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Medicine for the Outdoors

Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.

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Hospitalito Atitlan 4

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In a clinical setting such as that at the Hospitalito Atitlan, one is often required to participate in activities that would be referred to a specialist in a better resourced environment. We had the option to send patients on a two hour drive to a general surgeon, or a few hours away to obtain a CT scan, or four hours to Guatemala City hospitals, but there was no easy access to the diversity
of specialty referrals available here in the U.S. To see a dermatologist, rheumatologist, neurologist, etc. might mean months of delay and certainly, expenses beyond the means of most of the patients who came to the Hospitalito seeking care and advice. So, the medical practitioners at the Hospitalito continue to try as best possible to deal with problems locally, develop a culture of health awareness, and establish continuity with their patients. This is often not easy in a situation where the advice of a elder relative might carry as much or more weight than that of a trained physician, or the patient is simultaneously under the care of a traditional healer with a differing approach to solving the problem. Sometimes the Hospitalito represented the place to go after other prolonged attempts to remedy a situation had failed. This sometimes contributed to a condition or disease being in an advanced state upon presentation to the medical staff at the Hospitalito. Chronic hip pain might be a femur fracture of many years’ duration allowed to heal without intervention, and shortness of breath be lung cancer or complication of end-stage kidney failure. In those situations, comfort care was all that could be offered.

Other times, interventions could be made, and the outcomes beneficial and quite acceptable. One cheerful gentleman visited us because of a growth upon his lip. He didn’t remember any trauma or incident that initiated the growth, but it was continuing to enlarge and bothering him a great deal, particularly when he ate and drank. He was hopeful that we could fix the problem for him.

The lesion bled at slight touch, and seemed to be a bit crumbly in consistency, with the appearance of a pyogenic granuloma, which is a benign (noncancerous) growth that is well endowed with very tiny blood vessels – hence the bleeding. They often erode internally (to the lesion) – hence the consistency – but rarely invade surrounding tissue. Sometimes they become infected, but don’t seem to be caused by infections. A treatment often deployed in the U.S. is obliteration using a pulsed dye laser, but of course, that was not an option for us. So, we elected to go with the tried and true method of excision and then cauterization of the base, to eliminate any remnants of granulomatous tissue in the base from which might spring a recurrence.

We explained what we wished to do for our patient and he consented to the minor surgery. After taking him to our small operating room, we cleaned the granula and surrounding skin carefully with povidone-iodine disinfectant, then used a small injection of numbing medicine into his lip. We discovered a small string tied around the granuloma, which was an attempt by someone to remove the lesion by strangulating it at its base. While this was not a therapy that would be successful, it didn’t worsen the situation, and actually gave us a tag that we could use to apply traction to the lesion as we excised it from underneath. We sharply dissected the granuloma from his lip, and put it in a container to be sent off for a definitive pathologic examination, to be certain that it was what we thought it to be, and not a skin cancer. After the granuloma was removed, we cauterized the (bleeding) base to its margins, and applied a sterile dressing. If we were successful in zapping all the culprit tissue, the growth will not recur, the scar will be tiny, and the problem solved.

photo of Hospitalito Atitlan courtesy of Jennifer Jaggi

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About the Author

Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.

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