Hi everyone!

What an *amazing* trip! I know we've only been back for a few weeks, but I miss you all already.
If you have a moment, I wanted to share with you a photo journal of our trip on flickr. If you click on the "details" tab you can see the full captions beneath each photo. Please feel free to comment on or download any of these pictures.

Here's the link:
http://www.flic/kr.com/photos/elizabethchao/sets/72157601982586898/

Enjoy!

Elizabeth

Melissa's post

I can’t believe this is my last full day here! I started writing this blog entry during week 2, but got caught up with all the other exciting stuff to do in Oaxaca that I didn’t get around to posting until now, so I guess I’ll just do a quick reflection on the whole trip.

Centro de salud Xochimilco: It was great to have the opportunity to see a centro de salud—how it runs, the resources they have, the programs they offer to patients, how it compares to clinics in the US, etc. I spent most of my time in the consultorio with Dra. Salva. She was very nice, and willing to answer any questions I had, but I did have to put in some effort and really take the initiative to ask questions or find out about other things I could be doing, otherwise I would have just been sitting there watching her the whole time. I guess after spending a year as a patient advocate, I just felt like I wasn’t doing much or that I would be in the way if I asked to do certain things. I also attended a diabetes education class and one of the dengue walks, both of which were very interesting and demonstrated their emphasis on preventative medicine and community involvement.

My week with Dra. Margarita Acevedo Cruz went well. She is a family medicine doctor with a private practice. She was very friendly and was great about showing me how to do different procedures and exams and explaining different conditions to me. The first day was pretty slow, and we didn´t see many patients, but the rest of the week was better. She has patients of all different ages, and one thing I noticed was that almost all the patients came with at least one family member. It was a pretty relaxed atmosphere too, much less busy then the centros de salud, so she was able to spend more time with each patient and more time explaining things to me, and also let me take vitals for some of the patients. Although it was kind of slow at times, it was definitely a good learning experience.

The third week I was at CRIT, which is such a huge contrast to all the other sites I have been to here. I spent most of my time in physical therapy but also spent some time with the pulmonologist/pulmonary therapists and with the geneticist. One thing that struck me was just how loving and supportive all of the families are with the kids. I’m sure there are many times that are really hard on the families, but all of the families I met were so positive and also really open to talking to me about their child´s condition. I was excited to be able to help with some of the physical therapy, and both the pulmonologist and geneticist were great about explaining what they were doing with the patients and answering my questions. Also, there were several patients that I saw several days throughout the week, so it was pretty cool to get to know these kids and their families.

I thought our trip to Capulalpam de Mendez was great. It was really interesting to hear about how the centro de salud and center for traditional medicine work together and refer their patients to the other place. It seems like such a unique situation to have that kind of relationship, and it was interesting to see how they made it work. It was also interesting to see the difference between the curanderas there and the curandera that some of us met in Latuvi, who really emphasized the spiritual aspect and importance of faith in her work.

This last week I was at Hospital Civil, which I think has been my favorite so far. I saw a knee surgery one day, and was in peds the rest of the time. The peds attending and resident are both really helpful and great teachers, and I feel like I learned so much just in the short time I have been there, and the surgery was also very exciting to watch.


Basically I’ve had a great trip and have had so much fun here in Oaxaca. My host family was awesome and really made me feel like I was part of their family. I have learned so much in the clinics, from the lectures we have had, and in our Spanish classes (Javier even gave me a private lesson on soccer terminology the last day!). It was great to be able to visit some really beautiful places and meet so many local people that made my experience here really memorable. I would love to stay longer and hopefully will get a chance to come back in the future!




Hi!!!!!! I miss you all! I get back Saturday night, so I can tell you more stories then, but I just wanted to update you on my trip. Nothing too exciting has really happened since my last email but it has been a fun couple of weeks. Most of the group stayed in Oaxaca last weekend, so we just went out a few of the nights to some bars and clubs, and then on Sunday I went with my friend Megan to this place called Hierve el Agua that has this big petrified waterfall …it’s basically this big cliff where a waterfall used to be and now the rocks still look like a waterfall. We also heard that there were hot springs there but it turned out the water was cold which was kinda disappointing. It was really cool to see but maybe not worth the 2 hour bumpy bus ride up winding mountain roads. And also someone stole my cell phone on the bus so that sucked.

