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Mexican Community Medicine, Part 1

I almost missed the clinic entirely. It was a steep, narrow, 2-lane mountain road with ramshackled houses and buildings on both sides. With the grade and the glaring sun at this altitude blinding me through my too-dirty windshield at 7:30am, I was lucky to see a sign on a building on which the word “Dengue” stuck out amidst the text — this had to be it. I pulled into the dirt/rocky driveway and through the rusty white gates, trying in vain to park my Texas-plated, double-cab pickup into a parking lot made for Volkswagens. As there were still no signs which carried the name of the clinic, I thought maybe I was in the wrong place, but soon I saw a classmate arrive and felt relieved. There was a talk going on about condom use, but from my vantage point, most of the people I saw listening were elderly. If one of these men had a condom in their wallet (a point stressed not to do by an monotonously scripted talk) on the off chance they may get lucky, I certainly didn’t want to know. I would find out later, specifically when it was my turn to talk about AIDS prevention–in Spanish–that these talks were part of the deal: the government pays for your visit and you listen to public health lectures so they hopefully don’t have to pay more later.

They split us up into groups, some with doctors in consultorios, or exam rooms, and others in the nurse’s station. The first shock was the room itself. A rusty exam bed with the thinnest of cloth sheets covering a nearly rubbed-clean, flattened black pad was the first thing I saw. There were huge stirrups winging off the bottom, one of which was broken. Even in the exam room, the sounds of roosters crowing would be audible all morning, which added to the ‘rustic’ nature of the setting. The doctor’s desk was a typical, industrial green metal institutional variety with a fake wood top, a squeaky well-worn chair that one would barely consider garage sale material was comfort compared to the bare-metal chairs for patients. I should mention that the “normal” course of seeing a patient in Mexico is for the patient to come into the doctor’s office to talk. Only if the doctor feels an exam is necessary is one given; the main point is the dialogue between doctor and patient in a front-behind desk way, not the exam table way. Patients are absolutely, positively unquestioning in what their doctor tells them, at least to their faces. I am constantly referred to by patients and proper doctors alike as “doctor,” which is uneasy. Even the patients whom I know know I’m a student still call me doctor, because for them, since I know so much more than they do about medicine, I deserve the title anyway. I only say this to give you an idea of the mentality of the public at large. We certainly don’t go calling each other “doctor” on campus or be referred to by that by our lecture professors of course, so it’s a change.

Most of the patients are extremely poor. They arrive by walking and/or bus, waiting patiently on a first-come-first-served basis to get a ficha, or numbered ticket. Mexicans are often called lazy because their culture does not really value time pressures, but these people are up at the crack of dawn for something as simple as a blood pressure check. For those that do have appointments, it’s often way too far in the future to make it worth a damn, such as the uncontrolled, in-denial diabetic (”why should I have diabetes if I don’t drink Coke anymore?”) with a lab reported glucose of 350 from last week who is given some metformin and told to come back in 2-3 weeks. Since everything is government (federal or state) paid, there are strict prescribing guidelines. Amoxicillin, ampicillin or erythromycin are given 90% of the time an antibiotic is needed, almost regardless if that’s the best abx for the job. If an anti-inflammatory is needed, naproxen 90% of the time; if it’s serious, then the remaining 9% would be something gut-wrenching, like diclofenac. Runny nose or cold symptoms? Why chlorpheneramine, of course. There is no care in telling patients what common side effects they might experience (particularly w/NSAIDS–casually saying “take it with meals” is NOT the same as “this might make your stomach hurt”) and pills are dispensed (as everywhere in Mexico) in the original packaging from the drug manufacturer, so there are no helpful stickers and/or informational printouts from the pharmacy. In fact retail pharmacists are not pharmacists, but 7-11 clerks with a slightly widened vocabulary; pharmacy as a career proper seems only to be confined to the lab and hospital.

On top of our week-long rotation, we have to go get journal articles, write the book-report style patient histories, by the end of the week (very similar to the style that most MS2 or MS3s start having to do in the US but of course, in Spanish), so this new schedule that doesn’t involve a lot of classroom work is a difficult adjustment, particularly when you factor the commute, etc. I will write more tomorrow, but for now, I wanted to pen this introduction as the start of a 3 or 4 part series. I hope you enjoy.

