wanted to take a pic of this guy using a selfie-stick

Mas carnaval

Y mas

Al centro

The city’s dignitaries get to sit under the big tents, right on the main strip and in an ideal location for parade viewing. This is a shot from the city’s central park.

I would have loved to stay to watch the parade, but unfortunately had to leave before it began. There are only a limited number of buses that come back out toward the hospital in the afternoon, and since I was going to be on call starting the next morning, I had to make sure I didn’t get stranded in La Ceiba. When I arrived just outside of Balfate, I walked over to that gas station for a few supplies and ran into these two guys herding a bunch of cattle down the road.

I walked with them for a while on the way back toward Balfate. I can’t remember their names, but they said they were 10 and 14 years old and they had 31 head of cattle with them.

Once in Balfate, I had about 20 minutes to watch these guys play a pick-up game while I waited for a moto-taxi to pass by and take me the rest of the way back to the hospital.

Seizure On The Playground

May 22nd, 2015 by Garrett Hooker
Posted in Uncategorized|

Yesterday my 45 day old male with respiratory failure was still only able to tolerate bringing his oxygen down to 1/2 a liter, so he’s been admitted about 6 days.

At the start of clinic, Vance came and found me. There was a 27 yo G1P0 at 33-36 weeks with IUGR and poor dates. He said she was about to deliver, so I went over and sat around with her while she tried to push. She wouldn’t really listen to any instructions and just kept trying to give these half-hearted pushes. Vance finally ended up asking me to do a vacuum on her because she just wasn’t moving the baby down and he wanted to get started on his surgeries for the day…not really an indication for a vacuum in the states, but good enough here.

As penance for unnecessarily doing this vacuum, I got splattered with all kinds of goop as the baby came out. It was all over my arms and chest and even looked like I had peed my pants. Before somebody mentioned there were extra scrubs around, I saw a few patients and must have looked disgusting…at least it’s nice and hot here to make normally unpleasant smells especially offensive.

My clinic patients yesterday were as follows:

– 21 yo G3P2 at 37.2 wga for routine prenatal visit
– 5 month old M with reactive airway disease; O2 sat initially 82%, improved to normal with neb in the ED
– 20 d old female here for newborn check
– 32 yo G2P0 at 6 wga here for second opinion regarding need for a fertility workup due to prior SAB
– 32 yo G4P3 at 9.3 wga here for ultrasound to confirm intrauterine pregnancy
– 46 yo with cholelithiasis- sent to surgeon for removal
– 15 yo G1P0 at 25 weeks here for her first prenatal visit
– 36 yo F with missed abortion

Here’s another pic of one of the platos. This one was from yesterday. Ensalada, arroz, platano, pollo. This delicious feast costs about 40 lempiras, the equivalent of $2.

After work I went back over to the children’s center because they’re usually playing soccer or something and there’s not really anything to do at my apartment. Here’s a finished pic of that hut I mentioned from earlier on in the trip. All ready to go now!

You can see how they criss-cross all the leaves to improve the roof’s ability to wick off moisture. Another key feature is orienting the leaves so the concave side is facing out.

While I was over at the children’s center, I saw a bunch of kids standing next to this guy. I talked to the school mom about him and she said they were planning on cooking him for dinner…and she wasn’t joking. She told me these bad boys taste sort of like a cross between chicken and fish.

I initially picked him up by the stomach and luckily, before he had a chance to do it, one of the kids warned me these things bite if you don’t grab them by the neck. A lot of people sell these alongside the road for the purpose of eating. I think they cost around $10. I was really tempted to stay around and try some. About ten minutes after this pic was taken, I heard one of the kids yelling that the school mom was down on the ground. I ran over and realized she was having a seizure. There were a number of other people there just standing around, and one told me she did in fact have a seizure disorder. I asked if she had any injectable medicine around the house, and was told she had some Valium. I told them to run and get it, but by this time her husband showed up with the injection in his hand. He said these seizures usually only last five to ten minutes and usually stop on their own. This one seemed relatively mild to him, despite the fact that she was lying on the ground shaking all of her limbs. He said he doesn’t really like to give her the medicine because it makes her really anxious after it wears off. Back at Research if this happened, there would be no question what the course of action would be, and in fact on many occasions I have ordered an immediate dose of Ativan to abort seizures just like this….but here we just sort of sat there and watched for what felt like a few hours. Eventually, she stopped seizing and actually regained her lucidity pretty rapidly. I saw her husband today and apparently she’s back to normal…

After the seizure episode, a few of us took a walk down to the beach. It was getting pretty late in the day by this point, but just about the perfect time for a sunset shot.

Today that 46 d old male was still here trying to wean off O2. I was finally able to get him onto room air and ended up sending him home this afternoon. He’s supposed to come back in a week for follow up, but he and his family live clear up in the mountains so I’ll be surprised if they come back unless something seems seriously wrong.

I’m on call today, and received a wake up call this am just about 5 minutes before my alarm was going to go off that there was a 7 month on in the ED who had vomited a number of times since his arrival and according to mom had abdominal pain and had not been eating. After evaluating him, I think his vomiting was just post-tussive secondary to the viral URI all the kids around here seem to have. I gave him some Tylenol and Zofran and he went to sleep for a few hours. I sent him home but I’m going to have him come back tomorrow just to make sure he’s not getting dehydrated.

