These are several of the commonest concerns/chief complaints Belizean adults (ages 18 to 50) will present with on Mobile runs. Often it is necessary to educate the patient on what may or may not be done at home for both the mildly ill to severely ill patient. Also, it is helpful if they are instructed on what constitutes medical urgency vs. emergency so that they may plan accordingly. Remember, many individuals don’t have either hospital or ambulance service nearby. Taxis, ambulances and helicopters and hospitals need to be contacted via phone and, more often than not, there is no electricity or phone in the home. We hope that these brief pointers will be helpful.
-Daria & Julia, 2003
Prevention is the best form of treatment, and the most basic form of prevention is simple good nutrition and hygiene. For any patient with any illness, be sure to stress the following:
You will see a myriad of
cuts, scrapes, bites, rashes, and other skin problems in the patients here in
**Don’t forget to consider an allergic reaction, especially with a sudden-onset purities/rash coincident with a new drug, herb, or food.**
Most bug bites are annoying rather than harmful by themselves. Problems can arise when they become secondarily infected, which can happen when they are scratched raw and opened to invading bacteria. Discourage scratching, and recommend baking soda paste or other traditional poultices for the itching. Watch for signs of secondary infection. Fever with bug bites can signal a more serious illness – see the section on fever for info on malaria, dengue, etc.
There are thousands of causes
of skin problems, some familiar and some unique to
Many patients will present with cough/cold of less than a few days duration and some which have, per pt, been going on for weeks or months. It is important to determine if indeed it is truly a chronic cough or if instead it is what I call back-to-back URIs. TB does exist here, even if many are vaccinated with BCG. It is important to remember that TB is more prevalent during the rainy season. Also cough may be a sign of parasite infections, remember that some species migrate to the lungs (i.e. hookworm).
Insofar as some common sense advice, this is what I would recommend be said to the patients:
Many patients will come c/o abdominal pain, constipation and/or diarrhea and request that they be given worm medicine. It is important to realize that while parasitic infestations are very common here (there was a survey in 1986 that found >70% of the population was affected), constipation, diarrhea and abdominal pain are rarely signs of helminth colonization. It is important to have patience in extracting the details of the abdominal pain/diarrhea/constipation triad. Sometimes patients will think that diarrhea constitutes going to the bathroom twice in one day or that constipation is not having had a bowel movement that morning. It is important to pinpoint what they truly mean by abdominal pain. Sometimes the abdominal pain they are describing is more what we would anatomically define as pelvic or flank pain and often they don’t qualify the pain until you ask. It is also important to realize that many patients don’t look at their stools; however, it is still necessary to ask if they have seen anything in them, mucous, blood or worms. Fever is also key. It is also critical to determine how hygienic is their food preparation and to remember that many don’t have an icebox. Ask if they have any other illnesses (remember sometimes measles and UTIs and OM cause diarrhea, as well as AIDS and malaria) where their latrines are or aren’t, if they have eaten a lot of unripe fruit, if pigs and chickens and dogs have access to the house and if they are taking any medicines or herbal laxatives.
After you have determined the most probable causes of either the abdominal pain or diarrhea or constipation, this is what I would recommend be clarified:
As stated above, many persons will present thinking they have worms secondary to belly pain/diarrhea or constipation, however, it is important to investigate a bit further, specifically, into personal and household and village hygiene. Because if things such as latrines that are not 20 m away from wells, use of a common stream for bathing, cooking and drinking and sewage disposal, the undercooking or under-warming of foods, the cohabitation of farm animals and people as well as people walking about barefoot occur, then parasites are guaranteed a long sojourn, as well as other bacteria. It is important to stress the washing of hands before preparing foods and trying to keep leftover food away from flies/other animals, and thoroughly reheating it before it is eaten.
It is important that whenever you suspect a parasitic infestation to refresh the memory of the patients regarding basic personal and household and village hygiene as well as dispensing mebendazole.
These are the most common intestinal parasites you will encounter:
Most of the male villagers are subsistence farmers. It is backbreaking, constant work often without tractors or other more modern equipment. Women wash thing by hand, on their knees, carry and tote heavy loads, and carry babies on their backs. Chronic low pack pain, muscle spasms and strains are common here. NSAID’s do help most of these, however, for chronic problems, or repetitive strains, it is important to teach them that it is necessary to rest in between repetitive activities, if only for a few minutes, to stretch the muscles after staying in a particular position for hours on end, what exercises are needed to strengthen the injured muscle, to help with the low back pain. It is critical not to teach them things that they have done for centuries, such as carry their babes from a big kerchief wrapped around their head, are not wrong. They will continue to do certain things because it is Tradition or they have no other choice. I would also recommend giving the full course of medication for an acute sprain/strain/spasm, but for chronic aches and pains, to give only a 2-week course and a script.