Too lazy to tackle but you can dance?

If I were a coach in the NFL and I saw my running back or receiver slow down as they were crossing the end zone to be “cool” or “cute” the way the Chargers did today twice, I would have slapped that clown upside the head like a little bitch and said “Don’t you ever, EVER slow down on your way to the end zone…EVER.” I’d do the same thing with a batter slowing up at 1st base because he sees the shortstop field it and it seems an easy out. One never knows, and they have a job to do. It’s not like they’re working for minimum wage ya know.

To be fair, I was yelling the same thing at the Packers defense when they slowed up twice because an Eagles offensive player “looked” like he was going to score. If you’re close enough to dive, you may decide not to dive and I can respect that, but putting on the brakes well before the play is done is inexcusable.

On another subject, I was watching some college games today (I didn’t get to see Thursday’s sweet ass-whuppin’ UT put on A&M yet again) while cleaning up, and I noticed something was pleasantly missing: celebrating after every play. Useless celebrations after every play has long been a pet peeve of mine. If a defensive tackle flattens the quarterback on a sack, you betcha he’s gonna get up and pump his fist–that’s a special play. If a cornerback plucks a pass for an interception, runs, gets tackled and starts jumping up and down celebrating on his way back to the sideline, that’s expected. But when a wide receiver catches a normal pass or a running back picks up 5 yards, or a cornerback intereferes with a throw to his covered man, or special teams kick return unit stops the returner at the 30, that’s their job. That’s just another down, another good play. It doesn’t deserve a frickin’ pantomime of God-knows-what kind of epileptic contortions. Line up, get ready for the next play, and take your Dilantin if you have to.

New House!

“to a dee-lux house….in the skyyyy, well we’re movin’ on up!”

We finally signed on our new house! We are finally going to move out of this shithole (which I plan on advertising on UAGMD and the NASA office as soon as I can Obviously with addition to family we need more space, but as Jenna can attest, this place is LOUD with all the buses, traffic, noisy-ass ‘Rican neighbors who Lord only knows how they are still here because they can’t be passing… my chest hurts when I take a deep breath because of the soot from all the vehicular exhaust (evident on many items that don’t get dusted all the time as well, and one’s cilia/mucosa can only clean so much). We can’t get out of here fast enough. As soon as biochem is done with, movers will be here the next day to get stuff transferred. Electricity is already on and waiting; we’ll see how much of a hassle it is for cable, phone, etc.

To see preliminary photos that Claudia took w/the realtor, go to my brand new flickr page with this album. With the problems I was having with Gallery (where the photos are on my site, in my control, and therefore able to be massacred by me too), I decided I’d give flickr a try. It’s all the rage (has been) but I avoid such obvious ‘memes’ and ‘net fads. I think flickr kinda sucks in lots of ways for someone who’s used to having complete control, but I have to learn to give things up in this area if I want to have things work and not get stressed trying to “fix” something at the expense of studying.

Let me know what you think about the house!

Black Friday

I didn’t even realize today was Black Friday until I saw it on the news. Did I miss a national memo? Is my hypotryptophanemia (see yesterday’s entry) making me forget something obvious? A right-wing person I know blogged that he thought Black Friday sounded “[not] very Christmas-y to me. Sounds kind of perjorative and negative to me.” Aside from the knee-jerk “perjorative” comment (the last thing I thought was anything having to do with African Americans), I have to agree: there is nothing “Christmas-y” about waiting in line at 4AM at a Wal-Mart …. let me repeat that so it can sink in this time …. Wal…Fucking…Mart, not Nordstroms or hell, even Toys-R-Us……waiting in a line with people who are acting like ferrets on crack waiting to get into the store or (more like me) pissed off zombies who can list 100 things they’d rather be doing if you gave them 5 seconds but they are there because [insert spouse or family member] conned/threatened/blackmailed them into going. (yes Virginia, that’s a run-on sentence)

I have already alerted my family to the fact that if it can’ t be bought by a Mexican Indian (meaning indiginous Mexican, not an emigre from Bombay) it isn’t going to be given. As much as I’d like to not be a poor student once again to be somewhat more generous with presents, I won’t miss the buying frenzy that starts this weekend. There are some advantages to being here; not having to deal with “Black Friday” is one of them. I’m just waiting for someone to come out with the “Grandma Black Friday Smackdown” video from the inevitable assault-and-battery incidents that always occur today trying to get the hard-to-get toy fad or $10 DVD player.