Today clinic was a madhouse right from the start. Pts were as follows:

– 9 day old female I delivered for a newborn check
– 1 yo M here for a follow up from last week on a viral URI, hypertonic RUE, and anemia; now nothing acute going on and URI sx completely resolved
– 5 month old M with diarrhea, tos, gripe x 3 days. Tmax 100.7F at home. Currently afebrile. WBC 20K with lymphcytic predominance. Gave him an rx for Albendazole. I’ll have him come back tomorrow to repeat QBC, and get stool studies and sangre oculta.
– 20 month old M, previously healthy, now with dramatic weight loss. He was previously at about the 50th percentile for his age and is now well below the 1st percentile. Treating empirically for intestinal parasites and will arrange for close follow up with our pediatrician.
– Another 9 day old female I delivered here for a newborn check. Mom also concerned about eye discharge. Exam normal today, nothing to suggest gonococcal conjunctivitis given mom’s negative history, but from what I read gonococcal disease can affect up to 15% of babies of endemic populations
– 65 yo M with reducible umbilical hernia who wants it surgerized; also had GERD and viral pharyngitis
– 2 yo M named Fernando who I admitted about 2 weeks ago with a concussion. He still has headache, so probably has post-concussive syndrome. I’m sending him for a CT Head to rule out a bleed though, and restarted him on steroids.
– 51 yo F with GERD
– 24 yo F with LLQ abd pain mostly associated with ovulation. Has also had some difficulty conceiving since SAB about 1.5 years ago.

Here’s another one of my clinic pts from today. 7 yo F with viral URI. Also has had a weird rash for 6 years that somebody told her was due to “allergy in her blood”. I have no idea what that means, but some of the native doctors down here come up with all kinds of crazy stuff to tell people. It basically looked like a bunch of erythematous, scaling plaques mostly on the extensor aspects of her MCPs, PIPs, and DIPs. She also had similar lesions on her elbows and lateral malleoli. She had some other lesions on her palms and plantar aspects of her feet that looked like dyshidrotic eczema. I really don’t know what this is, but it’s responded to steroid cream in the past so that’s what I gave her.

This guy had been bit by a “barba amarilla”, or “yellow bearded” snake, which is basically one of the most venomous pit vipers in the area and a cause for some pretty nasty bite wounds. The way he treated it was sort of a folk remedy where you pour scalding hot water to the area after applying a series of three tourniquets all the way up your arm to prevent the spread of the venom. I’m pretty sure this thing would look a little less gnarly had he not dumped a bunch of boiling water all over everything, but I guess it’s working out okay for him.

Here’s a pic of one of these nasty SOBs I found during a google image search. Apparently they’re really territorial and aggressive, so I figured I should probably familiarize myself with what they look like. I don’t know how well you can see from the picture, but the pattern on their sides forms a letter “A”, which is one of their distinct features…along with a yellow beard.

Today a bunch of us went up to Peter’s house for Mary’s 21st birthday party. We had some cake and they were going to watch Pitch Perfect, but apparently there was some concern that it might be a little too racy for some of the audience members. Anyway, I wasn’t really planning on staying around for the movie since I’m on call and those radios are notoriously unreliable at distances far away from the hospital. As I was walking back down to the hospital, I saw this lurking alongside the road at the edge of the jungle abyss.

Turns out it was just this little guy….and luckily not a barba amarillla.

Lis-Lis

May 20th, 2015 by Garrett Hooker
Posted in Uncategorized|

I’ve still been rounding on that 44 day old kiddo who came in with respiratory distress and probably has pneumonia. I have him on Rocephin and nebs, but I think it’s viral based on his labs. I consulted with the pediatrician and she said she wouldn’t change anything. He’s slowly getting better, so hopefully we’ll be able to get him out of here by tomorrow if we can wean him off the O2. Right now he’s able to breathe pretty well on 1 liter without desaturating.

Clinic was pretty nice yesterday. A bunch of people didn’t show up so I only had to see a few, which were as follows:

-52 yo M with GERD, HTN

-42 yo F with chronic cholecystitis, sent her to surgeon to remove gall bladder

-3 yo F with viral URI

-2 yo with subjective fever and CVA tenderness; basically nothing going on there if I remember correctly

-42 yo F with lumbar strain and migraine h/a

-14 month old with viral URI

-57 yo F with lumbosacral back strain

-3 yo M with urticarial rash x 18 days

I had mentioned at some point to Peter that Maria is a dentist, so he showed me the dental set up yesterday:

Here’s a pic of one of the dental operatories, in case Dr. Wittman or any of her dental friends are interested.

lots of supplies, most of which are words I don’t understand in Spanish let alone English

Más cosas

Drill thingies, immediately adjacent to the fluoridation station basin

My original post said “they even have a pano hiding back there”. Somebody* pointed out that this is actually just an xray head. Thanks wife.