I still haven’t done any procedures (sorry Romy), but my clinic rotations the past two weeks have been really good. Last week I was in this huge rehabilitation center for kids with different disabilities like Down’s syndrome and cerebral palsy and a lot of other stuff too. All the kids I met were so cute and their families were so nice. I was in the physical therapy room for most of the time and for some of the patients I got to help with their therapy. This week I have been in the big hospital here which has been my favorite so far. The first 2 days I was in the pediatric department and just went around with the doctors and residents doing rounds, so I got to see a lot of different stuff…a few kids had appendicitis, a few had fallen out of trucks (like 4 of them…so random), one kid got shot through the jaw, and a bunch of other stuff. And then yesterday I went in to see a surgery, which was really cool. A chain saw had fallen on this guy's leg so they had to do a bunch of stuff to his knee so he could walk again. It took like 4 hours, but it was fun…they had music on the whole time, and the surgeons explained to us all the stuff they were doing. And also they asked the other girl who was in there with me to take pictures so I wanted to play who’s that guy but it didn’t really work because the pictures were only close ups of his knee.

Ok well that’s it for now, but I’ll see you all soon!

The City of Oaxaca & Oaxacan Street Children Grassroots

From the window of my room I can see the northern mountains. The grassy light green edges turn into luscious dark green trees before hitting the whiteness of the clouds hovering on top of the mountain. A towel hangs from the balcony of a blue house across from our house. APPO graffiti covers the wall of the street. The Good Year car repair shop blocks my view of Centro de Salud Xochimilco. To me, Oaxaca represents diversity. A variety of topography, architecture, politics, and people all converge in Oaxaca, Mexico. A city retaining its old colonial charms (the breath-taking Santo Domingo, the bustling Zocalo, and the colorful buildings) while being influence by globalization (in the form of Coca Cola, Kodak, Good Year Tire, and Burger King).

Having lived in Iran, I can understand many subtleties of the culture here. For instance, I understand why Sonia’s hostfamily’s relatives yearn McDonald’s chicken nuggets (Personally, before living in America, I craved Meal #2 which consists of two small cheeseburgers). The conspiracy theories about the bombs found two weeks ago and the election propaganda all ring bells of late night conversations my dad and his friends had about Iranian politics. At the same time, Oaxaca is very different from anything I have experienced in the US or in Iran. The fireworks which go on at six in the morning and twelve at night, having to leave the bus because the street had been barricaded by a political organization, and the spontaneity of musical and art performances on the streets are only a few examples of what has been unique to Oaxaca for me.

So, while some aspects of the city remind me of Iran and the US, Oaxaca remains mysterious and unique in many ways. I simultaneously feel at home and like a stranger here. I have enjoyed walking around the city, talking to strangers, stopping by musical performances and art shows. I will certainly miss Oaxaca and its memorable quirks.

I am very excited about the connection we are making with Oaxacan Street Children Grassroots. The three areas we can get involved in are consultations, health education/public awareness, and medical supply donation. In past lectures we talked about the correlation between education level and health. This organization helps children from poor and marginalized families attend schools! Therefore, their goals are practical, influential, and relevant to what we have discussed. Also, I think this would be a great opportunity to add a service component to future trips in Oaxaca. I know I have learned tons here, so it feels great to be able to give back to this community. To find out more about the organization, you could talk to Ann, Felicia, Jamie, or me. You could also visit the center if you have time (it is on Crespo, south of M. Bravo). Or you could visit their website (www.oaxacastreetchildren.org), which is unfortunately down currently.

Weeks 1-3: Belated Comments

Disclaimer: So I have to admit that I did not actually look at the blog until this week (I know, I’m a horrible person and will never get into med school), and I wrote my entry before I read what was already posted. I think I misunderstood the purpose a little – I thought it was more reflection and less feedback. Since I already wrote it, I’m just going to post what I have. I’ll post again later with more specific feedback since that seems to be what everyone’s doing. Sorry it’s so long!

