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maggots in a tunneling ulcer
Ah, the Asilo…one of the places we heard about here in Panama when we were still in Honduras. We found a unit seldom visited by a doctor (in a year), but with a wonderful staff of no more than a cook, cleaner and nurse on each of the two 8 hour day shifts and 2 on the night shift. There are 27 patients there, all elderly, ranging from totally mobile to totally bedridden, some without sight, some without limbs, many with varying degrees of dementia—they all have to be fed, bathed, many changed, floors cleaned, meals prepared and cleaned up after…the fact that the floors are clean and the patients are clean and fed is an extraordinairy achievement, but the patients need more attention.
When we got there I thought they were totally medicated…so many of them looked so catatonic…it turned out almost none of them were medicated,
They seemed so catatonic when we first were working there
or where very occaisionally medicated. They were just bored and unstimulated, almost into catatonia. It was months before some of them spoke; I came back from 5 weeks in California to find patients that I thought had no power of speech actually talking with me. It was like awakenings, and it isn’t because of medication, it is because of all the time our volunteers and people in the community have spent with the patients there. Many had not been out of the grounds for years, and now walk in town weekly—our friend Javier, a Colombian physiotherapist in town who also works at the Asilo, brought his four horses and our elderly patients dressed up and rode like kings and queens through the streets, looking down around them as if to say ‘So…this is Bocas, you say.’
one of 3 trucks of trash we removed
The mayor sent three trucks and we removed several tons of rusted metal and trash from the grounds and landscaped a little (more to go), repaired two broken washing machines and plumbed 3 in total (the only working one had been filled by bucket), installed handrails in the common area for walking and physio, changed the showerheads to removable handle versions, put a commode chair in the bathroom, created and update charts for the patients, provide medications, and have done our best to provide the additional more advanced care that the staff are sometimes not able to provide.
When we arrived, there was an elderly stroke victim, immobile and unable to communicate, and terribly emaciated and contracted with bedsores
emaciated, rigid, and covered in bedsores
all over. We worked for weeks, doing wound care and working with the staff to use advanced wound dressings we provided and creating turning regimens—our goal not to extend his life, but to allow him to die with more dignity and in greater comfort. At one point he got a chest infection and we stood by to administer oxygen and midazolam and buscopan to make him comfortable as he passed, but he rallied…and subsequently gained 12 pounds and the ability to focus and speak a little (very, very little) before he died quietly one night in his sleep a few months later.
ulcers spreading in a deteriorating body
And he died with not a single bedsore on him…that was a victory to me, at a personal level. I hate it when people die with their bodies disintegrating externally around them as well as internally. It is unnecessary, but totally natural for birth and death to be so awkward and difficult…the first time doing ANYTHING is usually awkward and difficult: the first day of school, first kiss, first great loss, first great love, first great adventure, the first and final sunset cruise, and finally, the end of the voyage.
Any ship, no matter what storms it has weathered and what damage it has sustained in a long life of navigating unknown waters, wants to look its best when it pulls into harbor for the last time. There should be dignity at the end, as much as can be wrenched from an unfeeling universe. Not always possible…but always a betrayal not to even try.
My cousin, a physical trainer, just arrived here for a few months…I have another patient in the Asilo who has not walked for 9 years after his stroke. He stood up the other day after exercising on his own, ferociously, with some basic exercises we showed him after we applied a difene patch to his paralyzed knee for knee pain, and he and we found out the immobility was more pain-related and he could move it a little. He freaked out an dhas been exercising like a fiend.
Our friend Bolivar snapped some pics in the asilo while we were working there one day
I came back from California and he collared me from his wheelchair and looked me in the eye and said ‘Yo Puede CAMINAR!’ And stood up, giggling like schoolgirl. Sometimes things are too much for me to process when they happen…later at night, especially when I’m writing a blog or making a facebook album of the day, I start to process…thinking about that patient a lot. I want to go for a walk with him before he dies—and he might live for many more years, so if he does, I’d like him to be able to walk, and he REALLY wants it, more than almost any patient I’ve ever seen. I feel tiny beside the strength of his determination.