After work, I was on call for the night. I had a fifty-something lady come in with pyelonephritis that I thought could be treated as an outpatient…so I gave her a shot of Toradol and some antibiotics and sent her on her way. The other one that came in was a 17 yo G1P0 at 41.2 weeks. I delivered the baby just a little before midnight. She had a second degree perineal lac but otherwise did well. Baby is doing well but has a right sided hip clunk, so he’s going to need some close follow up.

Clinic today wasn’t too bad either. Here’s a pic of the “plato” I enjoyed afterward, which is basically the dish of the day.

My clinic patients today were as follows:

-13 yo F with newly diagnosed sickle cell anemia
-7 yo F with tinea capitis

10 month old male with subjective fever and oliguria

-7 month old male with viral syndrome and also maybe oliguria (but mom’s history was sort of subject)

-28 d old with viral URI

-38 yo G4P2012 approximately 8-13 weeks with either a threatened abortion or missed abortion

39 yo G5P4 at 21-25 weeks (depending on the documentation) here for a routine prenatal visit

This is where the baby makin’ happens…makin’ them come out, that is. Notice that handsome brand new wood door in the background, escorted to the hospital by myself and a few other gents.

This afternoon I was trying to think of something to do…so I decided to take a mototaxi to Lis-Lis, another small town just west of Balfate. I cost me $1 and would have taken over an hour to walk there if that gives you any idea how poverty stricken the area is…and that’s probably even a bit steeper than most people are charged given the fact that I’m a gringo.

Just a regular afternoon stroll carrying a large bundle of sticks

Puente just east of Lis-Lis…can’t remember the name of the river though.

Pulperia en Lis-Lis

Farming and grazing land just west of Lis-Lis

I don’t know what these are, but I’m guessing they’re either delicious or deadly.

Calle de Lis-Lis

Just about 6.3 km from the hospital

As I was walking through town, I came across the local school where these kids were playing béisbol. Pretty sure this poor kid struck out. While I was there, I noticed a normal looking older guy just hanging out on the street. I went over and introduced myself and he said his name was Alfonso. He was waiting for the bus to swing by to take him to the neighboring town of Limeras, so he could get to church. By this point, I had decided I’d seen most of what Lis-Lis had to offer, so I thought I would wait for the bus as well…except I’d be going east and he’d be going west. We talked for quite a while as we waited. The bus isn’t really on a schedule. It just sort of gets there when it gets there. Alfonso said there were about 1000 people who lived in Lis-Lis. He also mentioned that everybody is really friendly, but they definitely takes note when there’s a random gringo walking around. That pretty much goes along with what I experienced. Everybody I ran into was really friendly once I said “buenos tardes” or “como estan” or something like that, but I definitely got the sense that they were also kind of like “what are you doing here?”. This part of the country is definitely pretty well cut off from the rest of the world…but I find these areas most interesting because I think the isolation has helped to preserve their unique culture, unlike a lot of other areas where people have immediate access to the internet and have sort of meshed their heritage with modernization.

Casa en Lis-Lis

I ended up taking the bus from Lis-Lis to Balfate and was dropped off right next to this barberia/pulperia…sort of like the Honduran version of a Taco Bell/KFC I suppose.

One of many roads that go directly to the beach

Playa de Balfate…sin que nadie presente

In the evening after clinic with the sun growing low on the horizon

Yet another selfie contraption

Another road to the beach

Maria doesn’t know it yet, but we’re thinking about buying this house. Note the proximity of the beach.

This guy lives in the front yard

It’s a bit of a fixer-upper

Una casa bonita en Balfate

La Ceiba

May 18th, 2015 by Garrett Hooker
Posted in Uncategorized|

Yesterday I had decided I wanted to go to La Ceiba to get some shopping done. I’ve been running low on groceries for a few days and haven’t had a chance to find any souvenirs to bring home. I was on call the night before, and admitted a couple people. One was a 40 day old male with respiratory failure. I think he has a pneumonia of some kind. Initially he had subcostal and intercostal retractions and was satting in the mid to low 80s. For a while I was afraid he was going to need to be intubated. I gave him a bunch of nebs and antibiotics, and he started doing a bit better. He improved from about 3 liters of O2 to now 1 liter when I saw him this morning.

The other person I admitted as an obs patient; 4 yo F with abd pain and possibly bloody stools. We can’t get labs at night and they live about 3 hours away, so I kept her here to watch. Everything came back normal the next morning and clinically she looked fine, so I sent her home. One guy came in with bilateral “kidney pain” that had been going on for a year and wasn’t any worse now that it had ever been in the past. We have a policy around here where if people come in with BS stuff in the middle of the night, they get charged double. This is unlike the policy we have at RMC and most other institutions in the US, where the ER is the place to get your primary care…and bonus, you can do it at any hour you damn well please. So basically, I told this guy over the radio that he should probably come back Monday unless he wanted me to walk all the way down to the hospital, evaluate him, and tell him the exact same thing…except charge him double.

The only other person that came in that night was a 35 yo M with an asthma exacerbation. I actually had to work on him quite a while because I didn’t really want to admit him. I had already admitted the other two and nursing was short staffed. I ended up giving him a few back to back rounds of nebs along with a big punch of steroids. He didn’t look perfect, but I thought he looked good enough to go home.

