Tag Archives: pediatrics

“UPED” is also a 4-letter word…

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I have a confession to make: I have no desire whatsoever to blog.

I feel so at home here in Tuxtla that it’s easy to forget I’m supposed to be a traveller. The truth is, I’m not travelling anymore – I have my home here, a job to go to every day, friends I can make plans with, public transit I’m comfortable taking, new cellphone chargers to buy when mine dies. It’s only when I consider blogging that I remember my time here is temporary, and as a result, I have been avoiding this blog like the plague.

However, with the month drawing to a close, it is becoming difficult to ignore the fact that I have another life in Canada, and when I return to that life, I know I’ll want these blog posts to remind me of my home in Mexico!

Centro medico

Let’s backtrack a minute to A Day in the Life of el Estudiante Sarita, and to that fateful comment posted by a faithful reader: “Your new position doesn’t make for as harrowing a blog post but it sounds much better for you – way to go on suggesting a switch.”

Now, let’s fast-forward to a week after I had comfortably settled into my routine in Pediatria. On Friday afternoon, after my regular debriefing with la Doctora, I kissed her good-bye and told her I’d see her on Monday, to which she responded, “Oh, I won’t be here on Monday – I’m leaving for holidays for the next 2 weeks!”

… say what?

I bemusedly contacted Lizeth, my exchange coordinator, informing her that my placement would need to change yet again, and somehow she worked rapid magic and found me a placement for the next week.

Remember my comment from my first week, about how I had little interest in Emergency and even less in Pediatrics? Well, the fates decided that I was giving up on both too soon, and I was to report the next work day to …
*drumroll please*

Las Urgencias Pediatricas Emergency Department (UPED).

Urgencias
Note the makeshifts tent set up along the gates, where people sleep while waiting for news about their family members
Tents

Upon arrival, I was introduced to Miguel, an incredibly kind if incredibly fast-talking interno (Year 5 of 6 in Mexican medical education). Our introductions were suddenly interrupted by shouting behind us, as the doctor doing rounds engaged in a heated debate with a nurse and a resident regarding a discrepancy in patient care. I have never heard so many creative variations of groserías as I heard coming from that doctor’s mouth. As his tirade was winding down, Miguel nudged me. “Go introduce yourself to that loco,” he whispered. “That’s your supervising doctor.”

Hesitantly, I approached the doctor, who was, self-admittedly, completely loco and not one to mince words when he felt his staff was slacking off. But he was also an amazing doctor, devoted to his patients and passionate about improving their level of care and his staff’s skill level. He warmly greeted me, and instructed Miguel to provide me with every possible opportunity to learn during my time in UPED.

UPED

Miguel took this to heart and took me under his wing, immediately walking me through the process of how to take a patient history for new entries, how to fill out a lab req, and where to drop off blood samples (Quick reminder: This is all in Spanish. Oy vey, my ears were bleeding from trying so hard to listen and absorb everything!) However, as Miguel and I were taking down the patient history of a 6-year old with a ruptured appendix, there was another flurry of activity as the surgeon came striding into the ER – there was a 3-year old with a perforated intestine requiring even more emergent surgery, and I was informed that I was to accompany them into surgery.

I do not know how much more clearly I could have stated, “I HAVE NO CLINICAL EXPERIENCE IN SURGERY. I HAVE NEVER SEEN A SURGERY BEFORE.” Before I knew it, I was on the surgical ward, changing into Miguel’s borrowed surgical scrubs and frantically trying to listen to how I was to scrub my hands and what to do with the surgical booties and where to stand so I wouldn’t contaminate everything. The surgical resident was extremely personable if extremely brusque, and as he was unpacking the sterile trays, he showed me each instrument and told me its name. I tried to absorb as much as possible, but since he was only showing me everything once and since I was very clear that it was the first time in my life I had ever seen these things – in English OR Spanish – I was assuming this experience was more of a bonus teaching session.

Assume nothing. Behind us was the operating table with the tiny patient already anesthethized, and within minutes, the surgeon was on one side of the table, the resident on the other, and I, the first-year exchange student, was beside the resident as the instrumentist for the surgery.

Pardon my Spanish, but ¡¿QC?!

Long story short: They quickly realised I meant it when I said I had no surgical experience, and another resident was called in to act as instrumentist. Once the resident took over as instrumentist and I was able to simply observe the surgery (which was all I wanted to do in the first place!), I was in awe. This was (as I have mentioned many times!), the first surgery I have ever seen, and it was beautiful. Watching the surgeon delicately slice through each layer of tissue, cauterizing the edges of the cut to control the bleeding, that distinctive smell in the air, the metres of intestines that literally came ballooning out of the body once they were freed from their confined space… The human body is incredible, amazing, miraculous, and powerful, and to see it exposed so carefully was a true gift.