Matt and I changing a suprapubic catheter blocked after 11 months of neglect
I tell all my incoming student volunteers (I have my little speech about this prepared): “You are so lucky we have the Asilo for you to volunteer in. Not only does every second you spend there interacting with some of the loneliest people I have ever seen benefit them beyond what you can know, but care of the elderly—and especially in this setting—is where you find out if health care is for you.
Eve and Sarah doing wound care on tunneling ulcers
“Yes, it’s challenging, the medical issues are very complicated, the patients may have dementia and can be challenging, and you have few resources to deploy except what you can somehow manifest…but beyond that, its where you learn things like ‘are you the type of person who is thoughtful enough to throw a corner of a sheet at least over the exposed genitalia of some bedridden shell of a human during some procedure that leaves them all exposed?’ Or ‘When you lift a frail contracted foot off the bed, do you automatically support the knee out of awareness (to avoid torqueing the knee)?’
walking the patients
“It’s a good place to learn PATIENT CARE…not something everyone can learn, because some aspects of it I just don’t think you can teach. I feel like I have to practice at it constantly…people are afraid of old people…can you learn to look past the rotting shell of their failing minds and bodies to ressurect in your mind’s eye when you look at them the glory of their individual histories? It is like looking at old ships tied up in the scrapyard and neglected, never to leave again…remember that those ships voyaged 70 or 80 years across 2 or 3 of your lifetimes…can you see who they were and what oceans and storms they have passed, somewhere inside the wrinkled, frail bodies awaiting their final voyage?”
I love the Asilo…my volunteers go more frequently than I (I only have 2 hands) these days, but I love going in and seeing my friends there. We need people in the community to each give 30 minutes once or twice a month…come on…an hour a month, that’s pretty good…want to walk patients with us? It is awesome—email us or (better) contact us on facebook if you want to go for a walk with us and be checked out to walk patients on your own. One hour per month…you saw the walkway we all built in La Solucion; a miracle happened because everyone showed up and made it with their hands and time.
giving time
Make a miracle happen at the Asilo…everybody give an hour a month, and every patient will be walked several times a week instead of never. They’ll get stronger and be more fit (less pain), and be more mobile (and they HAVE to be, the ones that are bedridden have the worst time of it). Let’s make it happen Bocas!
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Awesome O.T. Ashleigh Using Finger Paints With One of the Kids From the R.B.C.
On Wings Of Angels
A few days ago we did a house call from the RBC Center to a lady who was 6 weeks post stroke. The family’s house was at the top of a 35-foot steep slope, and she had pretty complete right sided paralysis. Her speech and cognition were affected badly; she seemed unable to understand questions and had no speech. She had a permanent indwelling catheter, and could eat and drink when fed but her swallow was affected and she seemed to be aspirating a little bit (saliva or fluid entering the lungs). Like most elderly or infirm family members in the developing world, she was being cared for at home.
There was not much I could do to help her improve, although her stroke was so recent that it was impossible to say how much spontaneous improvement she might experience over the coming weeks. We told the family to interact with her as much as possible and Annee demonstrated passive motion exercises the family could do with her to help prevent contractures and blood pooling, and discussed turning and bedsores. We talked about signs of urinary tract infection (always a danger with permanent indwelling catheters). And the folks from the RBC center are going to try and help out. Overall, the prognosis was not good, but there is one thing this lady had going for her that many elderly patients in the US and Europe never enjoy.
In the US and Europe, the general tendency is to stick elderly family members in nursing homes and visit them occasionally, usually out of some kind of guilt or obligation. I worked in Care of the Elderly in Ireland and I saw it everyday. The first time I did a house call on an elderly woman in Africa, who coincidentally had also had a stroke, I was ashamed of how we treat our elders in the developed world. Here in Honduras, as in Africa and Haiti and everywhere I have been, older people live with and are cared for by family members in their homes. They do this for two reasons—first, because they have no choice; there are few nursing homes to deposit and forget elderly family members. The second reason is because the culture in most developing countries has much more respect for the older generation, and elderly people get home care and attention from their families simply because that’s the way it is.