I went to La Ceiba yesterday with Steve, the local anesthesiolgist, and his family. Along the way, we saw this guy in the middle of the road and ran him over. Initially, he looked like one of the highly venomous and feared coral snakes. In fact, we pointed him out to some passers-by, and they confirmed it was a “serpiente coral”. I did a little more investigating, and I’m pretty sure this is actually a non-venomous milk snake. Either way, I’m glad it’s dead.

Sam, in the background, keeping watch for other “coral” snakes.

This is one of the mercado areas of La Ceiba. Immediately prior to this, we ate lunch at a really tasty sandwich shop called Cafeto, that sort of caters to Americans. It was basically like any coffee shop you’d find in the US. I looked around the market for quite a while for those hammocks that you can sit rather than lay in, but couldn’t find any. Note the electrical wiring here also. Giant cluster.

O mercado aberto

This is La Ceiba’s golf course. After being unimpressed with the hammock selection at the local mercado, I took a taxi up to an area around this bar called Expatriados, where the guy who owned Cafeto told me there was a market that was a little less known among the tourists and sold stuff that was actually good. Anyway, when I got back from that market I stumbled upon this golf course, which appears to be pretty straight, tight, and in need of some work.

While I was out messing around, Steve and his family went to go see “The Avengers” at the movie theater. Turns out the movie was completely in Spanish, and as you might expect not dubbed, so they aborted that mission shortly thereafter. Once I finished up my shopping, I had a little bit of time to waste before we were scheduled to meet back up. I found this handy gas station where I could sit outside and enjoy both the nice day and a couple Honduran beers.

As we were getting ready to leave town, we stopped at the Wendy’s right next to the mall and had some fun watching this birthday party.

Today, I decided to go on a hike up into the jungle. This is a picture I took from atop our water tower. The dark area sort of near where all those white caps are is where I go snorkeling. That really tall palm tree is visible in one of the first pictures I posted of the beach. Anway, that’s where the snorkeling happens. I think it’s at least several hundred yards away from the beach according to google earth.

Here’s another view from atop the water tower. You can see the smaller palm oil trees followed by the huge Ceiba trees leading down to the beach.

Apparently this is where we get our water. Haven’t been sick yet…so, good enough.

Hiking up into the jungle.

I kept on hiking along this sort of worn down trail, and eventually I saw a clearing off to the west. I crossed over a barbed wire fence and walked a little farther to be rewarded with this view of the coast.

A costa bonia!

E vista inspirada!

I decided I needed a picture with this awesome background, and the only solution was to improvise a sort of jungle selfie-stick. I was able set the timer on my phone and jam it into the concave portion of the leaf.

Quem é homen?

On the way back down

After all that work, it was time for some protein.

Buen provecho!

Woodworking: universally awesome

May 15th, 2015 by Garrett Hooker
Posted in Uncategorized|

Yesterday morning I delivered another OB patient at around 9 am. Luckily I didn’t have too many people in clinic, so it didn’t really disrupt my schedule. Vance was back in surgery, so I just got the baby delivered, sewed up the lac, and let him know when everything was good to go. Clinic ended pretty early, and I didn’t really have anything to do, so I decided to go back to Balfate and see if they had any little tiendas that sold trinkets or something I might want to bring back as a souvenir. It was a bit more overcast, so the walk was quite a bit more enjoyable than the previous day. I waited around at the hospital gate for a moto taxi, but I don’t think they come out this way very often unless they’re giving someone a ride from Balfate. Here are a few pics from along the way:

The one directly above is a picture of a neighborhood soccer field.

Once I arrived in Balfate, I ran into that machete guy from the day before. He hollered “amigo!” from afar and then started following me around. He rambled incoherently for a while then finally asked for some money. Around this time, one of the hospital vans rolled up after picking the kids up from school. I stopped to talk to them and said I didn’t really want to return to the hospital, but I might need a ride back if this guy didn’t leave me alone. Luckily, as I was talking with them, another one of the hospital work trucks met us coming from the other way. They were heading to Lis-Lis and I said I’d tag along with them for whatever they were doing. My plans to do any souvenir shopping had basically been foiled at this point anyway. So I hopped in the back of their truck and we headed west past Balfate until we arrived in Lis-Lis. Along the way, I learned that we were going to pick up some lumber for a door. When we arrived, I got a glimpse of a Honduran woodworking shop, which was pretty awesome. I talked to the guy who owned it for quite a while. He had a bunch of really exotic looking wood there, which I guess here is really more native than exotic. They had a table saw, router, band saw, planer, jointer, all kinds of hand tools…basically anything you’d find in a self-respecting shop in the US, just a little older and definitely more dangerous. Here are some pics:

Here’s a pic of us driving back once we got all the wood loaded up:

Once we got back to the hospital, we dropped everything off at the shop…which is an area of the complex I had not yet discovered. I found Joe, the husband of one of the docs here, working on a table he was building. He had a bunch of rough cut wood and was starting on the base. There was another guy there who within just a few minutes not only caused the planer to bind up twice, but also the radial arm saw. I cringed a little while watching. Thankfully he still has all his fingers and the tools aren’t completely ruined. I took a look around the shop and noticed they didn’t have any feather boards, which I figured Joe might be able to use to get his table top jointed…so I went ahead and made one. Turning a crappy old piece of fence into something useful was a pretty good way to spend some time. As far as getting those boards jointed, I would probably get them the correct dimensions, stick them side by side, and then rip them right where they meet. That should form probably about as good of a joint as you could get considering the equipment available. Also, this is the radial arm saw they use, which I believe is the exact same model my Grandpa had in his shop:

183

I capped the day off by heading down to the Children’s Center to see what was going on, and got smoked in soccer by a bunch of 6 and 7 year old kids.

