Friday, June 29, 2012

International Nosocomial Infection Control Consortium

The International Nosocomial Infection Control Consortium (INICC), spearheaded by my Argentine compatriot and colleague, Dr. Victor Rosenthal, recently published its report on hospital acquired infections in 36 countries. The paper is found in the American Journal of Infection Control.

The data was collected prospectively over 300,000 patients hospitalized across the consortium's ICUs.  Despite reporting that the use of invasive devices  was similar to that of US ICUs, the rates of hospital acquired infections were significantly higher. When compared to the CDC NHSN , the pooled rate of central line-associated bloodstream infection in the INICC ICUs was 6.8 per 1,000 central line-days vs. 2.0 per 1,000 central line-days reported in comparable US ICUs. Similar disparities were seen in ventilator-associated pneumonias (15.8 vs 3.3 per 1,000 ventilator-days) and  catheter-associated urinary tract infection (6.3 vs. 3.3 per 1,000 catheter-days). The frequencies of drug resistant pathogens was higher also Pseudomonas aeruginosa isolates to imipenem (47.2% vs 23.0%), Klebsiella pneumoniae isolates to ceftazidime (76.3% vs 27.1%), Escherichia coli isolates to ceftazidime (66.7% vs 8.1%), Staphylococcus aureus isolates to methicillin (84.4% vs 56.8%).

These are important findings. On one level, the results suggest that, in developing countries, invasive devices are used with similar frequency as in the USA. Patient acuity, theoretically, is similar. Infection control outcomes are clearly different. In developing countries, 
there are no legally enforceable rules or mandates to comply with infection prevention best practices. Absent this oversight in standards and safety, implementation of known risk reduction practices, even inexpensive interventions such as hand hygiene, will be erratic and suboptimal.

This underscores the ongoing need for research on practical interventions and implementation strategies to reduce hospital acquired infections. These must have universal applicability with minimal cost and resource barriers.

Wednesday, June 27, 2012

Unintended Consequences of Duty Hour Regulations for Medical Residents

Source : ENT Today
Here is a letter published in Academic Medicine on the unintended consequences of duty hour regulations.  What makes this letter most interesting is that it was written by medical residents and not the Old Guard.  A perspective published in the NEJM from a representative sample of US medical residents reported mixed feelings about duty hour restrictions. While positive responses were reported for potential improvement in resident quality of life under duty hour restrictions, both articles voiced concerns about the potential impact of less rigorous training. Under the new framework, graduates may be ill prepared for the demands of unsupervised patient care and for senior roles in hospitals.

I have previously commented on this subject. To date there is no quality evidence that these restrictions, whether duty hour or workload in nature, result in safer patient outcomes.

To become a competent doctor one must see many, many patients. To do so, one must spend long hours in the trenches. There are no shortcuts.   

Monday, June 25, 2012

HIV Diagnosis and Racial Disparities in Older Patients

HIV/AIDS Day Red Umbrella-, Richmond, VA, 2011
Do you think that HIV diagnoses are uncommon in older people? Think again. HIV diagnosis in patients 50 years of age or older occurs and racial disparities exist. Here is an article in the American Journal of Public Health on the matter.

The investigators analyzed surveillance data from the Centers for Disease Control and Prevention regarding HIV diagnoses during 2005 through 2008 in 37 states. 

The average annual rate of diagnosis (per 100 000 persons) for older persons was 9.8. Rates among older Blacks (49.2) and Hispanics/Latinos (19.5) were 12.6 and 5.0 times, respectively, the rate among older Whites (3.9).  The rates of HIV diagnosis among younger Blacks (102.5) and Hispanics/Latinos (39.0) were 7.7 and 2.9 times, respectively, the rate among younger Whites (13.3). 

Without question, racial and ethnic disparities in HIV diagnosis rates exist.  Older persons are more likely than younger persons to receive a late HIV diagnosis. In my opinion this stems from a bias that 'old' people are not likely to have HIV risk factors resulting in missed HIV testing opportunities.

HIV testing should no longer be risk factor based. The American College of Physicians now recommends routine HIV screening for all patients. HIV diagnosis leads to treatment and treatment is prevention

I couldn't agree more.