Centro de Salud – Xoxo

I spent the first week of the program at this clinic which is about 15 mins from the city center by bus. (I think it’s somewhat similar to a lot of the clinics that participate in the Patient Advocacy Program back home.) The first thing I noticed when Grace and I sat down to observe was the patients’ immediate comfort with the presence of two very young (somewhat useless) other people in the room. Most people greeted us with a “Buenos dias” and smile and then proceeded with the consultation without hesitation. I don’t recall anyone actually asking who we were or why we were there and only rarely did the doctor feel the need to explain. I guess there really is something to that white coat. I’ve shadowed doctors back home as well (with a white coat) and people would sometimes stare me down if the doctor didn’t immediately explain who I was. (Cultural Difference #1!) We asked the doctor about this and she basically said that the patients were used to having extra people in the room (other doctors, nurses etc.), so it’s not a big deal to them. I also found it interesting that the doctor did the admitting of new patients and started their charts (which sometimes required an hour of her time). This involved asking the patient’s name and address multiple times, asking about a laundry list of allergies, family history, pregnancies, etc. – things that may have been better recorded by an assistant if not a questionnaire (although not all the patients can read so some would obviously have to be oral). The doctor typed everything on a typewriter in full sentences which seemed like a waste of very precious time. Considering their level of training, as well as the need for skilled medical professionals in crowded clinics, I was surprised that the doctors were doing administrative tasks.
Another thing I found interesting at Xoxo was how tactile the practice of medicine was. Because they didn’t have all kinds of fancy equipment, a lot of their work involved just using their senses. In the week that we spent with her, Dra. Carolina used every sense (except for taste – that would be gross) when examining and diagnosing her patients. Maybe medicine is more or less the same in the US and I just hadn’t thought about that way before. Either way, it was exciting to see her check the progress of a pregnancy by literally feeling the head, back and legs of the baby with her hands instead of by doing an ultrasound. I don’t know much about how good her method was but it seemed good enough! It made me wonder just how necessary all of our high-cost, high-tech stuff is. I can’t cite any study specifically but I know from lots of anecdotal evidence that there’s something about a doctor’s touch that makes people feel better. When I got vague stomach aches as a little kid all the doctor had to do was examine me and I’d feel fine . . makes me wonder if patients back home are missing out on the placebo effect of actually being touched by the doctor . . food for thought. I noticed a few other cultural differences but I’m going to wait and see if the same issues come up with Dra. Margarita before I write about them because this entry is already too long.

CRIT (Centro de Rehabilitacion Infantil Teleton)

Organization and efficiency are two factors that I consider critical to the success of health care delivery through a system, program or facility. (Sadly, I think the US health care system is severely lacking in both but that’s another blog . . .) CRIT is the epitome of both. It’s a well-planned, well-organized facility with great use of technology and a level of coordination I have never seen before. The building itself is spacious, colorful and clean. It’s surrounded by grass, a playground, and a tent for fiestas. Different wings of the building are represented by different pictures (a saxophone, a rattle, etc.) . . . everything was clearly designed with children in mind. It’s a stark contrast from the sterile, white walls and corridors of most American hospitals. (I haven’t seen a children’s rehab facility in the US so I admit I can’t compare directly.) Patients’ cards are scanned as they arrive so that doctors and therapists know exactly who is in the building. Parents often shuttle their children from one type of therapy to the next and the facility seemed more or less paperless, so each doctor could just pull up each patient’s chart online. The online charts include a picture of the child and allow the doctor to see notes from all the other departments. Most of the doctors at CRIT seemed to know each other well and seemed to consult each other about particular cases pretty often via email or in the hallways. I got the sense that the medical staff was very much a team rather than a bunch of specialists who happened to be working in the same place. Along with that came the sense that they were really trying to treat and take care of the whole child and not just each little, individual problem. There was an article in The New York Times a while ago (I forget the title . . . ) about how the high number of specialists has changed the patient-doctor dynamic. It essentially told the story of a patient with several different but related illnesses and a different doctor for each. He felt that none of them got the big picture, and he was constantly being shuttled from one specialist to another without feeling that any one person was taking care of him. I got the sense that CRIT managed to overcome with problem by really putting a coordinated team of people behind each family, something I’d like to see more of back home.
On a personal level CRIT was both sad and inspiring. Seeing the staff and parents put so much time and care into helping their children was great. When I was playing with kids in the Peds Dept at Hospital Civil I found it hard to keep playing or talking with them if they didn’t respond much. At CRIT, many of patients are completely unresponsive, yet everyone continues to play and talk and sing to them as if they understood it all. I found myself watching the patients during the consultations – some would just sit like rag dolls, others would flail around, most would make noises and faces, their eyes were usually not fixed in one place (they would jet around the room especially towards the ceiling) – and I would wonder what was going on in their heads. What were they thinking? Were they even thinking? Some of them clearly were expressing emotions but others just seemed to be making faces randomly. Obviously seeing the kids is hard emotionally, but it also messes with your concept of what it means to be human. Philosophically it’s hard to distinguish a “mind” from a bundle of nerves in control of a body. It made me think back to some “theory of mind” stuff from psychology. I don’t really have any profound conclusion about this, but it’s something I found myself thinking about a lot.
Overall CRIT was very interesting, I enjoyed it (especially the last few days), and I think I got a lot out of it, but it’s not really the place to go if you want fast-paced, hands-on work.

