Hospital de los ninos - Rotation #1

Each week, I get to go on a different pediatric rotation, in different hospitals or in different specialties. The rotations are:
- Hospital de los Ninos (Children's hospital):
-Infectious diseases, Nephrology, Pulmonology, and Surgery
- Hospital los Andes: a pediatric clinic in El Alto (the poor neighborhood of La Paz)
- Servicio de Adolescentes: a clinic serving pregnant adolescents in La Paz
- Hospital Metodista: a methodist hospital with a pediatric ward
- Cardiology: a 2 week rotation with a pediatric cardiologist

The first 2 weeks we are already assigned rotations but I get to choose the next 4 weeks after that. Any suggestions?

This week, I was assigned to the Hospital de los Ninos, with Dr. Velasco in the infectious diseases ward. It is the only hospital to which I can walk to, and its about a 20-30 minute walk from where I live. The first day, I walk up to the 4th floor of the hospital and enter the infectologia ward - I immediately meet Dr. Velasco and his group of medical students and residents, and we begin rounds. The ward itself is quite small, with 14 beds, 2 beds in each room. The upper half of all rooms are glass though, so everyone can see each other, and the nurses can keep an eye on all the patients at once. The first child we see is Josef, a 5-6 year old who is diagnosed with hidatodosis (Echinococcus granulosa) - a parasitic infection that is common in Bolivia. It is usually contracted in children through dog feces which are left everywhere in the parks and streets of La Paz, within the reach of children. Once the parasite is inside the child, it lays eggs, which then create a cyst inside the child, usually either in the liver or the lungs (in this case it was the lungs). There are no symptoms until the cyst is large enough to impair function of the organ, at which point the child usually goes to the hospital, where they do an X-ray and see a large cyst in the lungs. Unfortunately, at that point, the only treatment is surgery (removal of the cyst) and this morning I saw them wheeling a crying Josef out of the infectologia ward to surgery. After seeing the patient, Dr. Velasco spent a few minutes talking about public health and regulations and its implications in the health of Bolivian children. If there were regulations that required owners to pick up their dog's feces and if street dogs were taken of the streets, then maybe the incidence of hidatodosis in children would decrease dramatically. Unfortunately, most people here get dogs for protection, and do not have enough money to feed them and take care of them. Next, we saw a little girl Victoria who had Leishmaniasis. Today, we did rounds again and I realized that there were 6 kids with Leishmaniasis in the ward. The infection can be visceral (inside organs) or cutaneous (cutaneous lesions). All these kids had cutaneous Leishmaniasis which is characterized by a lesion that starts out as a papule, turns into a nodule, and eventually develops into an ulcer with a center depression. The lesions do not cause any pain and continuously grow bigger, even as the center heals.
Dr. Velasco had me do a summary of a clinical history of one boy with Leishmaniasis that I had to present today along with all the other Bolivian medical students. The boy is 2.5 years old, who presented with a large lesion on his cheek 6 weeks ago that grew over the course of a few weeks. His mother tried different creams that she had around the house but the lesion did not go away, and 4 weeks later, developed a serous secretion from the lesion. The mother took him to the local clinic in the jungle (where they live) and the boy was referred to Hospital de los Ninos for treatment of cutaneous Leishmaniasis. What is interesting is that many of the patients in the infectious diseases ward are not from La Paz, where many of these infections do not occur, yet La Paz sees many of them solely because most cases get referred to La Paz, especially Hospital de los Ninos, which is the largest children's hospital in Bolivia.
Another case that we saw that day was a boy who had bloody ulcers inside his mouth and on his lips. His mother said he has had a fever for the past 15 days, had difficulty swallowing and breathing, but no soreness or lumps on the neck. The doctors went in to see the child and came back 5 minutes later with the diagnosis of Diphtheria - one in a few in Bolivia in the last 15 years. They immediately called a meeting of all the medical students and nurses, advising everyone to use all precautions necessary when caring for the child, especially since even vaccinated people can be carriers of the bacteria and spread the infection to other immuno-compromised patients. They also called doctors in other wards and hospitals to see whether there were any other cases of the infection. When I came in today, they mentioned how they contacted all the family members of the child and prescribed them antibiotics in order to prevent the spread of the infection. The boy looked utterly miserable, with sad and depressed eyes and with a mouth slightly parted that showed the bloody lesions that covered his lips and mouth.
The mother was questioned about whether he got all his vaccines when he was younger, and even though she says he did, the doctors believe he probably didn't.
The last case we saw that day was in the pulmonology ward, where a boy came in for some respiratory problems, and was found to have a thumbtack located inside his right lung that he inhaled around 2 years ago and had not presented with any symptoms until now. They performed a bronchoscopy to remove the thumbtack and now he is doing pretty well, recovering on antibiotics.

During all of this, Dr. Velasco was wonderful. At first he explained the basic points to me in English, and as I get more comfortable in Spanish, he involved me more in the learning and asks me questions as well as other medical students. the first day he taught us how to distinguish different pulmonary problems from the X-ray (alveolar vs. interstitial vs. pleuritis vs. hyperinflation) and what causes each type of pulmonary distress and thus how to treat it. Yesterday, we had grand rounds where we heard about an emaciated child with a hypothalamic pharyngioma, a little girl who burned her left hand by playing with an electrical cable, and a 14 year old girl who presented with intracranial hypertension and was found to have a large parieto-occipital tumor on the right side and also glioblastoma. Today, we presented our clinical history summaries and he gave us feedback. Tomorrow, I am presenting the clinical history of a 14 year old girl who was brought in by firefighters after they found her in an inebriated state with signs of physical and sexual abuse. Teen pregnancy is very common here, even in girls as young as 13-15, who usually become pregnant due to sexual abuse either by strangers or by people they know. Older adolescents usually get pregnant because they are not educated on contraception options or do not have the power to regulate their contraception use. Dr. Uribe, the medical director of the CFHI program, works with adolescent pregnant women and she says she enjoys seeing CFHI students because she sees that there are adolescents that do have a bright future and value education.

The doctors I work with here are incredibly altruistic and do phenomenal work with the people who need it most. Dr. Velasco is a strong proponent of public health and shadowing him this week really made me realize how important public health is to a society. You don't realize how important something is until you see what occurs in its absence. If anything, these 6 weeks will really help me understand why we learn the things we learn in medical school, besides the science. It seems that many of the illnesses I have seen so far could be prevented with better parental supervision. However, as Dr. Velasco was saying today, there are no beds and waiting areas designed for parents who come to the hospital to be with their kids (often from places outside of La Paz). When they do come, they leave the rest of their kids at home, many times unattended, where they can hurt themselves or burn themselves while cooking food. It seems like a never ending cycle. Also, today, we saw a girl whose mother was by her side. Dr. Velasco asked her whether she understood what was wrong with her daughter. The mother shook her head. Dr. Velasco went on to explain the swelling in the girls legs, how they had to drain the pus, and that she was going to recover well. Then, he asked the mother to repeat what he said back to him (just like we were taught!), but she said nothing. He finally asked whether she spoke spanish and she shook her head. So he said he'll have a nurse explain everything in her language. "Quechua or Aymara?" he asked. "Aymara" she answered. When we walked out of the room, he turned to me and said "None of us speak those languages" and Maria, a medical student mumbled "We really should learn." It's interesting to see the same things occurring in two very different countries, which are usually thought of being worlds apart. It was very similar to a Spanish patient who doesn't speak English, except here Spanish took the role of English.

Terribly sorry for the long post but I thought this would be interesting to most of you. I promise future posts will be a little more organized...maybe.