Friday, June 22, 2012

An Unconventional Housecall- A Transformative Experience in an Unlikely Venue

My essay titled 'An Unconventional Housecall' was just published in the Healing Arts: Materia Medica section of the Journal of General Internal Medicine.

The essay is a reflection on a transformative patient experience in an unconventional setting.

Due to copyright obligations, I am unable to post the essay on my blog. You can preview the essay, however, here.

Wednesday, June 20, 2012

Access and Barriers to Healthcare Vary in Honduras- Kate Pearson

Honduras researchers: Kate Pearson (background) and Gabriela Halder (foreground)
Kate Pearson, a rising VCU M3 medical student, has just published her paper on access and barriers to healthcare in rural Honduras in the International Journal of Family Medicine. Kate was a member of our 2011 Honduras research and clinical team.

The paper can be accessed and downloaded in PDF format here

Monday, June 18, 2012

Honduras 2012: Reflections and Perspectives

The Joshua Tree- La Hicaca, Honduras
Having returned one week ago from our latest medical relief trip, I find it helpful to pause and reflect. My reflective thoughts have previously been published here.

From the 2012 medical team:
  • Aside from the satisfaction that came with providing medical care to a population that otherwise wouldn't have access, I was most struck by the warm, welcoming spirits of the people we served. They lived simply, subsisting off the land, and yet they had everything they needed: family, friends, nature, love. Moreover, their necessary faith in a higher power to make the sun shine, the crops grow and the rain fall conferred on them, I think, a certain sense of humility that many Americans are perhaps lacking. How many of us in the US, living in materialistic luxury that many Hondurans could probably never fathom, are truly appreciative of all we have, and how little we actually need to be happy? 
  • The trip was an extremely humbling experience for me. The daily lives led by the the people in La Hicaca are extremely different from anything I have previously experienced. Their graciousness and genuine good spirits make me realize at times how trivial the things I tend to worry about really are.
    The brigade was both the most difficult and most rewarding experience I have had. It was truly a life-changing experience
  • Father Pedro's insights were very enlightening (click here access video interview with Father Pedro). In addition to discussing health care and public health interventions, he was adept at describing the social context of health in La Hicaca. He said the community was full of violence unchecked by law enforcement which was not trusted by the local community. There is a breakdown of the family structure and a lack of the institution of marriage. It was hard to miss the parallels between rural Honduras and urban Richmond.

Patient Care, La Hicaca, Honduras, June 2012
  • It is easy to not appreciate or even realize all you have until you have seen otherwise.  After spending a little over a week in Honduras for a second year in a row, of which the majority of the time was spent in a small, poverty-stricken, mountainous village, I have once again come home with an increased sense of awareness and am truly grateful for everything I have here.  Growing up in the suburbs in the United States, it is easy to take for granted all of the amenities that are provided.  Basic needs such as access to clean water are met without any thought.  All I have to do is decide whether or not I want to add ice or use my Brita.  Getting to a destination that is 15 miles away is easy in my car on paved roads, yet I still find myself getting frustrated being stopped by red lights or getting stuck behind a car that is driving at a speed less than the posted limit.  For someone in this small Honduran village, clean water is a luxury and getting to a destination 15 miles away would probably be a full day’s trek.  There are no roads or street signs, no one has heard of a Garmin, and the journey is usually made on foot.  It is hard to believe that in such a modern world where people constantly live in excess and worry over petty things, there are still places where basic needs for survival can be nearly impossible to obtain.  
  • It's difficult to imagine that within an 8-day span, you can feel as though you've seen and learned so much from a world completely unknown to you before. I don't quite know what I was expecting as I was flying into the country. Poverty, people in poor health, and lack of showering were all things that I had prepared myself for. But what caught me off-guard was that amidst all of the poverty, a greater sense of happiness, pride, and strength existed amongst the people of rural Honduras whom we were fortunate enough to meet during our time there. It was astonishing to me how, even though they didn't even have shoes to protect their worn, weathered feet, or proper nutrition, these Hondurans willingly trekked hours to the clinic doors and stood in the boiling sun, patiently waiting to be seen, dressed in the finest of their clothing, with smiles on their faces. Many of them walked back home knowing that certain chronic ailments of theirs would not, and could not, be treated by us, and yet they were simply happy to have been given so much attention and care by our medical group. 