Hospital Civil

I’m still trying to decide exactly how I feel about Hospital Civil. I was only there for a few days, so I don’t have much to say about it yet. My most distinct memory about it is that it isn’t well-ventilated and I found myself getting light-headed pretty often. It didn’t seem to bother anyone else (including patients with pneumonia) so maybe I was just being hypersensitive. I realize hospitals aren’t necessary pleasant places to work but it was frustrating to have to leave rounds periodically to get some fresh air and water. I’ll post more about this rotation some other time.

Traditional Medicine – La Curandera

Like the rest of the group, I was curious about the practice of traditional medicine and the role of the “curanderas” in Oaxaca today. Although for me, I think the whole concept was a little less novel because I’ve seen a lot of the same types of practices and figures in India and even among Indian immigrant communities in the US. My grandparents, who lived in rural Punjab for decades still hold on to a lot of their traditional remedies. And for being married to a doctor, my Mom is still surprisingly anti-modern medicine. She will always reach for the flax seeds before the ibuprofen. As a result I’ve grown up being treated with both homeopathic meds (which all taste like sugar pills to me, but sometimes they work!) and allopathic ones, getting blessed by spiritual healers, and carrying around all kinds of holy good luck charms (mostly to appease my grandmother). Having seen and done all that I was surprised that the traditional medicine we were introduced to didn’t involve more mysticism. Although there was a small room with a large crucifix for prayer, the basis of the medicine was clearly not religion but the plants and herbs themselves. The curanderas were very clear about what they could and could not treat. Of course, all of this could be the result of their relationship with the Centro de Salud next door, or the fact that they were presenting their work to Americans interested in allopathic medicine. While it was great to see the traditional healers and the allopathic doctors working together, the center for traditional medicine didn’t strike me as being typical. It seemed like the curandera that the people who went on the hike visited may have been more typical. But I don’t really have a sense of what an “authentic” curandera is so I could be totally wrong. All in all, it wasn’t exactly what I expected but definitely still interesting and worthwhile.

I promise to never post anything this long again.

- Sonia

Week 3 Feedback (8/6-8/11)

Cultural lecture (woman from Tehuantepec):

• Interesting, but the woman was a little brash and too business-like.
• I wish there had been more time for questions and a more interactive format.
  

Traditional Healer Presentation at Becari:

• This was excellent!
• The woman and her daughter did a really great job explaining what they do. I felt like I had a much better understanding of what a curandera is after this.
  
• The demonstrations were very interesting and it was nice that they offered to use students in the demos
  

Trip to Calpulalpan:

• We should have left at 8am at the earliest, since by the time we got to the mountains a lot of things were still closed (e.g. they are 1 hour behind and the Benito Juarez museum and the church in Ixtla were closed when we stopped in these places). And it would have been nice to have been warned that there would be so many stops before the Traditional Medicine clinic, or maybe there should have been less...
  
• The road (175) isn't that windy; wouldn't recommend more than 1/2 a dramamine -- I felt out of it for the first few stops.
• The guide was excellent! Great storyteller, I wish the first sites had been open so he could have taught more.
• Traditional Medicine Clinic in Calpulalpan: the concept behind this joint traditional/western medicine clinic set-up is really interesting and was cool to see in person. The demonstrations at the traditional clinic weren't as impressive or comprehensive as the one at Becari. The tour there was very brief, it didn't feel like it was the main destination. We rushed off to lunch pretty soon after a few elected to buy limpias.
  