The granddaughter of the elderly stroke victim hovered over her grandmother, stroking her hair and talking to her. The family washed her and cleaned her, emptied her catheter bag, fed her and talked to her and interacted with her. Lying there paralyzed, she received the most tender care and inclusion in the life of the family. There may have been no advanced tech available but this lady was being wonderfully cared for. And a week later, she got some of her comprehension and speech back, and some control over her right side mobility. With love and more care, hopefully she will recover enough to regain some measure of independence, but if not I have confidence in the care I know her family will provide if she remains permanently disabled.
The RBC Center, para los ninos con incapacitados, is staffed and run by people who have extended the kind of care they would provide a family member to the kids and people in the community who have cerebral palsy, have had a stroke. Ashleigh has been there nearly every day she was with us, providing Occupational Therapy and Physical Therapy and helping the clinic workers learn new techniques of therapy.
I am amazed, and very proud of what Ashleigh has accomplished at the RBC Center. She and Annee started a Yoga class for the mothers of the handicapped children, many of whom have bad backs and joint pain from carrying their immobile grown children everywhere. The women who come to the center love the class; one 57 year old woman said it was the first time she had ever exercised, and she was so proud of herself. Peggy from Clinica Esperanza gave us a couple of children’s walkers, and a few days ago a 7-year old boy walked for the first time, and a 9 year-old boy wrote his name for the first time.
Ashleigh does movement therapy, sensory therapy, passive massage; pretty much everything—Supertherapist! Fridays are my favorite day…on Fridays I always go to the RBC Center and see patients, young and old. I treat a lot of gastritis and arthritis there; the moms of these kids have lots of stress and physically challenging lives. But on Fridays, when I am there seeing patients, I get to see what Ashleigh and everyone is doing—giving attention to the children, giving the mothers a desperately needed rest from the constant care they have to provide, helping people get their mobility and independence back. Annee, Sky, Noah, Sirin, Rachel, and Nick have spent many days working with the people at the RBC., and I love when we get to all work in the same place.
It is wonderful what can be achieved when you are helping somewhere long enough to learn the lay of the land and what the real needs are, and make the friends and connections necessary to undertake more ambitious projects. Of course, you also need outstanding individuals like the volunteers that have come out to help us. Ashleigh was amazing in action; when she went home it was a sad day for us and also for the clinic staff and patients and families.
The clinic closes for an hour at lunch, and we usually walk down the road to our friend Sherman Arch’s Iguana Park. Sherman is caracol, meaning of white descent but an islander who speaks the patois of the island. He is second generation here, and on his property iguanas are not allowed to be killed, so over the decades they have congregated. He takes in rescue animals, including monkeys and coatimundis, and does turtle rescue. He often feeds us at lunch and sometimes gives us rides back to the boat in his truck or the 37-foot skiff he made himself. He has been enormously kind to us, esta un bueno hombre, another angel we have met.
High in the air during a night flight across the dark ocean a week or two ago, I suddenly remembered a story I read years ago that seemed appropriate for the moment. It happened on the way back from a patient transport in the helicopter to the mainland, and I was sitting in the back thinking about what Floating Doctors became after starting so long ago as a decision made on the plains of East Africa, when I decided to go back to the developing world with more help. I contemplated the path we followed to make Floating Doctors a reality; I thought of all the heartbreaking setbacks and the glorious triumphs that were achieved by the goodwill of people who seemed to come out of nowhere to help pick us up when we fell, and encourage us to keep going, and who worked side by side with us.
The story I remembered is about a man climbing a tall, steep mountain in his dream. After a desperate struggle, he makes it nearly to the top…then falls. The story says that when it comes to the dreams perched high atop the mountains of your mind, it is sometimes a mistake to climb to reach them—but it is ALWAYS a mistake never even to make the attempt. If you climb, you can either succeed or fall. And sitting there in the helicopter, thousands of feet above the dark, luminous, serpent-haunted sea, I understood in a very literal way the third option mentioned in the story: sometimes, when you fall during the climb to reach your dreams, you find out you can fly.
There have been many angels who caught us when we fell and who helped Floating Doctors continue forward. I know I talk about it a lot, but I don’t care. I wanted to thank you all again very much, and to know how much it means to me that you believed in us and helped us and worked with us to make Floating Doctors fly—both in spirit and, riding the clouds over the gulf of Honduras, in literal fact.