    Eye glasses station, La Hicaca, Honduras, June 2012
    We were fortunate enough to be able to walk around the village when we weren't in clinic, and the people of La Hicaca proudly, graciously, invited us into their small mud homes. Again, seeing how happily they lived, without complaint when they only possessed the barest necessities of life, made me wonder why it was that we, in a neighboring, FAR wealthier continent, lived in such lavishness and yet still did not seem to possess the same happiness and gratitude for life. So I was slightly disappointed in myself when I returned back after such an experience and found myself easy slipping back into my daily routine. I don't know what I was expecting; perhaps that what I had seen would change my world views so much that I would feel inspired to  make drastic, minimalistic changes to my own life. Yet, I came back and it was almost as though I had never left. But I think another thing that I had learned from this trip was not to underestimate people's ability to adapt to whichever environments they may find themselves in. I'm not only talking about the people of rural Honduras, but about the amazing individuals with whom I traveled to La Hicaca with. I know that many within our HOMBRE group had never before gone more than 2 days without hot showers, toilets, cars, or our mobile phones. And yet, we all managed, with little complaining, and a lot of laughter and good morale. 

    So although I re-adapted to my life back home without much trouble, I know that doesn't mean I will forget many of the important lessons that I learned on my trip. I know that I will continue to participate in as many of these incredible relief brigades as possible in the future. And in times when I can't find the means to travel on such international trips, I will always keep in mind one important thing that I learned from going on this trip: that even a little bit of time and caring to those in need can go a long way. 

From Dr. Michael Stevens:

Breakfast, La Hicaca, Honduras,June 2012
The people we see when we travel to La Hicaca are some of the poorest in the world, and face terrible health pressures such as sub-standard housing, poor access to clean water and sanitation, and a heavy burden of chronic illnesses (intestinal parasites, chronic musculoskeletal overuse disorders, chronic skin problems, et cetera). The medicine we practice in this setting is simple, raw, and emphasizes high-yield measures such as anti-parasite medicine administration and health screening. We have worked hard to maximize our impact over the years, and finally are addressing chronic health issues such as hypertension and diabetes, in addition to de-worming people and addressing acute health complaints. Having come to the same community for the past 5 years (often multiple times per year) we have developed strong ties to the community, its people and with our community partners and the local ministry of health; we are heavily invested in, and have developed deep friendships with many of the people in this area. Actualizing this work is an almost herculean effort, and is only possible via the efforts of many people across numerous organizations-I am especially grateful for our excellent students who give of their limited time and resources to fund raise for these trips; I am also indebted to them for what they teach me about selflessness, humility and service. I am humbled and count myself privileged to be able to witness students and residents being transformed by their new perspective on health and poverty. This always serves to remind me of what is important in both medicine and life; in their growth I find renewal. I am also grateful for Pat Mason and Gonzalo Bearman; both have showed considerable dedication and resilience in continuing our efforts to provide medical care to the people in and around La Hicaca: they have done this largely without personal benefit or recognition in the face of significant challenges. Most especially I am grateful to the people we see in Honduras-the perspective I gain when I participate on these trips is incalculably valuable, and I am allowed the awesome opportunity to practice medicine and public health in their rawest and truest forms. I am grateful, beyond measure, for what our patients have taught me-and continue to teach me-about humility, kindness, generosity and resilience.

From Dr. Pat Mason:

“Water, water everywhere and nary a drop to drink”

Water has always been an important part of my life and something we often don’t even think about in the US. Whether it’s for making our morning coffee, washing our car or watering our plants, we just know that when we turn on our faucets it’s always there.

Water Filters, La Hicaca, Honduras, June 2012
As I sit safely back in the US, with my overpriced cup of coffee and reflect on our recently completed 8th medical trip to Honduras, the old saying comes to mind. Once again water played a huge part of everything we saw and did while on our annual trip to La Hicaca, Honduras. While many in the US may not really give it a second thought, water is clearly a major driving force for many people of the world including those in La Hicaca. Its importance cannot be over emphasized and was clearly evident in every experience we had during our visit.

