It amazes me how a random little hospital in a remote part of the world can become a place you feel comfortable. I had only been in La Paz for two months and waking along the streets, over the bridge, buying my breakfast at the fruteria, and into Hospital del Niño became a ritual that I did every morning. The staff who had been so kind and patient with us Americans greeted us in the mornings. After the trip to Oruro with the local residents, even they were happy to get to know us and give us a call to go out on the town.

When I left I did not feel like I was leaving for long. Being a pre-med student around the medical students and residents showed me that this was a part of my life I can continue into my practicing days. I was exposed to all that I saw and learned all that I did so that I could return later on and continue to better myself and the world I am a part of.

Spanish class ended and my friends and I headed down the road to the fair the was going on. Tents were set up serving sweets, traditional foods, carnival games, and miniature replicas of everything you can imagine, from college diplomas to bedroom sets. We played some carnival games, I tried unsuccessfully to knock over some bottles with a soccer ball, then ate some pollo chicharron before heading home.

On the walk up the hill towards my neighborhood of Sopocachi we looked to our right and saw a man on the side of the road, standing around a short circular cardboard fence about 10 feet in diameter. In the middle of the circle was a guinea pig sitting on a small box . Along the fence were boxes numbered 1 through 10. The man was selling cards also numbered 1 through 10 for 1 Boliviano each. I reached into my pocket and pulled out some change that got me 5 cards. I took one and handed them out to my friends. I looked over and saw a small Bolivian boy, maybe 3 years old, watching the guinea pig next to us. I gave him a card, number 2, and he just looked at me about as aware of what was going on as I was. The rest of the cards were bought up by the small crowed that was beginning to gather and the game was about to begin.

The Bolivian man running the game walked over and placed a box over the top of the guinea pig. We all watched, unsure of what to expect. Then with one quick motion he spun the box and pulled it off the guinea pig. The guinea pig took off in the direction it was facing right into the box in front of it, box number 7. I looked down at the number 8 in my hand and quickly checked my friend’s cards for the 7. Ara was holding it it the air celebrating, so I quickly snatched it from her hand. I turned to the little Bolivian boy standing next to me and made the quick switch. He still didn’t know too much of what was going on but the crowd cheered as he was announced the winner. The Bolivian man placed two Bolivianos in the boys hand and he looked up with a huge smile that grew across his face. My friends and turned and left, laughing at what we just saw here in Bolivia. You just never know what to expect.

A clown entertains the children on the oncology ward at Hospital del Niño. Many of these kids are very sick and are not going to get better. It is very common for children to arrive at oncology for treatment extremely late due to the lack of education and unwillingness to pay for treatment by the parents. This leads to many kids dying from treatable cancers as well unnecessary amputations and deformations. Also, many of these kids have very long stays for treatment in La Paz. Their parents are unable to stay because they have other children to take of and cannot afford to take time off work, so many times they are left alone for months at a time with only the hospital staff to keep them company.  Resources are also very limited in Bolivia. There are some foundations that provide payment for children who are unable to afford treatment, but to qualify you cannot have any genetic predisposition for cancer; which makes children high risk and less likely to survive their cancer.

“Hoy es el dia a hacer consultarios solo por chicos con sindrom de Down,” Dr. T told us when we arrived at clinic. The consults will take place after we sit in on the presentations over difficult cases occurring in the hospital. The fist was a child with a large abdominal tumor that needs to be shrunk with chemo before it can be removed. The second was a very sick boy with a combination of TB and hepatitis who health is rapidly declining. After the presentations were given and the arguments were made we met Dr. T in the sala de consultorios, sala 5.

She is a late 50’s slender light skinned woman from Brazil who likes to ask how to say things in English. She has a face you can trust and respect and is amazing teacher of what it means to be a doctor. The first day I worked with her she sat me down in front of the computer to take notes in as she dictated to me in Spanish. You don’t know how hard it is to understand the word hyperactive spoken quickly and with a Spanish accent. I don’t know how many times she turned to look at the screen only to see Eper accion, and she would turn her head in a confused looked and I would just look blankly back like a puppy that didn’t do anything wrong right after chewing your shoes.

The previous day we had sat down in the cafeteria for a sweet tamale and coca-cola. She taught me one of the most important things I’ve learned this trip. The way you break the news to a patient is the first treatment for any illness. It sets their mind on the positive or the negative, the illness or the treatment, the past or the future. I would see this lesson in action today.

Dr. T called in the first patient and a mother and father entered the room with the child bundled in the mother’s arms. They took a seat and Dr. T greeted them politely and then began to ask them questions about their child.

“How old is he?”

“11 days,” the mother answered looking down at the bundle in her arms.

“What is his name?”

“David,” still looking down at her baby.

“How many children do you have?”

“This is our first,” she said turning and smiling at the father who smiled back.

“Felicidades,” I broke into the conversation.

“Sí, felicidades,” Dr.T repeated with a smile. “And how old are you and your husband.”

“I’m 24 and he’s 29,” she was rocking the baby side to side.