• Comedor de Truchas: there was nothing to eat besides truchas and spaghetti; this should be made very clear to the vegetarians so that people can bring lunches as necessary. And it was relatively expensive ~85/90 pesos if you had trout.
  

Spanish class:

• We didn't have Alfonso this week (Jose, or J. Lo instead), so the flow of progress felt interrupted.
• It would have been nice to have practiced more medical Spanish and mock patient interviews.
  

Thanks for contributing to the BLOG!

Hi all, I certainly miss being in Oaxaca! However, your stories and pictures make the place really come alive for me.

My flights back to the Bay Area were uneventful but despite 70 minutes between flights in Mexico City my checked bag did not make it on the Mexicana Airlines flight - they delivered them to the office 2 days later. I suggest that if you have a tight connection that you not place anything that you cannot live without.

I will be meeting this Friday with Ted Rico, the Director of the Centro Binacional para el Desarrollo Indigena Oaxaquena in Salinas,. This is a program supporting immigrant agricultural and service workers and their families from Oaxaca - their information is on this web page. http://www.fiob.org/centro.html

My hope is that we can establish a collaboration with them that will provide educational and service opportunities for all and the ability to understand better the issues that Oaxacans face when they emigrate to the US. I'll let you all know how the meeting went.

Our house is being torn apart today and the degree of termite damage and rot around a window we are replacing is terrible. Tomorrow we get the news as far as how extensive the reconstruction project will have to be. I doubt that I will be able to return next week.

Walter, make sure if you are not back to your usual health soon that you get some help from Dr. Tenorio.

To the rest of you, keep healthy and doing good things. Thanks for the update.

Gabe

Week 1- Lectures and C.S. America

Lectures:
The lectures have been a great doorway to Oaxaca’s health care system. Dr. Tenorio’s perspectives on the topic have served as background information for my interaction with the doctors and patients at the clinics. I think the accompanying lectures to Dr. Tenorio’s presentation provide invaluable insight into the Latino population’s relationship with the US health care system. As one of the few students here who has not participated with the Patient Advocacy Program, I find the lecture to be of essence to my gradual awareness of the similarities and dissimilarities of the US and Mexican health system. I hope future CFHI students have the chance to sit in on lectures of this sort.

Clinics:
The doctors and staff at Clinica America were very welcoming and helpful to me. On my first day, I observed Dr. Raul’s consultation’s, helped with vaccinations, and observed Dr. Luz in the “emergency room.” I really don’t think I would have had the opportunity to sit in on consultations and pap smears at clinics in the US. I really appreciate the opportunities I’ve had to sit in on consultations and medical procedures.
I really want to emphasize that the nurses and staff at Clinica America have a great sense of humor.

Home stay:
I have no complaints about my home stay family. They are very hospitable and are willing to help me with my questions. The food is great and the “aguas frescas” are amazing.

Spanish Class:
The Spanish classes with Javier were amazing. I decided to switch individual classes to focus on my grammar and vocabulary. I find that this is a lot more specific to my needs. I do miss the conversations with my peers in Javier’s class.

Free Time/Tours:
Although I had visited Monte Alban before, I found this trip to be much more structured and informative (then again, we did have an amazing tour guide). The weekdays are busy and I keep my visits to the mercados scheduled for the weekends.

Personal Reflections:
I have to say that the first week of this program was one of mixed feelings. I was overwhelmed by the amount of information we received within that period, not just from the lecture, but also from cultural differences. I think the walking and the getting use to a new country was the most tiring part for me. In retrospect, I am thankful we had the lectures with Dr. Tenorio, Dr. Garcia, and INSO, which have provided topics for my conversations with patients and doctors.

The curandera in Latuvi

I'll let Alicia do the honors of describing this experience in detail, but our time with Dona Pilar took us to another world. We were all moved by her orations and genuine belief in the power of faith and her remedios.

Weekend trip to Benito Jaurez, Latuvi and Lachatao!

I'm sure everyone will hear a million stories, so I won't go into detail. But for the record, I just wanted to have it noted that the overnight weekend trip to Sierra Norte (or Juarez) was an amazing experience. Aside from the beautiful scenery that we took in while biking (Melissa, Megan and Erik) or walking (Tiffany, Grace, Alicia, Malavika), we had some very special moments with the locals. Thanks to Melissa's soccer skills, we won the hearts of several locals which lead to tours of their homes and gardens (tasting the most delicious pears, apples and nuts). The people were incredibly gracious and very fun to talk with.