If you don’t befriend the guy wielding a machete, you’re doing it wrong

May 14th, 2015 by Garrett Hooker
Posted in Uncategorized|

Clinic today started out again with some more OB shenanigans. One lady came in overnight at 42 weeks, so we got her induced and started up Pit this morning. Another lady came in at 36.3 weeks and I delivered her a few hours later. Vance was in surgery all morning, so he basically just had me run the show and let him know when all the babies were out and moms sewn up. The second lady had a bit of a post partum hemorrhage, but it quickly stopped with a bimanual uterine massage. I’ve always been slightly amused that it’s referred to as a massage, because it looks like it would be anything but relaxing.

The rest of clinic was just kind of a mess. We were down a doc because she was sick, so we were pretty busy. I can’t really remember any interesting cases except for a 3 year old boy with what I think was probably a hydrocele. I’ll have him follow up with one of our surgeon’s to get it fixed. I saw a few people again as follow ups from last week, and they’re all doing better now. I saw several people for their regular OB appointments, one of whom was coming in for the first time. She thought maybe she was about 8 weeks pregnant, but had been bleeding for a few days. I obtained a urine test, which confirmed a pregnancy, but when I did a sterile spec exam on her there was a bunch of blood coming from the cervical os. So, I took her back to Vance’s office and we did an ultrasound that basically showed an empty uterus. It didn’t look like she had an ectopic, so she must have had a missed abortion.

That lady in respiratory distress ended up going home with her family today. I can’t imagine she’ll last much longer now that she’s off the oxygen.

After clinic I walked to the town of Balfate, which is about 6 kilometers to the west. I walked the whole way in the glaring heat, which turned out to be a bad choice. I did, however, make a friend on the way:

As I was arriving into town, a guy carrying a machete approached me. I can’t remember what his name was because I could barely understand him, but he apparently worked up in the mountains cutting down limbs. He also showed me a sack that was full of some kind of herbs. I have no idea what they were used for, but from talking to him I wouldn’t be surprised if they were hallucinogenic. There really wasn’t much going on in town. I think maybe about 500 people live there. He walked with me for a while and led us to a roadside pulperia, which he on more than one occasion told me sold cerveza. When we got there, I asked for guy for a couple of beers and he pulled two cans out from under the counter. They must have been about 95 degrees, but I went along with it and we stood in the shade and chatted a while. By this time, I figured I should get heading back, so my machete wielding friend directed me back to the road where he hailed a moto taxi for me. He said it would cost me 15 lempiras for a ride back to the hospital, which amounts to 75 cents. I gladly paid this to avoid walking several miles in the scorching sun. On the way back, we zipped back and forth over all parts of the road to avoid potholes and other vehicles. These moto taxis are kind of squirrely vehicles, and they drive them pretty fast. Here’s a picture of one that I found on google images just to give you an idea:

Once I got back, it was time to do some laundry. The washer here doesn’t work, so I had been doing everything by hand in a utility sink at my apartment…which pretty much resulted in me wearing clothes that were still dirty. So, I asked Peter if I could come over to his place to use his washer. He lives up the hill a ways in a good sized house that overlooks the sea. It’s a pretty awesome spot. They have a nice sitting porch, several mango trees, and a huge garden where they’re growing all kinds of stuff. He ended up asking me to eat with him and his family while I waited on my things to wash, so it was a pretty good ending to the day.

Two difficult OB cases

May 13th, 2015 by Garrett Hooker
Posted in Uncategorized|

I’ve been going in every morning to see that patient of mine who’s in respiratory failure. The tap seemed to help somewhat and she’s breathing a bit more comfortably, but it’s sort of a temporary fix and she’s needing Valium intermittently to stay relaxed. I don’t think she has much longer. I got her labs back today. Unfortunately, what we’re able to do at our facility is so simplistic it almost wasn’t even worth sending them. Basically they were inconclusive, but there were a few signs that the effusion is secondary to some sort of malignancy.

Clinic was busy yesterday, as are most Mondays. My patients were as follows:

– 14 month old male with viral gastroenteritis.

– 22 month old male with possible viral gastroenteritis. He was recently treated for Giardia but couldn’t leave a stool sample at the moment, so I don’t really know.

– 6 month old male with chronic cough…probably just GERD, but could be pertussis around here.

– 19 year old male with patellofemoral syndrome.

– 4 year old male with viral URI and a chalazion.

