Piaxtla: The Challenges of Village Treatment
Concern and common sense can make up for much lack in equipment and training, and in the last analysis are probably more important. Our village clinics are not really equipped to perform delicate surgery or manage patients requiring intensive care, and our volunteer staff frequently lacks adequate training. For all that we have had so many unhappy experiences as result of taking patients out to city hospitals or health centers that we often feel obliged to tackle ourselves medical problems which ordinarily we would much more happily - and wisely - refer. Examples of such unfortunate experiences include:
Ramon, a six year old with a broken thighbone, whom we took to the Hospital Civil in Mazatlán. Because the boy squirmed loose in traction and no one bothered to fix it, his bones knitted crossed and twisted.
Pastora, a pregnant girl with a severe kidney infection, whom we sent to the Centro de Salud in Mazatlán. No examination or tests were made. She was prescribed aspirin.
A little girl (whose name I forget), who got tetanus from a pierced ear. On entry to the Hospital Civil in Mazatlán, the head nurse asked, “Why did you bother to bring her? She will die anyway.” The child was left in a filthy basement room across from the morgue, without lights and with excrement in the corner. No doctor saw her until the next day. Fortunately, she died quickly.
Jose, a young man with a tubercular abscess of the throat, who I took to the same hospital. He received no food, drink, or medication from Friday afternoon when he was admitted until the doctors arrived Monday, at which point he was moribund. His wife begged me to take him back to Ajoya, and he died on the way, in my jeep.
Juan, a. villager who went to the coast and was hit by a car. He spent two weeks in the Hospital Civil in Culiacán with a broken leg, unattended until he sent me an S.O.S, for funds to pay for setting and casting his leg.
Joel, a youth who was shot through the thigh in a gunfight and suffered a major arterio-veinus fistula. We carried him 15 miles on a stretcher, then 150 miles in my Jeep to the Hospital Civil in Culiacán. The Director promised to operate immediately, yet when I returned two weeks later, no surgery had been performed. The leg now rank with necrosis, had to be amputated, a needless tragedy. Before taking Joel to the hospital, I had debated with myself as to whether to attempt the vascular repair. I still kick myself for not having done it.
Juanito, an old man with a broken hip, who I left at the Hospital Civil in Mazatlán, together with x-rays of the fracture. Due to some mix up, his hip remained untreated and a steel pin was put in his knee! He will never walk again.
These cases are of course extremes. In all fairness, it must be pointed out that many patients we refer receive satisfactory treatment, especially considering that these public hospitals are grossly understaffed and underfinanced. Moreover, things are improving a little. I have made friends with some of the hospital’s staff, and at times have given them, medicines items among our surplus among our own donated supplies. Furthermore, Dr. Laub has had the head nurse and two others fromCuliacán up to Palo Alto to visit him All this has helped gain preferential treatment for patients we refer. Still and all, treatment is often so far from ideal that, we now refer patients only as a last alternative, and do ourselves as much medically as we dare. Nearly all fractures we set and cast ourselves. Appendicitis we usually treat conservatively, with antibiotics (as in Britain). I have performed skin grafts and tendon repair as best as I can because I know that if sent out the patients lesions will be superficially dressed and that’s all. Tetanus cases we now handle in our own clinic (where at present we have a 50% survival rate, as compared to 20% in the Hospital Civil in Mazatlán, according to a nurse there).
The patient’s scalp had been lacerated and skull fractured in an auto accident
If patient management in the city public hospitals is poor, in the rural Centros de Salud, it is often worse. They are usually staffed by “pasantes”, doctors fresh out of med school who are required to serve for a year in a rural health center before they can practice on their own. In San Ignacio the Centro de Salad nearest us, the doctor fails to take his post seriously. The Centro is usually empty, partly because the doctor is so rarely in, and partly because the villagers (2000 in San Ignacio) have so little faith in him. Many would rather take the 17 mile journey over Jeep track to our Ajoya Clinic for treatment. Even town officials and State police bring us their sick children, and at times the Municipal President has sent us indigent patients for treatment.
