First few days in Guatemala

What a wonderful world we live in. A person can be in a totally different world in just a few hours.
My first couple of days here weren´t too exciting. I didn´t head out to the beach like I had originally planned but stayed in Guatemala City instead. On my first day here I participated in my favorite recreational pastime, sitting on my ass doing nothing. It was while I in the Central Plaza, engaged in this strenuous activity, that I met a gentleman named Hector. He´s a rural schoolteacher who was in the city to get some dental work done and file a dispute over his pay. Neither of us had much to do during the morning so he offered me a walking tour of the city. We ended up wandering around for hours practicing Spanish/English and admiring rows upon rows of dead animals in the market that tourists are warned not to go into. After a great lunch we parted ways and I ended up spending some time at the typical tourist sites. My second day was spent doing much of the same, with the added excitement of having my pocket picked on the city bus. They didn´t get much money but stole a sizeable chunk of my pride. In 20 years of traveling to somewhat sketchy places I´d never been robbed. Cest la vie. By the third morning my lungs were starting to feel like they´d been put through a meat grinder due to the pollution so I hopped the bus to Antigua.
I had forgotten just how beautiful this town was. There are a lot more tourists than I remember seeing 13 years ago but it´s still an incredible place to visit. Much of the city was destroyed by a large earthquake 200 years ago and several since, leaving some great ruins to visit. A luxury resort was built on one of those sites so people can enjoy crumbling walls for only $140 per night. Unfortunately my stomach started feeling a bit bad last night so I downed Immodium and Cipro and headed to the farmacia to stock up on gut goodies. An American woman stopped me at the counter and insisted that I try Xanax for my ills. She said she was a paramedic and gave it to her patients. Then she pulled out a blister pack of Xanax and offered it to me. She added that she also had a supply of morphine if I so desired and that it was all okay since she was a paramedic. Rule number 17 of international travel, the tourists are often far more interesting than the locals.
Well, it´s about time to head to the market, this time with my money in a safer pocket.

Last RUOP Journal

Journal 8 – July 8, 2006

It’s good to be back. Although leaving the clinic was pretty tough. I really felt like I belonged there, at least in the clinic, not necessarily the town. They even had a going away potluck and bought me a gift.

The kind of medicine practiced there is exactly what I’d like to do. The bonds formed between the physician and his patients make it a highly rewarding experience. The doctors and staff don’t seem to mind putting in the extra time and effort that it takes. There seems to be a higher level of commitment to their patients, probably because they’re related to, or at least friends with, most of them. I didn’t see this level of care at Group Health.

So am I getting ready to pack everything up and move to Cathlamet? Not quite. I was getting pretty tired of the area. It doesn’t have much to offer in the way of activities and there’s little diversity to speak of. Toward the end I started to spend more time with the ex-hippies out in Skamokawa. But the people of Cathlamet are wonderful. Maybe a bit conservative but refreshingly unpretentious.

So the big question is, can I find a place where this kind of medicine is practiced but still enjoy some of the life that a place like Seattle has to offer? Well, I still have three years to figure that out.

Last words of wisdom: If you’re ever in Cathlamet stop by Janet’s and get the Dungeness Crab and White Cheddar Omelet. That’s about all I have.

Journal 7

Journal 7 – July 5, 2006

I’m starting to get to know some of these people pretty well, or at least parts of them. Like MW’s knee which I’ve pumped full of Synvisc twice now or SG’s gouty toe. Funny, I don’t always remember names but I can remember problems. I bumped into a patient in the lounge one evening and again in the grocery store the next day. We had good, long conversations but I just couldn’t pull his name up from my memory. All I could remember was that he survived bladder cancer and has a stoma. Just running out of space I guess. I don’t know how I’m going to squeeze another year of classes in there.

We had a great 4^th of July here. Thankfully, nobody got hurt. The pager didn’t go off once. It gave us plenty of time to stuff ourselves full of burgers and ice cream and then blow a bunch of stuff up. Dr. Wright is a completely different person around a bag full of fireworks. The only bad part about last night was getting up at 5 this morning to go do rounds.

Kayaking in Skamokawa

The town of Skamokawa














Steamboat Slough





















more Steamboat Slough

















Skamokawa Creek outlet to the Columbia River

Journal 6

Journal 6 – June 30, 2006

It seems like they saved up the unusual cases just for my visit. I was expecting 4 weeks of otitis media and diabetes care. Now I can add transverse myelitis to the list. One of our patients is in the hospital right now paralyzed from the neck down with no apparent cause. The plan was to do an LP on Thursday to find out what happened but, the time I left on Friday, it still hadn’t been done. We thought the neurologist planned on doing it at noon on Thursday but found late that afternoon that he hadn’t even visited the patient (that he early said was the most serious neurology case in the hospital). When someone was finally able to get in contact with them he stated that the neurology department doesn’t do LPs and it would have to be done in radiology under fluoroscopy. Radiology said they couldn’t do it because they were going home. As if things weren’t bad enough for this lady. Being bounced around within the bureaucracy had to be frustrating.

Little obstacles like this seem to be quite common in Peace Health. I’m beginning to wonder if it’s the same in all large healthcare organizations. Is this my future?

Last note for the day: ambulances and people who get motion sickness don’t mix!

Journal 5

Journal 5 – June 27, 2006

This has been a pretty sad weekend here in Cathlamet. One of the volunteer EMTs drowned trying to pull someone’s jet-ski up from the bottom of the river. He was diving alone and just didn’t come back up. They still haven’t found his body. This kind of thing hits a community this small pretty hard. Not too many people were talking about it but the mood in the clinic has been noticeably gloomier the last two days. Just two months ago another EMT was crushed between two vehicles and passed away. I met his parents in the clinic this morning and was able to talk with them about it briefly, although I really didn’t know what to say. Nothing here has made me feel more like an outsider than listening to this couple talking about a tragedy that’s affected everyone else so deeply.