– 38 year old male with GERD and a headache.

– 1 year old male with one episode of hematochezia.

– 47 year old female with constipation and a lumbar back strain.

– 13 year old female with recent Chikungunya who came in for a follow up on her myalgias. She had a white count of 27,000 about 4 days ago.

– 44 year old male with constipation

– 55 year old female with atypical chest pain, probably caused by a combination of trapezius spasm and anxiety. Of note, she was also wearing a Yoda shirt that said “size matters not” and probably had not idea what the translation was.

– 53 year old male with newly diagnosed COPD and hypertension. Started him up on some inhalers and Norvasc.

I was invited over to Mark and Heidi Merritt’s house for supper. They’re both from Virginia and have been here for about 10 years. Mark is a family doc who’s been working with me on that lady in respiratory failure. A home cooked meal was appreciated since I’ve pretty much been eating like a bachelor for the last week. Here they have an interesting version of Neopolitan ice cream that contains strawberry and vanilla, but lime instead of chocolate. At the moment though, anything cold is nice.

This morning our ob/gyn, Vance, had to run to La Ceiba. So, the plan was for us to turn any OB patients away who weren’t imminently about to deliver since we didn’t really have coverage for c-sections. I’ve done a number of them in the past, but apparently they don’t just hand the reigns over to people they just meet…probably a good policy I suppose. Anyway, at no more than 12 minutes into the day, and 15 year old G1P0 at 37 weeks rolls in dilated to about 6 cm. The nurse comes to let me know we have someone here, so I went and checked her. She was actually more like 7 cm and her cervix was really thin, so I didn’t think there would be any way she’d be able to make it to another hospital. I went back to clinic and tried to see people between visits back to check her. After doing this for a couple of hours, she was complete and ready to start pushing. She actually did a really nice job and got the baby out in about 45 minutes, which is pretty good if it’s your first rodeo. Her pelvic outlet was pretty small, so she had a second degree perineal lac that I started sewing up…but blood just kept gushing down into my field of view and it was hard to get anything done. I eventually gave her a dose of Methergine in addition to the Pit which she was already receiving in the IV. This still didn’t stop the bleeding. The girl weighed in at probably about 100 pounds, and knowing her reserve probably wasn’t as high as some of our fluffier ladies, I decided to subject her to a bimanual exam. This is especially uncomfortable for somebody without an epidural. I was able to retrieve a couple handfuls of clots, along with what appeared to be some retained tissue…likely the source of the bleeding. After I got all that out, the bleeding stopped and I was able to go back to clinic. I was a little concerned for a few minutes though.

The patients I saw in clinic today included the following:

– 53 year old female her for an ER follow up from the other night. She came in with hip pain that I thought was probably just due to a strain. Turns out it was.

– 73 year old female here for a follow up on COPD and CHF

– 66 yo F with diabetes and osteoarthritis in multiple places

– 59 yo M with newly diagnosed hypertriglyceridemia

– 63 yo F with constipation

– 48 yo F with something I can’t recall

– 12 yo M with an elbow abnormality that’s been worsening over the past 3 years. Whenever he extends his elbow, the olecranon slides laterally over the humerus rather than into the olecranon fossa. I took an x-ray of it and will be sending him to one of our surgeons. I’m concerned it could be an osteosarcoma and he’ll need to have his arm amputated. Here’s a picture of it:

Right as I was finishing up with clinic, Peter came to tell me there was a 20 year old G1P0 at approximately 20.5 weeks with a threatened abortion in the ER. She’d been bleeding for about 2-3 days. Apparently yesterday she had an ultrasound done at another facility and everything looked normal. I got out the ultrasound and was able to find fetal heart tones, but it looked like the baby was breech and some of its contents were already outside the uterus. I moved her to the OB room and did a sterile speculum exam on her. Right away I could see her amniotic sac at the introitus and knew delivery was pretty much imminent. So I explained in broken Spanish to these people that basically the baby was about to deliver and would die within a few minutes of being outside mom. They of course were upset, but took the news surprisingly well. I’m thinking down here maybe people are just more accustomed to having a poor pregnancy outcome now and then. I ended up delivering that baby a little while later. Just to add to the excitement, it was breech. I’ll spare the details, but suffice it to say that didn’t help matters.

Feliz dia de las madres

May 11th, 2015 by Garrett Hooker
Posted in Uncategorized|

This morning we had a 20 yo G2P1 roll in at 38.4 weeks contracting every few minutes with ruptured membranes. Several hours after her arrival, I heard a desperate call over the radio for a doctor, amidst a screaming patient in the background. I ran over to the hospital and checked the patient, who sure enough was complete. In the seconds between that and grabbing a pair of sterile gloves (we check patients with non-sterile gloves due to the limited supply of them, but deliver with sterile gloves…I don’t know), the baby was crowning. About a second later, the rest of the baby flopped out onto the bed before Vance or I was ready to catch her. Everything went fine though and it was fun to tell the mom “Feliz dia de las madres” immediately after the delivery.