On one such patient we ended up performing brain surgery in a desperate effort to save his life. The patient’s scalp had been lacerated and skull fractured in an auto accident near San Ignacio; he had been taken to the Centro de Salud, where the wound was sutured and the patient released. The lesion subsequently became infected and when the Health Center declined further treatment, the patient sought aid from the Municipal President. The “Presidente” sent him with covering letter to our clinic. Fortunately, he arrived the same day that Dr. John McKean flew down with a team of doctors, so that Dr. Arthur Roswoll, a general surgeon. We re-opened the badly infected wound and removed gravel, paint chips and hair which had been sewn up inside the wound. A piece of skull bone: 4" long had sunk deep against the brain. Dr. Boswell and Dr. James Guye, an endodontist, skillfully sectioned away the offending skull fragment. The lesion was irrigated, a drain placed and the wound partially closed. It was a heroic effort, and after surgery the patient sat up and ate. On the fourth day he went into convulsions and died.
I don’t rant to give the impression that there are no good doctors or medical services available in the cities of Sinaloa. There are. The “Seguro Social” program has superlative medical facilities, but is available only to persons employed where payment can be withheld from the payroll. In other words, only those who could afford medical care elsewhere are entitled to Social Security. The poor village farmer doesn’t qualify. Apart from the Seguro Social, another excellent medical program, ISSTE provides free health care to all government employees.
Privately, here are also many well equipped, exclusive, inpatient clinics in both major cities. But for the most part their charges are astronomically beyond the financial possibilities of either the villagers or Project Piaxtla. At these clinics, however, we have found two fine doctors – an eye surgeon and a thoracic surgeon – who have taken an interest in our project and have done surgery for us at very reduced rates. Nevertheless, the rates at the clinics make it prohibitive for us to provide for many patients in this way.
For indigent patients, the Mexican Federal Government provides urban and rural health centers or “Centros de Salud”; the State Government provides the urban Hospitales Civiles. Both provide services at very reduced rates, but are so short on funds, personnel, and often scruples that the care provided is seriously deficient.
For our patients in need of specialized surgery, we have been fortunate to have cooperation of several doctors at the Stanford Medical Center. In a previous newsletter I described how Drs. Sissman and Shumway provided open-heart surgery for a ten year old with a congenital heart defect. More recently we have brought 7 more patients to Palo Alto for surgery. Five children, from 5 months to 13 years, all with cleft lips and/or palates, I drove up in my Jeep, together with two parents. Apart from doing the surgery, Dr. Donald Laub and his team at the Department of Plastic and Reconstructive Surgery also raised the hospital expenses and located private homes for the patients and their parents. We owe special thanks to the surgeons, to the foster families who gave the children so much love and attention, and to the Mexican Club of San Francisco, who helped meet expenses. The surgery, which was successful, will make a great difference in these children’s lives.
In June, a five year old named Sergio flew up with Dr. McKean for surgery at Stanford. Sergio had burn deformities adhering his right arm to his chest and his chin to his collarbone. Myra Polinger, who has donated -secretarial help to Project Piaxtla for six years, fell in love with Sergio on the flight home, and offered to be his foster mother. Sergio’s surgical repair has proven lengthy and difficult, with many set-backs. To keep hospital costs down, Myra has provided post-surgical care herself in her own home, a monumental task. Yet she has managed nobly. To date Sergio is still in California, and it may be months before his repair is complete and he can return to Mexico.
In July Martin Reyes brought with him to Palo Alto a terrified Patient with breast cancer. Dr. McKean, who examined her in Ajoya, considered the carcinoma so advanced that surgery alone would not control it. Back in San Mateo, he arranged with his X-Lay Department, to give her radiation therapy: Surgery was performed by Dr. Holderness at Stanford, and biopsy indicated the bisection was complete and X-ray therapy therefore unnecessary. Agustina is now home again with a new lease on life.