Upon our arrival and after a 20 hour travel and preparation day, the trip to La Hicaca was made even more exciting by water. The river crossing on the road to La Hicaca is always a little anxiety provoking but with the recent rains in this part of Honduras the crossing became even more exciting. After making sure all of our vehicles were in 4 wheel drive we ventured into the swollen river. Amazingly each vehicle made it safely across despite the water being up over the tires. What was just a nerve racking crossing for us is often a major ordeal for the people of Honduras. Needing to walk several hours on the mountain to get to the nearest store or hospital, the swollen river can become a major ordeal that influences the success or failure of a journey from this isolated little area.

Following our safe arrival into La Hicaca, our team of 19, which included students, doctors, a nurse and members of the local church and Health Ministry, settled in and began 6 days of clinics.  For the first time we had elected to spend our entire time in the central little village of La Hicaca. People from the surrounding areas (a total catchment area of over 2000 people) were each to come at scheduled appointment times. Through the hard work of the team we were able to see 440 adults and children. Each person received medications to prevent and treat worm infections as well as having their hemoglobin levels determined. All children had their teeth varnished to help prevent tooth decay, a major health issue for each of these communities. A Honduran dentist was able to join us and examined 50 patients for their dental concerns and we were able to provide over 150 reading glasses.

Through the generous donations to the Golden Phoenix Foundation, we were able to purchase over 400 vaginal speculums so that the Honduran health team who accompanied our journey could perform PAP smears on many of the adult women. For some, this may have been their first potentially life saving screen.

We were able to continue our clean drinking water project. While we were there the pipe that takes water from the local cistern was broken. This meant that the entire community had only the river (the same one we drove through and the cattle frequent) as a source of their drinking water. We were able to culture both the river water as well as that in the cistern and found that each not surprisingly was filled with E. coli (one of the major organisms found in stool). Fortunately most families around La Hicaca have already received their water pots and have clean drinking water.  Through the generous donations of our friends, we were able to purchase and distribute almost 100 additional water filters. This means that we now have over 150 water filters in use, serving more than half of the 280 total families in our area. In addition, every family who has a child less than 5 years of age has a water filter providing clean drinking water.

A highlight of our trip was being invited to the small little church in La Hicaca and be part of the Baptism and First Communion Ceremony of 7 children from the community. As we watched Father Pedro perform the joyous ceremony it was not lost on me the spiritual and healing power of the water that he was slowly pouring over the heads of these young children. It was such a wonderful honor to be apart of this experience and share the joy with the families and the community. 

Our last experience with water or more specifically the lack of water was going 6 days without the ability to bathe or shower. I do have to say that the entire group who came this year maintained great spirits and proved that if everyone smells than no one seems to notice it. Of course I would have hated to be the other people back in Olanchito when we finally made it off the mountain.

As I reflect on our trip, I am reminded how critically import water is. How too much of it can be such a burden to people who must live under these conditions and whose only means of transportation is walking. I am reminded how life sustaining clean drinking water truly is and how such a large portion of the world is without it. How much a struggle it can be to perform simple functions such as bathing or washing clothes. I am encouraged however that through the generous donations of the many friends of the Golden PhoenixFoundation, we are able to help so many families obtain clean drinking water through our water filter project. For only $25 we are able to provide clean drinking water for a family for up to 2 years. It’s amazing that so much can come from so little money. As I continue to return to my little 2nd home in La Hicaca, it’s is my hope and desire to eventually be able to change the old saying to “water, water everywhere and now plenty of water to drink”.

For more visit the VCU Global Health and Health Disparities Program website

Friday, June 15, 2012

Human Microbiome- 100 Trillion Bacteria

100 Trillion bacteria. This is the microbial mass contained within the human body. Think of these bacteria as our symbiotic allies, important for homeostasis and part of our normal flora. The human microbiome can vary between individuals and can be dynamic in nature.

Source: NIH
Here is an article published in the New York Times on the human microbiome. The Human Microbiome Project website can be found here.