For bad sprains/strains: recommend ice 20-30 minutes every hour or two for the first two days, to reduce the swelling, then hot soaks/cloths after two days. Elevate the injured part as much and often as possible, especially when sleeping. For bad sprains/strains: recommend ice 20-30 minutes every hour or two for the first two days, to reduce the swelling, then hot soaks/cloths after two days. Elevate the injured part as much and often as possible, especially when sleeping. For bad sprains/strains, keeping the joint motionless and well supported for 2+ weeks is recommended
Osteoarthritis is common here, from overuse, and it is necessary to explain to them that it is a chronic problem.
Don’t forget to recommend taking NSAIDs with food.
Discuss with them that if a joint is swollen, tender, red, painful, or if they cannot put weight on their limb or have sudden onset of back pain with parasthesias of feet/limbs or loss of continence, they should consider seeing a doctor. Also discuss the difference between a sprain and a fracture.
Prostate, Breast and other malignancies do occur here. Be on the lookout when someone presents with cachexia and horrible bone pain. Also remember Pott’s disease. TB does spread to the bone.
A common complaint, it implies and describes different things to different patients. It includes fatigue, tension, migraine, and fever. First and most importantly, clarify exactly when the patient means by headache – describe frequency, duration, onset, alleviation, interference with activities, etc. It’s always good to ask the patient what he/she would like you to do about the headache, as this will give you an idea as to how much the headache is bothering him/her. Don’t forget to ask about trauma history!
A. Tension headaches: The most common type, usually brought on by work/stress and relieved with rest.
- Get out of the sun
- Rest
- Drink plenty of fluids – better water/juice than soda/sugary drinks
- Eat something
- A warm cloth on the forehead or back of the neck may help
- Massage (neck, shoulders, etc.) either by self, friend, or traditional healer may also help
- While NSAIDs and Tylenol do work for these headaches, encourage patients to try other things first, and write a script rather than give lots of samples – these headaches may be uncomfortable, but they are rarely incapacitating.
B. Sinus headaches: Characterized by pain over the maxillary, frontal, or ethmoid sinuses, worsened by pressure/percussion of the sinuses. Often in conjunction with sinus congestion.
- Eat well, drink fluids, etc. to help body fight off acute infection
- Steam inhalation (lean over a bowl of steaming water with a towel/cloth “tent” to help contain and concentrate the steam) can help both acute congestion and chronic sinusitis
- Decongestants can help, but only for acute cases. A more thorough workup as to the cause of chronic cases is needed before dispensing medicine
C. Migraines: Classically throbbing, one-sided headaches with vision changes, nausea/vomiting, and light or sound sensitivity.
- First, recommend patient try NSAID + caffeine at first signs of one, especially if they are a chronic problem.
- Migraine medicines are available (although I’m not sure which ones are on formulary), but they can be hard to come by.
- Evaluate for functional impairment – if the headaches are interfering with activities, do a thorough workup and don’t be afraid to treat!
Many will come in
complaining of fever, and more often than not will be afebrile. If they are febrile, there is a policy in
It will be difficult to obtain a good history of the fever, for most patients don’t have thermometers or clocks, but it is extremely important that you try to obtain as good a sense of the pattern of the fever as you can. There are many infectious processes that are characterized by specific patterns of fever, malaria being only one of them.
Malaria – begins with chills and often a headache, the person shakes for 15 minutes to an hour, chills are followed by fever, often >40 C or more. The person is weak and flushed and often delirious. The fever may last hours to days. Finally the person begins to sweat as his temperature goes down. In the beginning a person may have fevers daily, but over time the pattern of fever is every 2-3 days. Look for a large spleen and pale mucous membranes as well.
Dengue – headache with periorbital pain, sudden high fever accompanied by delirium, severe arthralgias and myalgias that lasts 3-4 days. After 3-4 days everything resolves for few hours to 48. Then the illness returns, accompanied by a rash that starts on hands and feet and spreads to the trunk, sparing the face. It may be accompanied by petecchiae and bruises if it is the hemorrhagic subtype.
How to avoid both of the above? Easy: recommend mosquito netting and avoiding having things like old tires and broken pots and pans in the yard that may collect water. There are malaria and dengue control workers that go from house to house and spray as well as f/u on all malaria and dengue cases.
Meningitis – it does occur hear although most are immunized against measles, mumps and rubella. Think of it when there is the triad of severe headache, neuro deficits accompanied by vomiting and a stiff, sore neck. There is also tubercular meningitis, but it is rare.
Typhoid – Begins with a cold, sore throat, sometimes a dry cough. Temperature goes up a little more each day until it reaches >40C. Accompanied by bradycardia rather than tachycardia. Sometimes there is diarrhea and it may lead to dehydration. Delirium may occur. It is important to stress good hygiene. This is a disease that is passed via water contaminated with feces. It also often appears after a flood or other such natural disaster. Recommend that if anyone has typhoid at home he should be in a separate room and no one should eat or drink from the dishes he uses. His stools should be burned or buried in deep holes, away from water. Washing hands is critical. Also, remind them that people that recover may still spread the disease, and should not work with food. Remember Typhoid Mary?