Happy Thanksgiving

(drafted, completed later, and backposted to the original date)

Happy Turkey Day! Mexico obviously doesn’t celebrate Thanksgiving (although they recognize that Americans celebrate dia de pavo, missing the point of the holiday), so this is definitely a first. In addition, this is one of perhaps 3 Thanksgivings in my entire life that I didn’t celebrate it with my family. The only exceptions have been when I lived in DC/Reston and one other time. I guess I always lived close enough where not coming home wasn’t a good excuse and I didn’t have spectacular competing plans.

Now, as has been the case for a couple of years, we’ve sometimes needed to do things as our own family proper, and we rang in our first solo Thanksgiving with a roast chicken! Yes, my serotonin levels were artificially low due to no turkey this year since there is no way to get a frickin’ turkey unless you buy this huge monstrosity of a bird that is overkill for 2-3 people (not to mention that won’t fit in our “E-Z Bake”-sized oven). You can’t just get a breast from the frozen section or even from the butcher (at least not the ones in the supermarket; I wasn’t brave or free enough to look elsewhere). Having a ready-to-bake turkey loaf in a foil box with a gravy packet is most definitely an alien item here. Anything that means convenience is not to be found, since people here have all sorts of time since they don’t really value long work hours. If one has disposable income, it’s not wasted on convenience food, it’s spent on someone to do the work for you. Seeing as we had neither time nor money to burn, we had chicken.

I had J over so we could study, so that was a good time. She was also missing her family, so it worked perfectly. There was food (mostly carb-y sides of course, but fresh steamed green beans, too), football, and studying. 2 out of 3 ain’t bad!

Genital Anatomy and Sandwiches

I am up late studying for our third written section for gross anatomy, which is the thorax, abdomen, and pelvis. I’m decent with thorax, moreso the heart and I’m pretty confident about abdomen except for the esoteric vasculature and innervation. I don’t know whether it’s a mental block of mine not to be able to learn the autonomic nervous system or whether the teaching was so bad in this area, there’s no wonder I don’t know it.

The pelvic cavity, however, is impossible for me to get. It’s not the significant variations of anatomy for men and women, it’s the imaginary spaces, planes, floors, dividing structures. You have these everywhere in anatomy, such as the 6-some-odd neck triangles which are a PITA to memorize but straightforward in concept, but the pelvic ones are impossible for me to visualize 3D. I won’t bore the non-medical readers with examples of funky pelvic anatomy (or embarrass myself by exposing my inability to grasp what are probably simple concepts for others), so instead I’ll share some humor regarding this “special” area I have found in my studies this weekend.

I bought Clinical Anatomy Made Ridiculously Simple during the 1st part of anatomy. I was armpit deep in the brachial plexus (bad joke for those that get it) and a friend mentioned how the Neuroanatomy version of the same series helped him, so I got this. Mistake. I don’t think there was but 5 things I said, “Hey, that’s a good way to remember such and such” from this book, but I paid $24 for it (twice what Amazon sells it for — retail for specialty books from America are often list price + import fees if it’s not a “friendly” publisher or high-volume) so I keep trying to get some mileage out of it. The drawings, mnemonics, and “scenarios” are preposterous.

This example takes the cake. The urogenital triangle (imaginary triangle which contains the genitals but is in front of the anus) is described as “half of a deli sandwich” as a way to remember:

The bread of the sandwich represents the two fascial layers of the urogenital diaphragm. An olive (bulbospongious m.) rests on the sandwich and a toothpick (urethra) extends all the way through the olive and sandwich…. Inside the sandwich, is a round slice of salami (sphincter urethrae m.) which surrounds the urethra and has been pierced by the toothpick. For the female, stick an extra toothpick in the olive to represent the vagina. Also inside the sandwich is a piece of bacon (deep transverse perineal m.)…in the male, two capers (Cowper’s or bulbourethral glands) are also inside the sandwich.