Otherwise, things have been pretty much par for the course. The 18 yo with the heart problem is now in OSHU but his bed in the ICU has been taken by another one of our patients that has severe aortic valve stenosis. Dr. Wright was quizzing me on his EKG interpretation and I had to admit I’d only gotten 1/3 of the way through the EKG book he gave me to read. Although I did manage to salvage some dignity by catching an unusual T wave. Why can’t they pimp me on something I DO know? Ask me anything about intravesicular bacteria. Well, maybe not anything. Micro was such a long time ago.

Tourist for a Day

I thought I deserved a day at the coast so I cruised out to Long Beach and Cape Disappointment. I can't believe I'm getting paid to be here.













North Head Lighthouse




















Dead Man's Cove

Cathlamet Internet

Cathlamet's best internet access, the marina parking lot. You just have to be sure to get a shady spot.

Journal 4

Journal 4 – June 23, 2006

The last couple of days have been pretty mellow. Yesterday was a long one but there was nothing overly stressful. The afternoon turned out to be a mostly mental health afternoon. A lot of the local residents seem to turn to Dr. Wright for counseling even though mental health services are available. I like the fact that he doesn’t just dish out meds without really talking with the patient.

So I asked Dr. Wright about abortion yesterday on the way back from Longview. He, as well as the other practitioners in the clinic, is firmly against abortion. Women who want an abortion have to drive 1 ½ hours to Portland to get one. There’s a Planned Parenthood in Longview but they don’t offer the procedures. Although I respect the doctor’s right to not perform abortions it still troubles me that women have to go so far out of their way to get a legal procedure. I’m sure there are places where it’s even more difficult.

I was strolling through town today doing some street research for my III and people recognized me and said hi. That’s such a weird feeling. I can see why people like living in a place where everyone knows each other but, on the other hand, there’s a lot to be said for anonymity.

Cathlamet town pics

Journal 3

Journal 3 – June 21, 2006

Things have been hopping at the clinic. I can’t count the number of ambulances we’ve seen come through in the past 2 ½ days. Well, that’s not true, there’s only one ambulance, it just came a lot. The patients are brought to the clinic first for evaluation/stabilization before being taken to the hospital in Longview. Most were things like chest pain or stomach pain but one yesterday was a mystery.

An 18 yo was brought in because of severe orthostatic hypotension. His BP was almost undetectable when he sat up. He had been outdoors camping over the weekend and we assumed he was just dehydrated. So we started two IVs and pumped fluids into him but, after two bags, he was still hypotensive. As a matter of fact, he was cyanotic when he sat up. His ECG and labs were pretty normal so we sent him on to the hospital for an echo and heard nothing more about it before I left for the evening.

This morning during rounds we checked the computer before seeing him and got some pretty distressing news. He had an ejection fraction of <10% style=""> The cardiologist said he had never seen a case this bad in someone this young.

So giving him so much fluid (5 liters by the time he got to the hospital) was exactly the wrong thing to do. They spent all night in ICU diuresing him. The ARNP who saw him at the clinic was pretty distressed that she did the wrong thing but I don’t think she did.

So we started the day having to explain the problem to the kid and his mom. I can’t believe how tactfully the doctor presented such a dire case. Anybody know where I can buy some of this kind of tact?

Journal 2

Journal 2 – June 17, 2006

Part of my job here is to go with the doctors to do hospital rounds in Longview (about ½ hour away) each morning. The three practitioners rotate but I get to go every day, which makes for some pretty long days, although they recently rearranged their schedules so they don’t leave until about 6:30. Since St. John’s Hospital doesn’t use hospitalists the clinic docs direct their patients’ care throughout their hospitalization. I think I prefer this over the hospitalist system although I’m sure I haven’t had enough experience to be able to judge either. One drawback is that the doctors have to make the hour-long round-trip at least once a day and may have to change the clinic schedule at the last minute.

This week our schedule got a bit wacky due to a delivery on Thursday. We went to the hospital to admit the young woman on Wednesday night and stayed in the on-call rooms expecting to deliver early in the morning. But by nine she was only at 4cm so we headed back to Cathlamet to see a few patients. The call to get back to the hospital came about two hours later. I’d never seen a delivery before so it was a pretty amazing experience. I didn’t really do much except help stitch her up afterward but it was still memorable and I got to see my first Babinski sign. After finishing up there we headed back to the office and performed a vasectomy (not on the father). Quite a contrast in procedures for one day.

Interestingly, on the same day as the delivery the county made the final decision to stop doing Ob. at the end of this year. Last year they payed $60,000 in Ob. malpractice for the two physicians and only brought in $20,000 of reimbursement. Now women in Wahkiakum County will have to go elsewhere for care if they want to have children. It’s a shame but I guess it’s a sign of the times.

III Journal 1

Journal 1 – June 13, 2006

I came here with a sort of romantic idea about the rural clinic being continuity of care heaven. So far it’s been even better. During my first two days we saw maybe two patients the doctor didn’t know personally. Some had been coming to the same clinic for decades. So Dr. Goldstein wasn’t making all this up.

Dr. Wright and I had lunch at a local café and he noticed that everyone there was a patient of the clinic. He seemed to know everyone we met by name. As I was mulling this over this evening I realized that, although this makes for more effective care in the clinic, it also puts a lot more pressure on the doctor to perform well and to be professional even when “off the clock”. A doctor in Seattle could walk around their neighborhood for hours and not run into a single person they recognized. Even so, I still think I’d choose the intimacy I see here over anonymity. I could always drive to another town if I wanted to stir up trouble.