(Speaking of gifts, the surgery occurred on my sister’s birthday, and I kept wondering what her reaction would be if she were in the room :P)

Once the perforation was corrected by resectioning 20 cm of intestine (which were handed to me with the instructions, “Guardalo.”) and a stoma made in the side of the patient, the pinch-hitter resident and the surgeon left me and the original resident alone to sew up the incisions. And I kid you not – completely scrubbed up with only our eyes visible, standing on opposite sides of a draped patient with a gaping open abdomen, with my finger acting as an anchor for the stitches holding the abdominal wall together – the resident casually started to flirt with me. Oh, los Mexicanos!!

Once the incision was closed and cleaned, the resident left to chart and the nurse handed me a plastic bottle containing the 20 cm of intestine, and asked me to go prepare it in formaldehyde. I wandered into the hall, clutching my intestine bottle, and eventually found some very nice healthcare aides who took me to a jug of formaldehye sitting in the hallway and helped me syringe in enough to cover the sample. At this point, the resident had me fill out a Pathology report, then instructed me to go change. In the change room, juggling my borrowed scrubs, the Path report, the intestine, and a can of Coke the resident insisted on buying for me, I had a brief out-of-body experience and wanted to break into uncontrollable laughter.

Instead, I changed and met the resident in the ICU, where he proceeded to hand the intestine bottle to the patient’s mother, informed her that here was what had caused the problem, and pointed her to her daughter’s bed. He then turned to me and said, “Well, quieres una otra Coka?”

El tor de Chiapas

That was my first day in las Urgencias Pediatrias. And though I frantically reviewed and quizzed myself on all surgical instruments that night, I did not go back into the OR. Instead, the rest of my time in the hospital was spent finally being useful. I was comfortable enough with the layout of the hospital and in my lanugage skills to actually be able to type up patient charts, collect lab results, fill out reqs, and drop off samples at the lab, even understanding when there was an issue with one of the reqs and being able to correct it myself without having to bother an intern. The UPED staff were incredible to work with – so patient with my language skills and constantly finding things they could teach me how to do so I could do them myself. Los internos invited me to stay on for la guardia (night shift) one night, and it was very satisfying to be further included as a part of their team.

Friday was my last day in the hospital, and when one of the doctors found out, he started giving the interns a hard time, “Where’s her cake? It’s la canadiense’s last day, of course we need a cake!” I laughed it off as a joke, but sure enough, later in the day, Miguel came running in with a bakery box, and soon the entire UPED staff was gathered in the break room, toasting me as I cut the cake.

Gracias por el pastel, Dr. Keeven!

Los estimados doctores del UPED
UPED doctores

La buena gente del UPED 🙂
Internos de UPED

To make it a truly authentic Urgencias fiesta, after about 10 minutes of relaxing together, another doctor came running in, shouting, “There’s a head injury outside, the patient is seizuring!” With this, everyone shoved the last bite of cake in their mouth and bolted outside.

My time in Mexico has taught me too many things to count. But possibly the most surprising, and the most potentially life-changing, is that as much as I cannot believe I am about to admit this…

I love Peds. and I love Emerg.

And I have no idea where I will end up next!

Outside the hospital

A Day in the Life of el Estudiante Sarita

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• The alarm goes off at 6:15AM. Normally, I do not hear the alarm at first because it is set to the soothing sounds of birds chirping, but since there are nightingales that chirp all night outside my window, this is not very helpful. I should probably change my alarm.

• Go into the bathroom to try and coax the shower to (a) get at least quasi-warm and (b) provide at least a trickle of flow. If this is not possible, I can always wash my hair in the sink.

• Dress in my all-white uniform that I have actually come to quite like wearing, for several reasons:
1. Although it seemed insane to me to wear pants and a long jacket in +39C weather, you would be so hot no matter what you wore that at least in long pants, you’re not sticking to yourself (/the 19 Mexicans crammed into the bus next to you) with sweat.
2. Scrubs material is way cooler than dress pants.
3. I never have to think about what to wear in the morning, hallelujah!!!
4. From Day 1, I have never felt out of place in the hospital, even though I’m a different race, a different culture, and speak a different language. When I walk down the street, all anyone sees is yet another medical student dressed all in white.

Uniforme!