¡Pinche Tlayuda! ~ La Primera Entrada

Por fin, estoy enfermo. Hace cuatro semanas que he vivido en México, comiendo como si fuera Superman, como si tuviera un estómago de acero. Los días anteriores no eran agradables. Tal vez, sería la enfermedad a causa de las pastillas de hydrochloroquine. O acaso, sería la tlayuda (me cobró 25 pesos, pero tenía mucha grasa) que comí con cerveza y mezcal gratuito. También, podría ser el agua oaxaqueña que he usado por dos semanas para cepillarme los dientes. Cualquier razón que sería, estaba enfermo con el aparato digestivo. Tuve calentura, dolor de cabeza, dolor de ojos, náusea, vómito, molestias de todas partes del cuerpo, diarrea… lo normal, ¿sí? Pues, escuché demasiado pláticas acerca del dengue, y temí que lo tuviera. Sin embargo, he tomado no menos de cinco tipos de medicamentos, de Tylenol, aspirina, Pepto Bismol, antibiótico, hasta el Imodium. Ahorita, me siento mejor (gracias a Dios) pero todavía voy a cuidarme el estómago. A lo menos, ya no tengo la constipación. (Dr. García… si todavía estuviera aquí…)

Pues, una mera enfermedad no va a dejarme de disfrutar mi viaje aquí en Oaxaca. Me encanta Oaxaca. Me he divertido cada momento cuando he aprendido una palabra o un modismo más de español. Una de mis metas de este viaje es de mejorar mis conocimientos de conversación en español. Creo que he tenido más confianza en mí mismo. Descubrí que me gusta platicar con la gente mexicana, para conocer más de su vida, su historia y sus aspiraciones. En la clínica estas semanas pasadas, en el Centro de Salud Xochimilco, no podía hablar mucho con los pacientes, sino los médicos y enfermeras. Ellos me compartieron mucha de su perspectiva de salud. La verdad es que todavía no estoy seguro si quiero ser médico. Creo que mi vista de salud no es bastante madura para confirmar esta carrera. Pienso que aún hay algunas cosas dentro de mí que quisiera cambiar. Aun así, conocí a un hombre en Sinaloa que me dijo, “Si tocas la puerta, abrirá.” Se llama Jesús y anda por silla de ruedas y no ve muy bien. No obstante, tiene un negocio de gallos en su pueblo, y quisiera ahorrar dinero para comprar una guitarra aire. Tal vez, a pesar de mis faltas, debo animarme y sigo explorando. Ojalá que pueda recuperar mi curiosidad en este mundo, por que ya estoy tan agotado, cansado, y cínico de aprender. Espero que mi corazón suavice, que ya no sea complaciente con no hacer nada. Poco a poco, paso a paso, yo creo.

Ya es bastante con cosas pesadas. No les observaba yo con tal regularidad a los médicos en los Estados Unidos, y por eso he aprendido mucho aquí en Oaxaca, poco a poco. No me importa que no haga mucho en el consultorio, pero todavía hay mucho para aprender. Antes no sabía que el estetoscopio tiene una seguridad que disminuya el sonido. También, es interesante observar los estilos diferentes de cada médico. (Muy diversos.) Algunos me parecían muy ocupados, muy cansados, cuando tuvieran demasiado pacientes. Otros estaban más paciente y trabajaban sin tanta prisa ni frustración. Uno le interesa mucho del aspecto académico de medicina, puesto que hay mucho que leer, muchas cosas interesantes que se debe aprender constantemente. Uno quisiera ayudar a los pobres porque necesitan consulta también. Los serviría aun si no tienen dinero. Voy a tener todo eso en cuenta y pensar más para el futuro. Pues, voy a extrañar a Xochimilco, pero ya estoy listo para cambiar, para ver más de la sistema de salud en Oaxaca. Bueno, que les vaya bien. ¡Hasta luego!