“Ok, and do you notice any problems with your child?”

“No, but we were told he has Down’s syndrome,” she turned her eyes to the doctor.

“Do you know what Down syndrome is?”

“No.”

The small family of three was calm, a bit anxious to be in the doctor’s office, but calm.

“So we are going to perform a quick exam and then we will talk, ok.”

The mom lifted the light package in her arms onto the exam table and unwrapped the gift that was hiding within. Dr. T and I were gathered around the newborn and the exam began.

“Notice the eyes, slanted, oriental,… the hands, one line strait across the palm, we have two lines,… the feet, same one line, plus fisherman’s sandal,… weak muscle tone (she pulled the baby up by the arms),… check the heart, we’ll also have to run tests for thyroid problems that are also common in Down’s.” (This was all in Spanish of course)

I grabbed the stethoscope and placed it to the heart of the small child. I turned and reported back I couldn’t hear a problem, no murmur, no extra sounds. She confirmed but reminded me this does not mean there is not a heart problem so more tests must be run.

Now she turned and took a seat in front of the parents.

“So you child has Down Syndrome,” she looked at them with a calm and confident face. “I’ll explain what it is.”

She then explained to the Bolivian family from the campo, with very little education, what a chromosome is, what trisomy 21 is, how we have pairs of information that determine who we are, how in Down syndrome they do not separate correctly. How it was nobody’s fault but the lottery of life. She even drew a picture of pairs of round circles each numbered, then an extra circle at the number 21 that had an arrow pointing to the words Down.  The fathere was leaning over with his elbows on his knees nodding that he understood. The mother was standing with the bundle in her arms, staring into it with a mothers love, rocking it back and forth, back and forth. Dr. T then began to explain to them what to expect, about the delayed development, about the difference in appearance, and what he will be able to accomplish.

“This is a happy time. You have a beautiful healthy baby boy who will have a great life,” she announced with a smile on her face. “It is going to take a bit more effort and commitment, but he will go to school, get a job, even have a girl, you will see.” She told them how they will have to work with their son, first to build muscle tone, then to walk, speak, and perform basic tasks in school, and eventually to be able to work.

“You just can’t feel sorry for yourselves or the child.” She said these words seriously.

The look on the fathers face is one that I will never forget. He was quiet looking blankly at the doctor. His eyes were welling with tears that never came. His mouth was slightly open but stiff, as if to keep his lower lip from quivering. It was his first child, a son, and he is forever changed. All I can do is watch the mother, swaying her child back and forth, looking into his eyes as if she never heard the doctor’s words.

Dr. T walks over to a shelf and pulls from pamphlets off the top. She then hands them to the parents and me and smiles as she says she’s going to be attending the conference for Down syndrome in Florida.

“There are organizations around to help you with your son and provide you all of the information you will need.” “You and your son are part of a community now.” “This is a happy time.”

They flip through the pamphlet together and look up at the doctor with broken smiles. She hands them the orders for the test they will need to have done and gives them directions at the door as they slowly make their way out of the office with the child in the mothers arms. A child that will never be the same again.

Today in clinic was a bit different then the last. I was in the infectious disease ward doing rounds with the residents, doctors, and other student in the program. Everything word was in Spanish and medical jargon, so it was easy to get lost. The other students, being 4th year medical students and residents, could at least understand the medical lingo so they would turn to me and give me an update on what was going on.  “Pneumonia with air trapping” or “Leishmaniasis which can cause organ failure if left untreated” would be whispered to me as we stood around the patients bed, arms crossed, listening to the doctors and local residents read off the chart and debate the treatment.

We got to one of the patients rooms and the doctors and residents put on their mask and told us not to go inside. The patient was a 14 year old boy who had severe TB and Hepatitis. We watched from behind the window as they went over the chart and then pulled the mother out of the room for further questioning. There were two attendings on the ward and they were debating whether or not to stop the medication. The dilemma was whether the Hepatitis was being caused by the TB, or the medications used to treat it.

The Doctor, a tall Bolivian who enjoys a position of power, stands in front of a short, stalky Bolivian woman dresses in traditional dress. A long thick skirt hangs down to her dark brown path-beaten feet, shawl is draped over her layers of hand made blouses. The Doctor is asking her for information about her sons case, taking a history that could save her sons life. If his hepatitis started before treatment began it would be proof that it was caused by TB and they would up the dosage of his meds. If it began after the treatment then they would stop the treatment completely to allow his liver to heal so that treatment could be resumed. The answer lies in the Mother but all she knows is that her son is sick.

“Help me help your son,” the Doctors pleads in Spanish to the Mother. The woman mumbles some Spanish, saying her boy is sick and that he’s been sick for a while as she stares at the floor and then nervously looks up at the Doctor.  It was not what the Doctor wanted to hear and he was getting noticeably frustrated. He looked down at her and noticed her short clubbed fingers and quickly pulled his mask up to cover his nose and mouth. The signs of chronic TB stand in front of him as she too was inflicted with the disease. She nervously rubbed her short, thick fingers together as the Doctor continued the interrogation, his voice rising and becoming more impatient. “No sé, no sé,” she repeated as she shook her head. “La fecha, la fecha, I need the date of when you first noticed these symptoms,” the Doctor asked strongly. Obviously not getting nowhere he announced that he had no time for this right now and walked out of the infectious disease ward.

