Hospitalito Atitlan 5

Towards the end of my week at the Hospitalito, one of the staff members asked me to speak with the parents of a teenager who had suffered an electrical injury in the past few days. The young boy had climbed onto a roof in pursuit of a kicked soccer ball. The young man was sweating, and he recalled wearing a wet tee-shirt. The ball had come to rest near the business end of a power-supplying transformer. The boy’s head came sufficiently close to the transformer to cause it to discharge an arc directly onto the top of his head. The youth was rendered immediately unconscious and thrown by the force of the current. He remembered climbing up onto the roof and waking up in an ambulance, but nothing in between. The errant power discharge tripped the breakers, or he might have been killed.

Although it was his misfortune to have been struck by the electricity, he was incredibly lucky with respect to his landing spot. The perimeter of the roof was ringed by a raised concrete edge with embedded chunks of sharp glass, placed to deter intruders. There were only a few small sections of the edge without glass, and he landed face down in one of them, or he might have been impaled and shredded. His friends called for help and he was rushed to emergency care, from where he was transferred to a hospital. According to his parents’ report, he was managed very well, as the doctors considered injuries to his brain, bones and muscles, kidneys, and heart. Again, luck prevailed, as his only serious injuries appeared to be burns.

The burn pattern was a hybrid between what one would expect to see with a lightning strike and an industrial injury. That is, the electricity entered via the top of his head, appeared to flash over his body, and exited via his legs. He suffered first and second degree burns on his scalp, across his chest, and down the front and back of his legs. The current followed what was probably the pattern of superficial moisture on his body. However, they did not have the typical “ferning” or “punctuate (flower-like)” configuration of a lightning strike, but appeared more like scald burns. So, he suffered a “flashover phenomenon,” but with a lesser voltage than would have been incurred by a lightning strike. He also did not suffer other common sequelae of a lightning strike, such as ruptured eardrums, visual changes, or significant amnesia.

I examined this very nice young man a few days after he left the hospital. The burns on his body were doing nicely, except for some deeper second degree burns on the backs of his legs. These needed to be treated more aggressively with topical moisturizing cream to decrease dessication and increase pliability, and to allow the initiation of physical therapy (gradual stretching) to prevent his muscles from forming contractures. Both the youth and his father were very gracious, and gave me permission to take photographs for the purposes of this description and teaching. In a few weeks, I fully expect his soccer career to resume.

Preview the 25th Anniversary & Annual Meeting of the Wilderness Medical Society, which will be held in Snowmass, Colorado July 25-30, 2008.

Tags: Hospitalito Atitlan, Guatemala , wilderness medicine, outdoor medicine, healthline

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Pain Management in Difficult Situations

A reader writes: "I just came back from an elective in Nepal in orthopedics. A lot of what you describe (about Guatemala) sounds eerily familiar... especially what you mentioned about pain management. If the situation in Guatamela is anything like it was in Nepal, I think it's not that they're more stoic there... they tolerate the pain because there is no choice. And I think that tolerate is probably the wrong word... I'm sure it has the same negative effects on a patient there as it would here. In Nepal, we didn't always have anesthesiologists or a GP with us, and ortho surgeons are not allowed to administer procedural sedation. Strictly speaking, they're not supposed to do bier blocks or nerve blocks either. Which meant that we ended up doing a lot of closed reductions without any anesthetic. I can't imagine how the patients felt, but I have to say that I was just horrified. I wonder if you had similar feelings, and if so, how did you deal with them?"

Whenever a health care provider doesn’t have the equipment or drugs needed to optimally manage a patient, he or she must make due with what is available. Sometimes this means that you can manage the problem fully, but sometimes it is only possible to achieve a less-than-desired result. I am a bit surprised that the orthopedic surgeons were not allowed to administer local or regional anesthesia, because they are usually trained to do so. In any event, if no one was available to provide significant pain management, then one would have to decide how best to proceed – allow the victim to endure the persistent pain and possible adverse outcome of a nonreduced fracture, or proceed with a painful intervention and know that as soon as the bones were properly aligned, the pain would rapidly diminish. I have been in that situation many times, most often on the athletic field, where a quick reduction (usually of a dislocation) is momentarily painful, but solves the situation.

There are other techniques that sometimes diminish pain for the victim. Ice packs properly applied make a difference, as can emotional distraction. Still, without “real” pain medicine, moving a broken bone really hurts. I’ve been there myself with a fracture-dislocation of my ankle, and the narcotic injection was most appreciated.

When I wrote that the patients were more stoic, I did not mean to imply that they didn’t feel the pain. Many of these persons do not have easy access to medical care or the copious number of pharmaceuticals (including pain medication) that we expect in the U.S. So, they are indeed more stoic, complain less, and are more accepting of a delay to therapy and relief than are most persons in our culture. Given their attitude, the pressure is even greater on the providers to work diligently to make these patients more comfortable, because they may not be fully expressing their true needs.

How do I feel when I’m caring for someone and I can’t do everything I would like to do? If I think the outcome will be acceptable, I live with it. If things are going poorly, I get frustrated, unhappy, and sometimes angry (at the situation, or even myself, for not being able to improve the situation). But I always do my best to hide any negative emotions from the patient, family, bystanders, and other health care providers. Much of the time when I practice medicine, I am in charge, and if I “lose it,” nobody benefits.

Tags: Guatemala, pain, wilderness medicine, outdoor medicine, healthline

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Hospitalito Atitlan 2008

I am spending a week working at the Hospitalito Atitlan in Santiago, Atitlan (state of Solola) in the highlands of Guatemala. I have visited the hospital twice in the past (2007 and 2006), but never before worked as a clinician at the hospital. The building is a temporary solution that must serve the people here until such time as a new hospital can be built to replace the structure that was destroyed in the mudslides associated with the hurricane in October of 2005.

Santiago is a busy small city of very friendly and industrious persons, although it appears to have become more intense and less relaxed than it was a year ago. In the morning, the air is dense with smoke from wood fires used for heat and cooking. Not surprisingly, many of the local people suffer from pulmonary diseases associated with exposure to this smoke.

The purpose of my visit is to learn better how this hospital can be supported with doctors, staff, and money. A new hospital is being planned, but construction cannot accelerate until there are more resources identified.

The patients are certainly in need and very appreciative. The volunteers and paid staff are phenomenal in their dedication and rapidly improving expertise. My participation in just the first few days has been filled with moments of improvisation, because the supplies are limited and decision making must take into account conservation of supplies, the expense to the patients, the relative inability to easily obtain tests we take for granted in the U.S., and the wishes of the patients and families. It is a collaborative process, and I am hindered somewhat by my inability to speak Spanish or Tz'utujil, the Mayan language spoken in this region.

The patient mix is varied - the first day saw a mixture of obstetrics, neonatology, trauma (tuk tuk accidents are quite common, as these three-wheeled taxis are driven by individuals as young as 8 years of age), infectious disease, an acute urological emergency, lung problems, and much more. My wilderness medicine training has helped in at least a few situations, and as is often the case, duct tape is quite valuable.

I can't say enough about how important it is for local medical facilities like this to be successful. This hospital provides an extraordinary service to the Santiago residents and other inhabitants of this locale, and it is clearly understood that for this to be a long term success, it needs to be based upon the recurring expertise and efforts of the community and Guatemalan physicians. I will collect more of my experiences and my thoughts at the end of this experience, and write more.

Back to work...

photo by Kathy Roach

Tags: Hospitalito Atitlan, Guatemala , wilderness medicine, outdoor medicine, healthline

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