Typhus – Similar to typhoid insofar as pattern of fever, however, after a few days of fever and headache and chills and myalgias, a typical morbilliform rash begins starting at the axillae and spreading to the trunk, then the extremities, sparing the face, soles and palms. It is spread by lice, ticks and rat fleas. Personal hygiene must be stressed, as well as not allowing dogs in the house, and not handling dead rats. Dead rats should be burned or drowned.
Hepatitis A – a low grade fever accompanied by loss of appetite, abdominal pain in RUQ, emesis and jaundice. Oral fecal precautions.
Rheumatic fever – Pain in joints with high fever after a sore throat are clues. Remember the criteria. Also, think of it if you are told the child has fevers and spastic, dance like movements.
Brucellosis – this disease arises from drinking un-pasteurized milk or it may also enter the body through scrapes in the skin and contact with sick animals. Usually starts with increasing tiredness, weakness, loss of appetite and stomaches. The fevers usually begin in the afternoon and chills in the early morning. In chronic brucellosis the fevers may stop for several days and then return. Lymphadenopathy is sometimes present.
Of course, there are more common causes of fevers, such as PID, UTIs, OM, pharyngitis, etc. but again, I cannot stress how important it is to obtain the rest of the history from the patient, for often they will not volunteer or have noticed a pattern to the fevers or other symptoms until you ask. Insofar as advice to give:
DM, especially type 2, is a
common and chronic problem here, just as it is in the
For chronic patients, medication changes will be made largely based on their level of control. Ask what time they took their meds that day not just if they take them in general. If they don’t take their meds, find out why. Remember to keep medication regimens as simple as possible – no more often than twice a day for chronic meds. Most patients can and do get into PG Hospital to have prescriptions filled, and we have a limited supply to meds, so it is best to give two weeks’ worth of meds and a script. Be sure to document that you gave a script and for how many refills, so the next group of volunteers don’t repeat the process. (Along the same lines, be sure to look at previous records to see if they already have a script with refills.)
Just as in the Western World
the people who have high blood pressure often are not aware of it, have comorbid conditions such as diabetes, and must be reminded
to take their medications. It is also
difficult, just as in the
I would advise as follows:
You will be doing prenatals in a hammock. You will encounter grand multips and teenage
pregnancy. It is normal here.
Hospital deliveries are not common. In fact, most women deliver at home. The grandfather and grandmother usually supervise the first delivery of a couple. It is important to stress to them that if they plan to deliver at home that they have access to a trained medical professional and to discuss with them the warning signs of pregnancy…bleeding, headaches with weight gain and abd pain and facial edema, foul discharge, back pain with vomiting, dysuria. It is critical to explain that the woman needs to eat plenty of food, to consume legumes, leafy greens, plenty of protein and milk. Most will need vitamin supplementation and may or may not get it at the pharmacy, but it is critical to stress that a generic multivitamin does not contain enough iron or foliate for a pregnant woman. I would recommend giving out about 30 days worth when visiting as well as writing a script. I have sometimes been told that PG hospital has run out of vitamins, recommend that they also look at the store or pharmacy. Also, some believe citrus is bad for babies. Please try to encourage consumption.
It is important also to explain to have clean (as in boiled) instruments to cut the cord and clean towels on which to lay the baby. Often Mayan babies are delivered from the squatting position onto the dirt floor or a pile of dirty bags or old towels. It is also critical to explain to them to cut the cord short, let it dry on its own, not to cover it or to spread pastes on it. Tetanus may infect the baby in such a fashion.
Insofar as the placenta, in Mayan home births most husbands tie the cord to the ankle of the squatting woman and wait until it comes down on its own. Please stress to them that if it does take longer than ½ an hour or if bleeding occurs that they should take her to a hospital or contact a midwife or other health worker.
Try to encourage them to have some monitoring from a professional if possible, but don’t feel put out if they resist it. Tradition is a powerful thing as well as the inability to access health car all the time. Just help the pregnant couple plan in advance for contingencies and complications and often that will be sufficient.
Patients will often ask for these. It is important to realize that most people actually eat a healthy diet here and don’t require vitamins or supplements. Stress the importance of a varied diet – vegetables of different colors, fruits, grains, and some fat/oil. It is much better to get the necessary vitamins from food than a pill. People are starting to pick up the American habit of relying on a pill to fix their problems.
However, if a woman or man appears anemic, you must consider supplementation as well as further formal evaluation. Think of parasites, malaria, neoplasms as well as problems with nutrition. Most women are iron deficient from a string of pregnancies. It is better to give them iron pills alone than multivitamins, but multivitamins are better than nothing. Vitamins may be bought as stores, found in pharmacies, both hospital and private. If you are to give any out, give enough for a month as well as a script with refills. Tell them that they will need only one script. Recommend that they continue to eat healthy. Vitamins are not the only thing that keeps one healthy, nor are they a cure-all.