As an infectious diseases physician, I cannot overstate the importance of human microbial 'normalcy'. Disruption of the normal microbial ecology can result in infections such as C.difficile colitis and yeast infections. In some cases, restoration is achieved through microbial transplantation, as in fecal microbiota transplantsIn other cases, interventions such as invasive devices, immunosuppressants and cancer chemotherapeutic drugs can result in bacterial invasion by our resident microbes from the skin, gastrointestinal and genitourinary systems. 

This last point is relevant for those who advocate the complete eradication of hospital acquired infections. Quite simply, the state of science in infection prevention is not yet robust enough to prevent all infections. When we subject patients to surgeries, invasive devices, immunosuppressives and strong chemotherapeutic medications, resident bacteria are given the opportunity to translocate or invade. For more, I refer you to Michael Edmond's insightful commentary on healthcare without infection.

Thursday, June 14, 2012

Honduras 2012: Interview with Padre (Father) Pedro O'Hagan

On June 7, 2012 we sat down with Father Pedro O'Hagan of the Catholic Church, our collaborator, to discuss the scope, impact and future direction of our medical relief trips.

Below is our interview (parts 1-3) with Padre Pedro O'Hagan, a collaborator on our recent medical relief trip to Honduras.

Additional footage can be found on the VCU Global Health and Health Disparities website

Wednesday, June 13, 2012

How Doctors Die- Understanding the Limits of Medicine

Source: Zócalo Public Square
Physicians choose to die peacefully at home, or in hospice, unlike many of their patients. Here is Dr. Ken Murray's original essay on the matter, published in Zócalo Public Square and a related article in the Guardian UK.

Many physicians would not subject themselves to aggressive end of life treatments. They treat themselves differently than patients, preferring to die peacefully at home or in hospice. Patients often receive aggressive and futile end of life care, frequently in an intensive care unit.

The reasons for these differences are multiple and are explored in the Dr. Murray's essay. The system can victimize a patient at the end of life as medical decision making is driven by:

  • unrealistic patient expectations (heroic 'saves' of patients, as seen on TV) despite a physician's understanding of the limitations of end of life care
  • fear of litigation
  • a fee for service medical system that rewards physicians and healthcare centers for more care with additional reimbursement
  • physician coping mechanisms for end of life issues (previously discussed on this blog)
As a profession we should strive to thoroughly make clear the limitations of aggressive end of life treatments and resuscitation. This should result in less doctor-patient information asymmetry and more reasonable decision making during end of life care.

Sunday, June 10, 2012

Honduras 2012: Final Day

The adventure has come to a close and we are heading back home.
With Drs. Mason and Stevens

The three amigos paused for a parting photograph.

We ran across the Honduran national football (soccer) team, en route to Canada for a World Cup qualifier. I snapped a photo with Noel Valladares, the goalkeeper of the Honduran national team, who also played in World Cup 2010 in South Africa.  An act of football solidarity, from one goalkeeper to another.

With Noel Valladares of the Honduran national football team
The medical relief trip was successful beyond expectation and I left with a humble sense of accomplishment and renewed excitement. For those who know me and my passion for football, it should come as no surprise that this parting photo moment with a World Cup goalkeeper was way cool !

Saturday, June 9, 2012

Honduras 2012- Day by Day

La Hicaca from above
Day #1, June 2nd, 2012: Departed the USA at the crack of dawn to arrive in San Pedro Sula by noon local time. Per usual, passport control and customs were interminable, delaying our departure from the airport by several hours. Finally, having collected our considerable baggage, boarded the transport bus, and picked up our rental 4x4 trucks we were off for the 5 hour drive to Olanchito. The last 3rd of the trip was in a torrential deluge raising concerns about reaching our destination safe and sound.

Health Center- La Hicaca
After a late arrival and a quick dinner in the Catholic Church boarding house in Olanchito, we pressed on and prepared the mobile pharmacy for the coming week. By 11 PM, we were thoroughly exhausted and turned in after a 20 hour day.