The boys health is rapidly declining and he has since been moved to intensive care.

TIRED. It’s the word that is in my head right now. A day listening to Spanish alone is tiring, not to mention the uphill blocks, the patients, the Spanish exam, and the lecture over the Bolivian health insurance system.

I arrived at the hospital this morning and an energetic Bolivian doctor greeted me enthusiastically. Dr. Velazco, an infectious disease doc and a highly respected man at Hospital del Niño would be who I would be following. I now think of him as one of the most amazing people on the face of the earth. We were in his office calling in patients one at a time. The mothers would hurry through the door holding their baby in their arms or pulling their toddler by the hand. The babies would be wrapped in layers of blankets and to perform an exam you would have to pull the layers back like the rose petals of an unbloomed flower. Under the wrapping comfortable blankets would be a dark brown baby wearing a jumper and a little handmade cap.

I had no idea what I was doing. I have never used a stethoscope on a human before, much less a tiny little baby. The hearing piece seemed to cover half the back of the child so it seemed to make little difference as I slid the round silver across the back of the baby. Dr. Valazco showed me where to correctly place stethoscope to hear the heart and the lungs. he assured me that all of the babies I would be looking at would have normal sounding lungs so I would just get comfortable hearing the healthy sounds.

As the day continued the kids would come in and Dr. Velazco would ask me to do the exam. I felt awkward in my white coat with the parents watching me, sometimes asking questions. All I would tell them was I can’t say and to ask Dr. V. They had no idea that I had no idea what I was doing. And I liked it that way. I started to get more comfortable placing the stethoscope and listening for the sounds. I would do the exam and turn to Velazco and nod as if I knew everything was fine. The fact is he knew what each baby had the minute they walked in the door, so me performing the exam had no effect on the outcome of the child’s treatment.

One of the last children of the morning, a small native Bovlivian boy hopped up on the table. As before Dr. V asked me do the exam as he struck up a conversation with the mother. I started to glide the stethoscope across the back of the child. I heard a faint crackling whistle. My eyes got big and my head popped up. The mother noticed and asked me what I heard. I had no idea what I heard. I felt bad because I probably caused the mother to worry for no reason. I turned to Dr. V, who was busy doing paper work, and asked him to take a listen. He pressed the scope on the back and turned to me and said, “this is not normal, good job”. “Sounds like asthma”.

I felt pretty good about myself about then. On my 7th or 8th pair of lungs in my life I noticed brachial dialation. I could have never of diagnosed the boy or knew what was even going on. I just knew something didn’t sound right, something wasn’t healthy. I guess this is how everyone starts their careers in Medicine. Notice a faint sound here and there. See a x-ray with a slight anomaly. And before you now it your calling the shots, providing treatment, and saving lives.

IT’S 8:00 am here in La Paz and I am starting my first day at Hospital del Niño. I am feeling a mix of excitement and uncertainty. What will I see? Will I know what is going on? What will they expect of me? My main goal is to learn, to watch, and to absorb everything. The language is what is most important to me now and the knowledge of medicine will come in the future as I make my way through medical school.

I have my black sweater pulled over a blue button up with some khakis pants and vans on my feet. i am sure all of the medical students and residents will be wearing their scrubs to clinic but I have yet to earn mine. Hopefully with their help and my constant prying for information I will be able to gain some clinical knowledge and know a bit more by the time I start medical school. If anything it will be my motivation to enter the world of medicine and work my ass off so I can continue to make trips like this one and make a positive impact on this great big world.

So today I step into a new world and a new chapter. A world of science, evidence, and reason. A world of learning and teaching. And a world that will be mine for the rest of my life.

South America

Bolivia. Located in the middle of South America and bordering Peru, Brazil, Paraguay, Argentina, and Chile. It has a mix of landscape, from dense forests to towering mountain peaks. I will be living in La Paz which is in the mountains at 13,000 feet above sea level. It has a diverse population of natives, mestizos, and foreigners. Native languages are still spoken throughout Bolivia till this day.

So I am just 4 weeks away from getting on a plane to La Paz, Bolivia where I will be shadowing physicians and getting an up close and personal view of how medicine in practiced in an impoverished country. My plane takes off February 1st at 7:00 pm and it is going to get here in a hurry. Then it is off to a new land, a new family, and a new language. It is quite intimidating now that I think about it. Also, I have  never really had much clinical experience so it I am looking at this trip as entering a new profession and a new chapter of my life, devoted to medicine. I start medical school in July at UNM school of medicine so I have very little knowledge of the practice of medicine outside of some biochem, chemistry, and anatomy courses I have taken along path to med school. Through this blog and these experiences I want to keep a record of how a person goes from being a kid fresh out of undergrad to a practicing doctor that people rely on. And so it begins…