Walter

Hospital Civil (Week 2 Feedback)

An unexpected experience in the Urgencia

• We are on rounds. Two beds away from her. She had been intubated (she was in a severe coma according to the Glasgow Coma Scale). Even with intubation, her abdomen and throat made random, violent movements with every breath. Nurses rush to the doctors and ask if he could check on the patient whose heart had stopped beating. One doctor climbs on the bed and starts cardiac resuscitation. After a minute, he gets off and a nurse climbs on and continues the duty. Others are standing by the defibrillator machine, waiting to move in. But they do not. The nurse climbs off the bed. The heartbeat flat lines. A doctor announces time of death, 10:23 am. Why had the doctors let the patient die without doing everything medically possible to save her? Did they believe that, with their limited resources, resuscitating a brain-dead person with a failing heart was not fair to other patients needing to be intubated who had a better chance of recovery. Initially, I was disappointed by the lack of more effort. I had always taken the side of quantity in the “quantity vs. quality of life” debate. But then seeing the lady, who finally looked at peace, I may have understood why the doctors chose to “let nature take its course.” The debate is more complex that I previously thought and I am not sure what I would have done if I were in the doctors’ place. I believe, with the limited resources and big patient population, the doctors are forced to make such decisions often.

General health problems in the Urgencia:

• Diabetes: Advanced stage (kidney failure, brain problems, gangrene, etc.
• Accidents:

1. Alcohol related (ex. falling off a bull)
2. Traffic related (this increased my already heightened fear of the buses!)
3. Work-related (ex. cutting arm while making chocolate)

• Others:

• One suicide-attempt
• Attacks against others (two men, who had protected their sheep from a thief, were attacked with knives. Although hard to believe, this is true!)

Physical condition in the Urgencia is very poor.

• The Urgencia is not big, (relative to the number of patients there) and dually serves as an ICU (as many patients stayed there for several days).
• 22 beds (way more patients; on thursday, there were 30; some where put in hallway); “Casa llena,” as an intern named Miguel calls it, is a an always-present condition in the Urgencia.
  
• There are only ten beds equipped with a heart monitor and intubation equipment.Felicia had told me that Wednesday night, two patients needed to be intubated, but all the machines were being used. Therefore, the two patients were manually intubated with the help of interns who stayed up and took turns squeezing balloons.
• Loud construction work on tuesday morning
  
• Windows open to street; early in the morning air that comes in is good, but as traffic increases, so does the smell of smog that blows in the ER.
• On the first floor, close to the ER, the ceiling is either completely gone or dangling. Water drops fall every so often from the torn ceiling. The tiles on the floor are also in ruins.

Trauma

• Doctors here are very eager to have students shadow them
• I suggested at the group meeting on Friday for students to visit this department. The orthopedic doctors see patients from 10 to about 3 in the afternoon. They see about forty to fifty patients per day.
• Dr. Gil, whom I was shadowing, explained the diagnosis of every patient that came in with me. He showed me x-rays, pointing to where the bone had fractured.
• He had a patient who had experienced a knee injury and now had blood collected behind her knee cap (Dr. Gil had me apply pressure to her knee to notice the Jell-O-like feel of it). Dr. Gil drained the blood quickly and the patient was off. I had a great experience shadowing Dr. Gil. I highly recommend it to anyone going to Hospital Civil.

OB

I saw one C-section

• Vertical abdominal cut
• Four minutes – baby & placenta were out

Just as in the Urgencia, the doctors expressed lack of resources, and especially space, for the number of patients.

• Each day 25-30 babies are born; of these, 10-12 are by C-section
• C-section is performed only when it is absolutely necessary.
• The department is very small for the number of patients. Therefore, after giving birth, the mothers and babies are discharged ASAP.

Centro de salud xochimilco (Week 1 Feedback)

Dra. Morales – She serves as a filter. Quickly trying to figure out what the patients’ complication is and what specialists and/or tests are needed for such problem. Patients get referred to specialist and sent to labs for labwork.

• A lot of paperwork is involved with her position. Every piece of paper (referral, prescription, lab work) must have patient information (name, number, address, basic health facts, etc.).

• This results in more almost half the visit spent in silence while she writes the information down.
  
• Sees patients nonstop (around 15 by midday).

