My first week at Hospital Vozandes del Oriente has been a mix of time spent in their small emergency department (three beds) where I see anything from headaches to a monkey bite to dressing changes from previous wounds; clinica externa, the outpatient clinic with its usual mix of prenatal care, gyn visits, checkups, and so on; and hospitalización, the inpatient service which includes surgical and medical patients and has been between 8-12 patients. Each resident follows the patients they admit, but we all hear reports on everyone and often help with dressing changes on others' patients if we are on call or in emergencia, so I have been able to see a wide variety of cases, including many things I've never seen in the States.
One patient was a 74-year-old indigenous woman from adentro (inside - i.e. inside the jungle) who came in with her seventh snake bite. Ecuador has two types of snakes, Bothrops snakes (pit vipers) called "X" (equis) for the X-like pattern on their back and corales, coral snakes with red and black markings. The venom of X is cytotoxic while corales are neurotoxic. Most snake bites, at least that make it to the hospital, seem to be cytotoxic, and there is a risk of blood clotting problems (DIC), renal (kidney) failure, hypotension, and rhabdomyolysis (muscle breakdown) as well as subsequent infection. There is a snake bite protocol we follow, which includes doing a whole blood clotting test by taping a clean test tube of blood to the wall for 20 minutes and observing to see if more than 50% of the tube is a clot by that time. If not, the patient needs antivenom (antiofídico). There is a risk of allergic reactions since the antivenom comes from horses, so we pretreat with Benadryl and steroids (hydrocortisone) and have epinephrine (adrenaline) on hand in the case of an allergic reaction. This woman thankfully did not have an allergic reaction, although she did develop cellulitis later, which was treated with Augmentin.
We also had a 45-year-old male and 35-year-old male come in within a day of each other with electrical burns, one from accidentally contacting an electrical wire during house construction and the other from being struck by lightning during one of the many storms here. In my subsequent reading, it seems that up to 40% of serious electrical injuries are fatal while up to 30% of those struck by lightning die. The major risks are cardiac arrhythmia, respiratory failure, and burns. Bones have higher resistance to electrical current than muscle, so they can heat up and cause serious deep burns, damage to the bones (even osteonecrosis), and muscle injury while the surface burns appear mild. IV fluids are required as well as cardiac monitoring. The man with the lightning strike actually went home after a few days with relatively mild injuries, but the other patient has larger areas of second- and third-degree burns, and his outcome still remains to be seen. He requires sedation for dressing changes, and thankfully we have a morphine pump for his pain control.
On my second call this week (it's been every 2-3 nights together with an Ecuadorian resident until I am comfortable on my own and an "intern" equivalent to a fourth year medical student), we had a 14-year-old girl with monkey bites on her buttock and legs. Apparently she was eating sugar cane, and the monkey decided to attack her. We were told that one is not to bring any food or bags or wear jewelry Besides needing suturing of her wounds, monkey bites also carry a risk of rabies and a risk of B virus (Cercopithecine herpesvirus 1) infection, especially in bites from macaques, which can cause a fatal encephalomyelitis in humans. We don't have macaques here, but untreated B virus has a mortality rate of 80% prior to aniviral therapy, so we sent her with acyclovir prophylaxis anyway. She also got her first rabies shot of a series of four or five (I think on day 0, 3, 7, and 14 is the regimen in the States) and Augmentin for prevention of infection. We saw her back for curación (dressing change) today, and her wounds are well-approximated (aligned) without signs of infection.
More stories later this week. In the meantime, I will be avoiding eating sugarcane in front of any monkeys (and avoiding monkeys in general!). I also look carefully where I step and where I put my hands to avoid any snakes or other unknown and unwanted encounters!
One patient was a 74-year-old indigenous woman from adentro (inside - i.e. inside the jungle) who came in with her seventh snake bite. Ecuador has two types of snakes, Bothrops snakes (pit vipers) called "X" (equis) for the X-like pattern on their back and corales, coral snakes with red and black markings. The venom of X is cytotoxic while corales are neurotoxic. Most snake bites, at least that make it to the hospital, seem to be cytotoxic, and there is a risk of blood clotting problems (DIC), renal (kidney) failure, hypotension, and rhabdomyolysis (muscle breakdown) as well as subsequent infection. There is a snake bite protocol we follow, which includes doing a whole blood clotting test by taping a clean test tube of blood to the wall for 20 minutes and observing to see if more than 50% of the tube is a clot by that time. If not, the patient needs antivenom (antiofídico). There is a risk of allergic reactions since the antivenom comes from horses, so we pretreat with Benadryl and steroids (hydrocortisone) and have epinephrine (adrenaline) on hand in the case of an allergic reaction. This woman thankfully did not have an allergic reaction, although she did develop cellulitis later, which was treated with Augmentin.
We also had a 45-year-old male and 35-year-old male come in within a day of each other with electrical burns, one from accidentally contacting an electrical wire during house construction and the other from being struck by lightning during one of the many storms here. In my subsequent reading, it seems that up to 40% of serious electrical injuries are fatal while up to 30% of those struck by lightning die. The major risks are cardiac arrhythmia, respiratory failure, and burns. Bones have higher resistance to electrical current than muscle, so they can heat up and cause serious deep burns, damage to the bones (even osteonecrosis), and muscle injury while the surface burns appear mild. IV fluids are required as well as cardiac monitoring. The man with the lightning strike actually went home after a few days with relatively mild injuries, but the other patient has larger areas of second- and third-degree burns, and his outcome still remains to be seen. He requires sedation for dressing changes, and thankfully we have a morphine pump for his pain control.
On my second call this week (it's been every 2-3 nights together with an Ecuadorian resident until I am comfortable on my own and an "intern" equivalent to a fourth year medical student), we had a 14-year-old girl with monkey bites on her buttock and legs. Apparently she was eating sugar cane, and the monkey decided to attack her. We were told that one is not to bring any food or bags or wear jewelry Besides needing suturing of her wounds, monkey bites also carry a risk of rabies and a risk of B virus (Cercopithecine herpesvirus 1) infection, especially in bites from macaques, which can cause a fatal encephalomyelitis in humans. We don't have macaques here, but untreated B virus has a mortality rate of 80% prior to aniviral therapy, so we sent her with acyclovir prophylaxis anyway. She also got her first rabies shot of a series of four or five (I think on day 0, 3, 7, and 14 is the regimen in the States) and Augmentin for prevention of infection. We saw her back for curación (dressing change) today, and her wounds are well-approximated (aligned) without signs of infection.
More stories later this week. In the meantime, I will be avoiding eating sugarcane in front of any monkeys (and avoiding monkeys in general!). I also look carefully where I step and where I put my hands to avoid any snakes or other unknown and unwanted encounters!
glad you're being careful. how's the Spanish going?
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