The hospital in Veracruz

This is where I began working on my first day in Mexico, the Emergency Department of the Hospital Regional de Alta Especialidad de Veracruz:

There's always a crowd of people outside waiting to be seen, accompanying patients, or waiting for relatives who have already been admitted. Throughout the night people sleep outside on the curbs. Sometimes soldiers are posted at the door and in the hallways for reasons that are not quite clear; young men in helmets and boots with rifles at the ready. This is also where the ambulances pull up to deliver patients.

Inside is a triage area, a trauma bay, and the main ward:

This photo is pretty classic. It was taken around 6:00 am, when these residents had already been on duty for almost 24 hours and with another full work day to go before the end of their shift.

On the desk are typewriters for patient charting. In the absence of a computerized charting system, all patient notes are typed on vintage manual typewriters. Immediately following rounds, the ward is filled with the clatter of progress notes being typed on half a dozen typewriters. Despite my limited Spanish skills I was able to help with a little of the more mundane typing, but I needed a refresher course in ribbon management.

In the center a resident holds a film up to the ceiling lights to examine it. There's a light box in the trauma bay, but not one at the resident workstation. Thoroughly examining a film using an overhead light fixture requires a certain art. In the background is a patient on a ventilator, and to the right another ventilator is standing by. It's not unusual for there to be three or four patients on ventilators here at a time.

I just flew in from Mexico City and boy, are my arms tired

Got home a couple of hours ago. Many stories to tell and many pictures to post -- after some sleep.

Letting it all hang out

This week finds me in la cirugía -- surgery -- so this morning I go to the supplies window in the operating room suite to be issued my scrubs for the morning’s cases. The students here get disposable scrubs made of papery fiber and so that’s what I get, along with my ration of mask and shoe covers. I change clothes and head on into the OR with my usual enthusiastic how-can-I-help-you smile where, after being introduced to everyone, I grab the patient’s chart to read about the upcoming case. What a dedicated medical student! Looking down at the chart under the bright lights of the OR, however, it occurs to me that I can see my socks awfully clearly through the legs of my scrub pants. Horrified, I realize that my thin papery scrubs are practically see-through! At first I’m hopeful that the worst of it is just being able to see my socks, but a discreet and increasingly mortified inspection reveals that I am basically standing there in a room full of anaesthesiologists, surgical residents, and nurses in my underwear. What can I do? I opt for a lengthy examination of the patient’s chart, but with the chart held a bit lower than usual.

Fortunately I manage to communicate to the friendly and helpful Dr. Gomez the fact that I would like to change my scrubs. Like most operating rooms this one is kept a bit on the cool side, so he asks if I want to change because I’m cold. (Can this possibly get any more humiliating?) I’m happy to let him run with that theory, however, because if I tried to explain any more in my limited Spanish I’d probably be arrested. Or sent to the Psych floor. I’m beginning to realize why so many people here seem to either bring their own scrubs or wear long coats.

At this point it’s all I can do to just keep looking straight ahead, repeating over and over to myself “it’s not what you wear, it’s how you wear it.” I reluctantly give up my modesty-preserving chart and Dr. Gomez escorts me down the hall back to the formidable woman guarding the supplies window. Dr. G asks the gatekeeper if I could get a robe or coat, but that is absolutely out of the question—“they’re only for doctors, not for students!” Finally he manages to talk her out of a set of real cloth scrubs. The pants legs only come down to mid-calf on me, and the shirt only just barely reaches the top of the pants, but at least they’re opaque. Now I can return to the OR without living the nightmare where you walk onstage for your trombone recital and realize that you’re stark naked.

And so, clinging to my last shreds of dignity, I scrub in for the surgery. As things turn out I get to do a lot of suturing and Dr. Gomez teaches me a stitch I’ve never used before, earning me a “¡muchacho!” from the junior resident.

At least, I hope the comment was for my suturing….

Las Urgencias

My first week in Veracruz I worked in the Emergency Department of Veracruz Regional Hospital -- Las Urgencias. It's the equivalent of a county hospital, taking urban walk-ins and referrals from smaller surrounding cities. Although I've seen a few diseases that I wouldn't see in Iowa, mostly what I've seen is familiar diseases but in much more advanced states than I'm used to. I've had to ask about the calibration of the lab numbers, because some are literally ten times higher than what I'm used to seeing back home.

Of course, there are also plenty of traumas. As I mentioned earlier, it's rather nerve-wracking to be involved in a trauma or code in a language that you're not fluent in. However, in many ways I'm more comfortable with traumas than with some of the medical management. When a trauma comes in on a backboard by ambulance the initial steps are very much the same as back home, so I have some idea of what to do. My biggest limitation is that, although I've gotten to the point where I can (sort of) discuss a case with the doctors and residents, I can't really take a reliable history from a patient who is often in distress and has an accent I've never heard before.

But in general the challenge is that the patients are so sick. The ER has 13 beds plus a trauma bay. Of these, there are usually two or three patients on vents (sometimes more), and often additional patients on gurneys are wedged in between the regular curtain slots. Meanwhile, the parking lot outside is always full of people waiting to be seen, and the triage area is usually packed. At night I've seen whole families sleeping under the chairs in the laboratory waiting room.

The room with the computer I'm using is closing so it's time for an abrupt sign-off....

See one, do one, teach one

Well, I've seen more than a few, and I've done my share. But last night I lived up to my end of this venerable tradition of medical education by teaching another student to place a Foley catheter -- entirely en español. Turns out I've picked up some Spanish words along the way that I didn't even know I knew....

And I have, in fact, been shown a procedure or two (with explanation in Spanish, natch) and then expected to repeat them. It can be a bit nerve-wracking, especially while sleep-deprived and operating in subtropical heat and humidity. On the other hand, I made a splash with my ultrasonography attempts. ¡Vamos!

Hello and thank you

A quick post from Veracruz, where I'm in the thick of things, including figuring out how to type on the local keyboards (with their different layouts and cryptic diacriticals). I remember once seeing a form where one's level of medical Spanish skill was graded from "Basic" to "Trauma" and thinking how intense it would be to work in another language in a trauma situation. Well, now I know. And yes, it's very intense. (My level of skill definitely isn't "Trauma" yet, especially when it's getting toward the end of a 36-hour shift.)

I wanted to be sure to offer my thanks to everybody who has sent me their good wishes about the Match results in the past couple of weeks, via comments on the blog and by e-mail. In addition, I offer my apologies for not replying in person. The week between Match Day and Mexico Departure Day was a bit hectic, and I haven't had much chance for internet access here so far.

In any case, I should have more internet access starting next week, and I've got some incredible stories to blog.