The antithesis to that story is the one of this lady I’ve mentioned I’m taking care of in the hospital. She’s just not getting better and is still on 8 liters of oxygen. The steroids and antibiotics aren’t working. It looks like she has an effusion, but several doses of Lasix haven’t helped. It looks like maybe she has a mass in her right lung, so Peter and I took the ultrasound into the room and found a pretty good sized pleural effusion. We gathered up all the stuff to tap it, and were able to drain off about 40 cc of serous fluid. Even that didn’t help as much as I had hoped. She still has air-hunger and looks pretty uncomfortable. I’m sending the fluid off to the lab, but I’m guessing she has a malignancy of some sort. We don’t really have the means to treat her here, and frankly there’s probably not really anywhere else around that does either. If we intubate her, she’ll never come off the vent. Most likely we’ll end up shipping her out to La Ceiba if the family wants to pursue more aggressive treatment (assuming we can get her stable enough for the trip). She may want to just go home, which is reasonable as well. I don’t think the family wants her to stay admitted here if she’s going to die anyway, but at least we’d be able to give her morphine and some other stuff to make her death more comfortable. Unfortunately we only have one hospice bed available, which I believe is currently occupied. Assuming this is in fact a malignancy and she has as poor of a prognosis as I think, that would probably be the ideal disposition for her…but again, we’re dealing with extremely limited resources and those types of things aren’t always an option.

To lighten the mood, here are some pictures of a monkey I saw while going for a walk today:

Semana primera

May 10th, 2015 by Garrett Hooker
Posted in Uncategorized|

This is my first ever attempt at blogging, to let’s all get our expectations down to a reasonable level. To start with, I had to get from the airport in Roatan to the ferry, which would take me to La Ceiba. This provided me my first opportunity to dust off my rusty Spanish skills. I quickly failed in doing so as the taxi driver told me the cost was “veinte cinco”, or twenty-five. I thought that seemed a bit steep, but paid him the $25 since wasn’t really in a position to argue. If I didn’t make the ferry, I had no idea where I’d be staying the night or how I would meet up with my contact person at a time other than what we had originally designated. After a short taxi ride, I got on the ferry and later realized the driver meant 25 lempiras, the local currency, which amounts to a little over a dollar. I took the ferry from the island of Roatan to La Ceiba. It took about an hour and a half and could hold several hundred people on board.

Once I arrived in La Ceiba, I met Peter, an ER doc from Arizona who’s acting as my “sponsor”. We headed to the grocery store and bought supplies for the next couple of weeks, loaded them up in the back of his truck along with several containers full of gasoline, and headed east for about another hour over bumpy roads until we finally arrived at the medical complex, which is near the town of Balfate. They’ve set me up in my own little one bed, one bath apartment. It’s in a larger complex of apartments that has sort of an open air theme.

There are a couple suspension bridges between my house and hospital. You can also see the ocean from the property.

121. hospital

The next day I took a walk to the beach, which is only about ten minutes away. On the way there once I got off the road, I had to first pass through a field of palm oil trees, which believe it or not are used to make palm oil. Afterward, I had to pass through sort of a lagoon-like area with these big towering trees with really thick trunks. I’m not sure what they’re called, but they were pretty impressive.

Peter and his family invited me to go with them to a nearby waterfall later on in the afternoon. On the way there and back, we had to ford a river in his truck because the bridge had been washed out.

We passed this cemetery on the way back, which I was able to photograph from my bumpy seat in the truck bed.

On Monday I started working in the hospital and clinic. It can get a bit warm at times and there’s no air conditioning. The humidity is almost always about 100% since we’re right next to the ocean, so everybody just sweats all the time and there’s not much anyone can do about it, haha…but I get to go down to the beach before work and snorkel, so you can’t really beat that.

I usually get to the hospital a little before 8 and see the people I’ve admitted. I was on call overnight that first Monday, so I quickly rounded up some people to admit. The first one was a little boy named Fernando who basically just got dehydrated and needed some fluids overnight. Here’s a picture of him and his family:

The second was a pregnant woman who came in at about 2:30 a.m. She was eclamptic and actively seizing when she arrived, so we had to do a crash c-section on her. Back at Research, we see a lot of people with preeclampsia but rarely full blown eclampsia. Apparently it happens not infrequently around here.

As far as clinic goes, I’m seeing anywhere from 6-10 patients per day. That’s actually less than I see back home, but it feels like a lot more work here…probably because I’m still kind of unfamiliar with their system and also the fact that everybody here speaks Spanish. I’ve only met one other person (who’s not a missionary) who speaks any amount of English. I can already tell my Spanish is improving. That first day was a real struggle though, after not really speaking Spanish on a regular basis for several years. Luckily there’s a translator here who I can occasionally have step in if I really get stuck, but for the most part I’ve just been trudging through as much as possible.

On the second day, I had a patient with a virus that I had previously never heard of. It’s called Chikungunya, and basically causes fever and joint pain. I guess they see it fairly often around here. There’s not really any specific cure, so I just gave her supportive treatment and return precautions.