I swear I couldn’t have made this up if I tried. There is a picture but it’s of little help; it’s just a pencil drawing of a dissected pelvis with a sandwich (with olive and toothpick) sitting on top. This is more work remembering the crazy-ass analogy than to learn the anatomy. I can see myself on the USMLE, “Crap! Is the olive deep to the bacon or vice versa?” After this gem, the author then likens the two anal sphincters to doughnuts of different proportions. Please, please: save the food analogies for some aspect of the limbs or whatever. Don’t make food analogies with the anus, genitals, urinary tract, etc. That’s just bad form (unless it’s a 9-1/2 Weeks kind of thing…)

The last bit of genital nonsense has to do with the penis. The penis, like many structures has fascia or membranous “packaging” that keeps things together and/or separate. It has a superficial fascia, which contains the outer vessels/nerves for the skin, and it has a deep fascia for the erectile tissue called Buck’s fascia (I guess after the guy that discovered it). Buck’s fascia. You’re hard pressed to get more “manly” than Buck. Maybe there’s a Bubba’s sphincter, or a Mack’s canal. It wouldn’t be right to say, “Melvin’s fascia,” ya know?

If I wasn’t so tired, I’d come up with some witty ones, but I’ll leave that to the commenters, if there’s even anybody that read this far. I’m blogging about penile anatomy and genital sandwiches, so if that’s not a “Danger Will Robinson!” indication for me to go to bed, I don’t know what is. Buenas noches.

Avian Flu has reached California!

I didn’t believe it, but this picture proves it:

Clearly the close contact had by so many tourists means that through untold return flights from this population-dense attraction means that the pandemic has begun. Aiieeeee!!

Dead Ringers

Yet more doctor horror stories:

SEATTLE (Reuters) - A jury convicted a Seattle-area gynecologist on Wednesday of four counts of rape in the sexual assaults of two patients.

Charles Momah, 49, also faces civil lawsuits in which women claim that they were also sometimes deceived into being examined, operated on and sexually fondled by his twin, Dennis Momah, a general practitioner who is not certified in obstetrics and gynecology.

During Charles Momah’s criminal trial, prosecutors said he sexually preyed on vulnerable, desperate women, many of whom had few other places to get gynecological care or were addicted to drugs.

I think when they send these slimeballs to jail (16 years max sentence) they should distribute plastic speculums to all the men in their cellblock to give these two a proper welcome when they arrive.

arrgh!!! Damned 24 hour news media

I need sleep but I must vent!!!
I am a cowboys fans. I am the type that will tape the games and turn off TV’s to keep the score a “surprise” for later..
mock me if you must.
I tivo’ed todays MNF phil vs dallas. a

I was traveling back from work at the hospital tonight at 11:30pm mon. got in the car, turned it on

I had left it on espn radio that morning, so the radio turns back on when the car cranks.
I turned to changed the station, as my finger moved I hear the radio come to life, then the FIRST THING out of the speakers….:

“…. and so what do you think about that donovan mcnabb interception that won the come from behind game for the cowboys?….”

CRAP. too late

dammit, this medical stuff is a sacrifice!!!!!

Genetics Haiku

I have my final (and unfortunately, only exam grade) in Medical Genetics at 3pm today. After days of ineffective studying, I have decided to pen some haiku to help balance my chi in preparation for the exam.

Recessive disease
With consanguinuity
Hillbilly patients

X-linked recessive
Mothers carry mutation
Sons can not escape

Hardy-Weinberg math
Okay if square roots work out
No calculator

Oncogene two-hit
Cell cycle regulation
Mitosis can’t stop

Genetics word games
Too many definitions
Mostly common sense

Prof knows not her stuff
Study on my own I try
Procrastination

Oh well, I thought I’d try anyway…