Clinic Registration
Day #2, June 3rd, 2012: Bright eyed and enthusiastic, we packed our bags into the six 4x4 trucks and land cruisers to take us through the valley and up the mountains to La Hicaca. Given the previous night’s cloudburst, the road was muddy and the river was high, making for a nervy crossing. We prevailed and landed in La Hicaca at 11:30 AM. Our phenomenal group of medicals students, pharmacists, nurse and residents promptly unloaded the vehicles, and, after a quick lunch we held our first clinic session, seeing patients from the aldeas of San Felix and El Cruzete. 

By late afternoon, we were off to sample water for bacterial colony counts, from homes with previously installed water filters, as part of our ongoing research efforts.
By 6 pm, we experienced nightfall, darkness and a sense of isolation as no electricity, water or sanitation is available in La Hicaca. Restful sleep was at hand in a humid environment, on a dirty, open windowed school room floor. The school served as our home, headquarters and clinic. La Hicaca at its best.

Patient Care
Day #3, June 4th, 2012: 1st morning in la Hicaca, with sunrise at 5 AM. The roosters and livestock sounded the early morning sun up. The first order of business, after breakfast, was to begin preparing the water filters for distribution. The clinic was slow to begin, however, by the afternoon, it was in full swing. Our exceptional medical students, residents, nurse and pharmacists were up to the challenge.  When the afternoon coffee arrived, prepared by our trusty cook, the jolt of caffeine stimulated us to finish off the clinic in form. The first day’s cases were not beyond the routine and we were successful in launching the mass deworming, point of care hemoglobin checks, and dental varnish projects. Concurrently, our Honduran ministry of health colleagues began cervical PAP smear screening with the 480+ vaginal speculums supplied by the medical team.

By nightfall, we were thoroughly sweaty, exhausted and ready for dinner and bed. When in rural, mountainous Honduras, bedtime is early. With no electricity, what else is there to do?

Jean Rabb, RN- coodinated water filter distribution
Day #4, June 5th, 2012: 2nd full day in La Hicaca.  The evening was best characterized as steamy, made more uncomfortable by a torrential downpour. A hole in the school room roof was discovered, fortunately the flooding was minimal. After a breakfast of delectable pancakes with peanut butter and jelly washed down with strong, black, Honduran coffee, we were fully charged and ready to face the day. The morning’s clinic was busy on both the pediatric and medical sides. The patients were from the aldeas of Santa Maria and El Urraco. During the lunch break, after a quick meal of rice, beans and tortillas, a small group of us set out to collect water filter samples from the homes in La Hicaca. The locals were more than willing to let us invade their homes for our public health pursuits.

Water filter sample testing
The afternoon’s clinic was best characterized as steady yet not overwhelming. The heat was intense. The patients were from the aldeas of Puerto Rico and La Florida. We capitalized on the smaller patient volume to break from the clinic and to set out on an intense, door to door, drinking water sampling mission. By nightfall, we had sampled the water from filters in nearly all of the 50 homes of La Hicaca. We were also making progress on our survey based, indoor air quality research project.

VCU Med Student/Researchers: Audrey Le & Jackie Arquiette   
The day was gratifying. Both the IRB approved water quality and indoor air quality research projects were in full swing.  The clinical program was gathering steam and we were in the groove.

Data entry of clinic patients
Day# 5: June 6, 2012. Despite another stifling and humid evening, we were awake and optimistic for another day in the field. Our research team was off early in the morning to gather the last remaining home water filter samples. The morning’s clinic was steady, with patients from the aldeas of Agua Sarca and La Vega.

In my discussions with the Honduran campesinos, a clear picture of the typical day emerged. As subsistence farmers, they are up before sunrise to cultivate corn, beans and coffee. Swinging a machete in the blinding sun and searing heat is hard work. It is no wonder that repetitive strain injuries and dehydration are common diagnoses. The workday is completed by 3 pm so as to be home to recover for the subsequent day. Bedtime is usually 7-9 pm. A veritable grind by any standard.

Visual acuity and eyeglesses
The afternoon was back to business as usual. Clinic and patient care, this time the patients were from the aldeas of Lomitas and La Culata. Our students, residents, nurse and pharmacists were functioning as a top notch crew. The patients were from the aldeas of Lomitas and La Culata.  An additional 30+ water filters were distributed. By the end of the day the total filter count was 72.