One other patient I had that day was a 4 year old girl who had a fall and broke both the bones in her forearm. It’s really interesting working here because we don’t have any other doctors to consult with. When you get an xray, you’re the one who has to read it. There’s no radiologist to call up if you can’t figure it out for yourself. This was a pretty obvious fracture luckily. We had to consciously sedate her, which again was a little bit different of a process than how we do it in the states. Much less monitoring involved. We just gave her some Ketamine and were able to yank her arm back into the correct position to apply a cast. I’ll see her back in about two and a half weeks to remove it.

The other people I saw that day had some pretty common things I see a lot back home. One was a girl with pityriasis that I treated with an antifungal ointment. The other was a guy with an enlarged prostate who we ultrasounded. He’ll follow up with a urologist and probably have it removed. Another person was a guy with abdominal pain probably caused by a kidney stone, but I don’t really know. One guy had an asthma exacerbation caused by an upper respiratory infection. I think that was it that day.

After work I walked down the road a ways to the children’s center and there were some guys outside building a hut. They have to climb up these trees about 40 feet and chop down the branches with a machete. Then they dry the leaves out on the ground for a few days. Once that’s done, they bundle a few rows of these branches together and lash them to the frame. The guy I talked to about it, Silvino, said the roof on one of these buildings can last about 6-7 years, or maybe longer depending on how many rows of branches they lash together.

The next day my clinic patients included…

• 45 year old female with constipation
• 5 year old male with cough variant asthma and his 6 year old sister who had the same thing
• 65 year old male with right shoulder arthritis who got a steroid injection
• 18 day old female with a viral upper respiratory infection
• 5 year old female with community acquired pneumonia requiring antibiotics

It’s kind of nice that clinic here only lasts from 8 am until 1 or 2 pm, so you can’t really get overwhelmed with too many patients. Worst case scenario is you get an hour or so behind and are still done around 3 pm.

After clinic ended, a 39 year old G6P5 came in at about 4 cm. I got her admitted and watched her all afternoon because I was the one on call overnight. She wasn’t really doing anything, but I decided to keep her because in the words of one of our distinguished faculty members, Dr. Philgreen, “you can never trust a grand multip”.

Later on a 14 month old came in to the ER with “fever”, diarrhea, vomiting, and decreased oral intake for the last few days. She was actually afebrile and didn’t really look that dehydrated, so I just give her some fluids and had her come back in the morning for lab work and a follow up visit (we can’t do labs at night here, so there’s not really any point in just baby-sitting, plus the nurses are always stretched pretty thin and the hospital census is kind of high at the moment).

A little bit later on that night I ended up delivering the mom mentioned above, so I’m glad I didn’t send her home even though she didn’t seem to be in active labor. The baby was huge and at first I couldn’t pull it out because its shoulders were so big. I had to exercise a couple of shoulder dystocia maneuvers and was finally able to get it out after about 45 seconds of struggling…that’s always a bit scary. Another lady came in as well and delivered a little bit later at around 4 am. I also admitted a 66 yo F who was having a COPD exacerbation and maybe has a pneumonia by looking at her xray. She’s still in the hospital now and I’ve started up some antibiotics on her. The little girl who got dehydrated came back in to see me in clinic the next morning and I gave her some more fluids and sent her home.

The next day, clinic was kind of a blur. The most interesting thing I saw was a 23 yo M with seizure disorder, which has been well controlled on his current meds. He’s only had the disorder for about 4 years, and the etiology is thought to be due to neurocysticercosis, which in the developing world is one of the most common causes of seizure disorder. Here’s a view of his CT, where you can see a number of calcified granulomas throughout his temporal lobes:

Here are a few other fun pictures I’ve taken from around the complex:

This is just an awesome jeep that mine aspires to emulate one day.

These are some pics of my roommate, Sr. Guillermo. The other cuddly little guy is barely visible, but is a scorpion I found in the bathroom. He’s about ten seconds away from getting kicked out of the house.

157.route to beach 158.coral

Here’s a satellite view of my house in relation to the beach. There’s also a giant coral reef a few hundred yards off the shore that has tested my ability to not have a heart attack while exercising.

Mother’s day flowers I (digitally) sent my mom. I found these all within about 50 feet of my house.

I’m on call again at the moment. I just got back from the ER where I saw a 53 yo F with probably a left hip strain. It started immediately after she tried lifting her leg while getting out of a car. She did have a temp to 100.5 F, but I don’t think she has a septic joint. Unfortunately we can’t really get labs or imaging at night without calling someone in from far away, so we just have to sort of make a guess based on their clinical appearance. I gave her a shot of Toradol and some Tylenol and NSAIDs to get her through the next couple of days until clinic reopens unless things get worse.

My First INMED Blog Post

May 6th, 2015 by INMED
Posted in Uncategorized|

Hello! My name is Garrett Hooker. I am a senior family medicine resident at Research Family Medicine Residency, and I’m starting my INMED service-learning experience at Hospital Loma de Luz in Honduras, beginning in May 2015.

Carnaval

Seizure On The Playground

Lis-Lis

La Ceiba

Woodworking: universally awesome

If you don’t befriend the guy wielding a machete, you’re doing it wrong

Two difficult OB cases

Feliz dia de las madres

Semana primera

My First INMED Blog Post

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My INMED Training Site

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