• Her efforts against intimate partner abuse:

• She gathered a group of nine government workers including a psychologist, doctors, social workers, and lawyers. Doctors at Xochimilco are trained to be able to identify victims of DV and patients are followed up with psychologists who go through a thorough questionnaire to idenfity level of intimate partner abuse and file a report with the police.
• Psychologistat the clinic gave presentation to patients sitting in the crowded waiting room about intimate partner abuse (among other topics).
• Nobody forces the victim to make any decisions. The police report is simply put on file as evidence to help the victim in the future if, and once, the victim decides to “denunciar” the perpetrator.
• Problems:

• Medical school curriculum does not include detecting intimate partner abuse
• “Mandatory reporting” is ONLY in cases in which firearm is used against victim or the damage to the victim’s body takes more than three days of hospital stays to heal (According to Dr. Victor Tenorio).
  

Consultation rooms are definitely not as equipped as they are in the USA

• Patient bed sheet not changed all day long (and possibly not washed overnight).
  
• Smallroom; uncomfortable chairs; also serves as storage room (people occasionally come in during patient visits to take out documents from cabinets); no airconditioning system.
  
• Limited medical equipment

Preventative care and community health is highly emphasized here.

• Presentation EACH day to waiting room (DV, raising teenagers, etc.
• Dengue prevention – community visit (one case from the area, send nurse and administrator to surrounding community to check people’s patios, hand out abate-grains that kill mosquito larava-)
• Diabetes weekly meeting – check blood glucose levels, weight, blood pressure, give words of encouragement and health tips. Patient community. Free amazing food!
• COMMUNITY FEEL – everyone knows each other (ex. nurse talked to someone on the street about why she had not shown up to her visit, neighbors informed others of dengue problem, etc.)

General patient health conditions

• Adults:

• Diabetes, overweight, pregnancy, depression (other psychological problems)
• Lack of insurance (seguro popular)

• Children:

• Accidents, underweigh (I only saw three or four children patients)

Overall, the Centro de salud xochimilco impressed me immensely. Their mixture of disease prevention, community health and primary care was not only thorough, but also very effective.

Week 2 (7/30-8/3) Feedback

Clinic (Hospital Civil OB/GYN - 4th Floor):

• Day 1 was really slow and slightly frustrating because 2 other non-CFHI students were there and the staff stated that there should be no more than 2.
• There was no point person who was informed of our presence, which made it difficult to identify who we should work with. Eventually a 4th yr resident helped us out and an intern was patient with our questions, but it felt uncomfortable putting them in this teaching position when they're so busy already.
  
• Day 2 was better because there were many more births and more of the staff seemed comfortable with having us there.
• Day 3 was even better as we have become more familiar with the staff and various routines associated with the operations of the department. We even got to offer minor assistance with procedures.
  

Reader:

• Consider distributing the reader before school ends, so that people have time to read it before the program starts (I've had a really hard time finding time to read while here).
  

Week 1 (7/23-29) Feedback

Lectures:

• Dr. Tenorio is a wonderful lecturer! Very lively and his Spanish is easy to follow.
• It was nice to have a lecture on the healthcare structure in Mexico/Oaxaca before starting clinical rotations. The info on Seguro Popular, Oportunidades, IMSS and ISSSTE made it much easier to understand the forms in the Centro de Salud and I was able to help the doctors fill them out.
• We should make an effort to end on time, so that the homestay families aren't worried and we don't disrespect the lecturer by needing to get up to call.
• It'll be nice to have discussion time or the opportunity to ask more questions in future lectures.

Clinics:

• CS Volcanes is a great clinic. Dr. Victor Jaurez and Dra. Ana Maria Lopez Guitierrez were both very nice and patient. They allowed us to be very involved in every encounter. They seemed to genuinely enjoy having us around and thought that 3days was too short (4-5 is probably ideal).
  
• It would be nice to have 1 map with all of the clinic sites on it.
• We didn't have great directions to CS Volcanes -- should update the handout that Nick distributed.

Homestay:

• Sra. Clara Hernandez and her family are very nice. Food is great and room is cozy.
  
• The location (Joaquin Amaro 306-B) is great -- close to Becari, the gym and only 12 min from Hotel Anturios.

Spanish class:

• Alfonso is a wonderful teacher. He teaches us about the culture in Oaxaca/Mexico while doing Spanish, which is really fun.
  
• Enjoy having medical vocab, but wish we practiced it more in class along with practicing medical encounters.

Other:

• The trip to Monte Alban was really fun: very interesting and a good length of time.
• Have the cultural lectures end by 8pm.