After several days in La Hicaca, we were well aware of the tremendous resilience and patience of Honduran campesinos, willing to walk 2-3 hours each way and then wait in queue for a near eternity to access limited medical care from a transient, medical brigade. Admirable.

Interview with Father Pedro O'Hagan
Day #6, June 7th, 2012: Fatigue set in and the group was slow to rise. We were anticipating a busy day. Black Honduran coffee and pancakes were all that was needed to jump start us.
The day began with a special twist. Drs. Stevens, Mason, Popovich and I sat down for an interview with Padre Pedro O’Hagan to reflect and strategize on our collaborative medical relief effort. The video will be soon available for viewing on this blog and on the VCU Global Health and Health Disparities Program website. Check back.

As always, collaborating with Dr. Stevens
Today’s clinic patients were from the aldeas of Chorro Viento, La Esperanza, Aguacaliente. The volume was steady in the morning and then trailed off by 3:30 pm. This allowed ample time for our research team to complete door by door interviews for the water and indoor air quality research projects in the late afternoon and early evening. By nightfall, we were thoroughly exhausted.

Day #7, June 8th, 2012: Last day in La Hicaca. Per usual, awakened early by the cacophony of the roosters, livestock and dogs. Morale and enthusiasm was unflinching. After a breakfast of peanut butter and jelly and black Honduran coffee, we were back to patient care. The morning clinic proved to be slow with all clinical work completed by 11;45 AM.

At week’s end, we had seen a quarter of the area’s population in the clinic. This included mass deworming and anemia blood sampling of all clinic patients. All children received dental varnish. What transpired was medicine in its most raw form, with an emphasis on clinical skills and medical judgment, devoid of fancy hospitals, advanced diagnostic tests, and specialty care.

2009 Census- La Hicaca and environs
Travel time (walking) to La Hicaca Clinic
La Hicaca
Agua Caliente
40 minutes
La Lima
1 ½ hours
El Cerro
2 ½ hours
Puerto Rico
1 ½ hours
La Culata
2 hours
Chorro Viento
1 ½ hours
La Vega
1 hour
El Urraco
3 ½ hours
1 ½ hours
Agua Sarca
3 hours
Santa Maria
5 hours
La Florida
2 hours
4 hours
San Felix
4 hours
El Portillo (I and II)
I :5  hours; II :  6 hours
1 hour

Other accomplishments included the distribution of 91 new water filters (9 filters shattered in transit). One hundred and seventy new pairs of eyeglasses after visual acuity testing, with 125 pairs of eyeglasses donated to the Health Center in La Hicaca. The dentist saw 50 patients for teeth extractions in one day. The Honduran public health nurses were performed 43 PAP smears with the speculums donated by our group. Over 400+ disposable speculums remain, for the use by local health services to provide PAP smears for the remainder of the year. We donated sizeable quantities of amoxicillin, doxycycine, Tylenol, albendazole, ibuprofen, anti-fungal and steroid creams, enough to last the Health Center for 6-12 months.

By 1 PM, we were packed up, and after a group photo, boarded our 4x4 trucks and land-cruisers to head down the dusty, rocky road, to Olanchito, where water and electricity awaited in the dormitories of the Catholic Church.

Map of La Hicaca et environs- click image to enlarge
On reflection, we feel that this was our most successful brigade to date, despite a lower patient volume. The public health focus and collaborative effort with local authorities and the Catholic Church will ensure longitudinal programs with long lasting impact.

Day 8, June 9th 2012: Awoke at 5 AM to a passing thunderstorm. Within thirty minutes, the rain stopped, allowing several of us to set out on our now traditional Olanchito countryside jogs. The early morning, dirt road, country jog was made surreal by a fresh mist, the breaking sun over the surrounding mountains and the syncopating beats pumping in the headphones of our i-pods.

After a tasty breakfast, we packed our bags, bid our generous hosts a farewell and pushed off for the 5 hour drive back to San Pedro Sula. Uneventful. Back in San Pedro Sula, at the Hilton Hotel, the fatigue of it all set in.

 Our Honduran adventure came to a close. We will be back, as always.

VCU Honduras "Norte" 2012