• Go downstairs for breakfast, which normally consists of a literal (yes, Phil Cook) heap of local fruit: mango, papaya, bananas, and cantalope. Once, for a special treat, they gave me imported apples 😛 Other breakfast essentials include coffee (from a local coffee finca) and tortillas. This morning, I tried to be helpful and prepare everything myself, but apparently committed a gross error: the minute Ubel walked into the room, he looked at my plate, aghast, “Sara, you didn’t warm up your tortilla?” When Magali walked into the room, he turned to her immediately, “Sarita is eating tortillas that were not warmed up.” “Sarita, ¿por qué?” she gasped, horrified.

Canadians, please take note: YOU ALWAYS WARM UP THE TORTILLAS.

Breakfast

• Get driven to the hospital by Ubel, where we talk about Canadian politics (all of Mexico will be well aware of my views on Mr. Harper by the time I leave!), compare prices between our countries (“Un coche es barato o caro? Guayaba es barato o caro?”), and learn English swears (please take note that it was not I who initiated the latter!)

Calle al hospital

• Report to la Pediatria for rounds at 8AM. Unlike las Urgencias, la hospitalización pediátrica contains about 20 beds, with only 2 patients in a room – and the rooms have doors that close! Of the 20 patients we saw, nearly half had severe fevers that were in the process of being diagnosed as either Dengue or Chikungunya, two mosquito-borne viruses that are endemic in this area. On the other side of the ward is a single large ward for los Lactantes (nursing babies), with 15 cribs arranged in a large circle around a central nursing desk. Dengue and Chikungunya are also problems in these infants, as is malnutirition, food-borne illnesses such as Salmonella, hydrocephalus (increased fluid in the brain), and encephalitis (inflammation of the brain usually due to a virus).

• Rounds are finished by about 11AM, at which point I either talk to other students about differences between our medical schools, discuss differences in healthcare policy between our countries with la Doctora, or spend some time researching the topic I’ll be asked to discuss during the afternoon Neuro consults.

• At noon, I leave for lunch. Sometimes, Ubel packs me a little lunch, which is always exciting because it has the potential to be absolutely anything. Once it was leftover pancakes folded around leftover salad, and once it was a hotdog and mayonnaise sandwich (and honestly, both were delicious!) Otherwise, I either walk to the cafeteria outside the Walmart across the street for gringas or quesadillas, or I walk to the OXXO and buy a yummy but bizarre sandwich that always insists on hiding some kind of pickled veggie. I usually eat in the hospital lunch room with Lizeth, one of the student SCOPE coordinators in Tuxtla, who has been my tour guide/translator/lunch buddy/general lifesaver!

Walmart parking lot

Family-run booths selling everything from tamales to Jell-O outside the hospital
Tiendas del hospital

Unas gringa para una gringa!
Gringas

• Between 3-5PM, I join the neuropediatrician for external consults. Each consult is about 30 minutes long, during which time I try to follow along as the neuropediatrician takes a detailed birth history and history of presenting illness (that 95% of the time is some kind of seizure) and then be alert to the very subtle look given by the neuropediatrician that is my cue to take the patient to the other room and perform the neuro exam.

I am now conducting the neuro exams on all the patients, which is alternately amusing, educational, and bien pinche dificile. Performing neuro exams on kids in general is hard (they think you testing their reflexes is hilarious, and therefore refuse to go limp because they’re too busy giggling); performing neuro exams on kids with severe disabilities is very hard (when a child cannot respond to their name, it is hard to communicate that you would like them to follow the movements of a little bell using only their eyes and nothing else); and performing neuro exams on severely disabled kids IN SPANISH? Let’s just say I am sharply honing every single non-verbal communication skill I possess!

I both greatly respect, am severely intimidated by, and don’t always agree with the neuropediatrician whom I am fortunate enough to work with for the month. While I often think that in Canada, we don’t expect enough of kids, I think there must be a happy medium between our two worlds. Here, I’ve seen suspicion of neurological damage when a 13-year old boy was asked what season it was and he responded (very appropriately, I thought!), “Summer.” The doctor paused, looked at him gravely, and then intoned, “What day is solstice, young man? Solstice occurs on June 21. Therefore, we still have three days of spring.”

So perhaps I too have neurological damage. 😛

However, whatever I may think about this doctor’s bedside manner, I am in awe of the patience and generosity of time he shows to me. At the end of the first day, it was already 5PM and I was ready to thank him and leave, when he asked, “Oh – do you need to leave immediately?” I turned to find him setting up his laptop where he had a presentation on hipertensión endocraneal ready to go, and launched into a mini-lecture. Every day after that, he has given me a subject to research for the next day (anything from classification of seizures to pathological reflexes to UMN lesions), and once consults are done for the day, he asks me to present what I’ve found while he adds in any missing information. He is intimidating enough that I would never dare slack off and not do the research, but there is also something very endearing about how much he wants to teach me that puts me at ease with him. I’ve also made him laugh twice, which I consider a supreme accomplishment!

• Around 5:30PM, I walk back outside into the blinding heat and catch my combi just across the street. Comfortably inconspicuous in my white uniform (which miraculously, even in rainy season and even with riding a crammed combi, somehow isn’t black by the end of the day!), I wedge myself between a nursing mother and an impeccably suited gentleman, and pass my 6 pesos up to the driver. I know I’ll barely have my foot in the door at home before Magali will be insisting I eat something and Valeria will be telling me where we’re going out that night, so I savour my half hour of solitude (well, as alone as you can be when you’re in the back of a truck with 19* other Mexicans) and look forward to whatever the evening will bring!

Combi-ridin’ combi-ridin’
19 of us and room for more!

Evening view from my front door
Sunset at home

*I didn’t want to publish false information in this blog, so I made a point to count the gente in the combi with me today.

“Plan” is a 4-letter word

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If my time in Mexico has taught me anything in the first week, it is to accept that initial plans ultimately look nothing like reality.

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When I first received my exchange placement, it was in the department of Neurology, which had been one of my chosen fields. When I was given the name of the doctor I would be shadowing for the month, I saw that my department was now Pediatric Neurology – different, but still within the realm of what I was anticipating. When I arrived at the hospital on Monday morning, crisp and shiny in the requisite all-white uniform, I was told to report to Pediatric Neurology consults from 3-5PM; but in the morning, to report to Las Urgencias — aka the ER.

Ready for anything… except perhaps what came next.
First Day!

Within ten minutes, I was at the bedside of an unconscious patient in the Shock room. “Hiciste un chest tube antes, si?” asked the ER resident (You’ve put in a chest tube before, right?) I think I literally laughed in his face, as I assured him most emphatically, “Uh… non!” I watched with shock and awe as the resident took an endotracheal tube and began sawing off a portion with his scalpel. “We don’t have the resources here to buy chest tubes, so we have to make do with what we have,” he explained as he made notches in one end and tied off the balloon valves. “It’s not the best chest tube, but the most important thing is to save the patient’s life.”

He counted ribs, numbed the area with Lidocaine, and made his cut. “Venaquí,” he instructed me, holding out a sterile glove for me to slip on. “You can feel where to insert it?” Suspended in disbelief, I watched myself wiggle my finger in between the patient’s ribs, trying to find the space to insert the life-saving tube that would drain the fluid and blood from around his lungs. The resident deftly placed stitches, clamped the tube, inserted it through the cut – and immediately, a gush of frothing pink fluid poured out. This patient had a massive hemothorax (immediate evacuation of over 1L of blood after insertion of tube thoracostomy), requiring urgent surgery.

And thus began my introduction to Mexican medicine. Las Urgencias is a chaotic series of hallways lined with stretcher beds, with la Sala de Choque (the Shock room) as a separate salita with four beds for patients in shock. In Choque, urgent minor surgeries (like our thoracostomy) and CPR are performed, comatose patients are held, and in the middle of it all, a bespectacled senior doctor sits on a stool, ceaselessly churning out reports on a typewriter.

In the next few days in Las Urgencias, I attempted to take blood from a patient using a rubber glove as a tourniquet while transferring the blood into a test tube because vacuum tubes are not available; did an assessment on a comatose patient we were later told was pronounced brain dead; and correctly diagnosed a man with COPD from a distance (and only finding out later that the “EPOC” written on his chart was Spanish for COPD!)

I also spent many, many hours straining to just hear the doctor’s report. Not only is the noise level in Urgencias quite deafening at times, but I could not quite get used to the affect of the ER doctors… They would be lecturing a patient or delivering notes to their resident, when suddenly, with zero change in tone and definitely not even the slightest indication of eye contact (literally, they can have their back to you), they would be asking me a question on what process was contributing to the patient’s renal failure. I could not decide what was most challenging: knowing the answer to the medical question, understanding their rapidfire Spanish, or just frickin’ knowing when they were even talking to me!

For those reasons, I approached the exchange program about changing my placement. I loved the variety of cases I was seeing in Las Urgencias, but I had to admit that the atmosphere was not the most conducive to my learning. A senior Neuro student advised me to try and procure a placement with a Doctora in Pediatrics who was apparently “muy amable y tiene mucha pacienca con los estudiantes,” which was exactly what I needed!

Thus, from Neurology (in which I was interested but had no experience)
to Emergency (in which I had a glimpse of experience but little interest)
to Pediatrics (in which I have neither experience nor interest)…

Who knows where I’ll end up next!

But I’ll keep you posted ☺

Hospital Chiapas Nos Une