There will always be patients that leave an indelible mark upon your career, future treatments and personal emotional strength. Yet medical providers do their best to find coping mechanisms to prevent the emotional burnout of seeing tragedy after tragedy, but these barriers can be overcome. I've had a few very influential patients in my short time working with medicine, but there is one at the Primeros Pasos clinic who continues to interrupt my thoughts because of his illnesses and how he his plight affects my deepest personal values. I've seen this patient three times now and he has become a frequent forethought during my time here in Guatemala. He came in once for a follow up clinic visit after going to the hospital a week before and then he came in a second time to introduce himself and discuss his future treatment options with Lauren and me. This patient, named YE for the sake of identification, went to the emergency room two weeks prior to visiting the clinic with vomiting, diarrhea, diaphoresis (sweating), abdominal tenderness, anxiety and all the other side effects of the body's attempt to ride itself of a poison. He was diagnosed with "intoxication" given fluids and some medicines to control the symptoms and sent home. In my realm of possible medical diagnoses, 'intoxication' only triggers thoughts of alcohol poisoning and a mistake perpetrated by alcohol. In Guatemala however, the diagnosis of 'intoxication' is entirely different and it was an enlightening, but very depressing learning experience for me. Intoxication is very common among men, especially farm workers and is at the top of emergency room differential diagnoses. These patients come to the hospital because they are poisoned from significant pesticide exposure in the farm fields and their bodies cannot cope with the poison properly. The field workers are absorbing the chemicals through their skin and then their bodies go into a form of shock in an attempt to filter the foreign matter as fast as possible. There is a form of chelation therapy treatment in the local hospitals that can help bind the chemicals and flush them from the body and assist the liver in the purification process, but rarely is it used due to cost and the less than impressive results.
One of the studies I found during my research on pesticides cited that the immediate consequences of exposure to small amounts of pesticide include a rash, nausea, vomiting, and blurry vision. Immediate effects of a larger and more prolonged exposure include disorientation, loss of continence, coma, and even death. Delayed consequences of pesticide exposure may include sterility, birth defects, neuro-degenerative disease, and cancer. It sounds as if YE was fortunate enough to fit into the first category where he only had the nausea, vomiting and blurry vision, but with waves of the more significant symptoms like abdominal tenderness (liver damage) and disorientation. The first time I encountered YE he was with his 5 year old child in the clinic and complaining of persistent paresthesias (symptoms of tingling and burning) up and down his legs and significant fatigue. The medical director recognized that with YE's recent intoxication diagnosis and that the legs being the frequent site of absorption for pesticides, YE's ailment was a result of the chemicals. These toxic pesticides were hypothesized to have been absorbed through the skin of YE's legs when he was spraying the crops and the subsequent exposure caused nerve damage throughout his legs and lasting discomfort.
Children of migrant workers are also at a high risk for pesticide intoxication because they come in contact with the agricultural chemicals as their family members, who work in the fields, bring the chemicals into the house via their boots, clothing, or work equipment. There have been multiple research projects in the United States studying the levels of pesticide metabolites in children's urine and the neurologic complications of organophosphate toxicity from pesticide exposure. One study, with a sample of 60 children and performed in North Carolina by Acury et al., found that one of the children studied had no evidence of pesticide metabolites in his/her urine, ?ve children had one pesticide, another had two different chemicals, 16 children had three pesticides, 17 children had four pesticides, eight children had five, nine children had six pesticide detects, and three children had seven different harmful chemicals in their urine. A combination of several toxins in a single child may have a synergistic effect and among the 60 children in the study by Arcury et al., 54 had at least two or more pesticide metabolites. Another study by Eskenazi et al., discovered that children whose mothers were exposed to pesticides during pregnancy scored lower on IQ tests and about 50% of the exposed kids at age 2 had some neurological/developmental deficit. These statistics are not merely meant to draw shock and drive fear by depicting the trauma the farmers and children of farmers suffer, it is only meant to illuminate the fragile connection between food production and health.
YE has been victimized by the chemicals used to farm here, but his medical history began 8 years before I met him and in a much more serious manner. I had heard the story of a special patient at the clinic and due to his medical history and the story I was told, I envisioned an old man, but upon seeing a strong 29 year old man with a 5 year old wrapped around his leg, I was surprised to find the contrast between my imagination and reality. I saw YE the first time when he was seeking follow-up care after the intoxication diagnosis, but it was not until hours later that I was relieved of my ignorance that the 'special patient' was the 29 nine year old man I'd treated moments before. YE moved to the United States when he was a teenager and the time when he returned to Guatemala is still unclear. He was living well for himself and was pressing for the American dream 8-10 years ago when devastating headaches started afflicting him daily with sequelae of serious visual disturbances. He had been in the United States for roughly 4-5 years and working in northern California when the headaches began. The profound headaches and visual changes were devastating and he dragged himself to the one of the best emergency rooms in the country. At the hospital he was able to use health insurance to receive the rapid and necessary testing for optimal medical care. The doctors ordered a CT scan of his brain and noticed a tumor residing near the optic chasm and sella turcica (where the pituitary gland sits) and this tumor was pushing on his optic nerves. He was referred to a neurosurgeon who followed up with more blood tests, which showed that this was likely a prolactin (hormone released from the pituitary) secreting tumor that is oftentimes controlled with medication. It appears from the paper work YE brought with him that the surgeons performed the surgery to remove the tumor in hopes of restoring his vision because he was nearly blind in his left eye, alleviating the headaches and then after the surgery they would proceed with the medication to control the prolactin levels. The surgery went well enough and he was able to go home the next day, but in the report the surgeons mention that they were unable to completely remove the tumor.
This all happened 7 years ago in the United States where Y.E. received the best care at one of the best hospitals in the country. Now he is having an exacerbation with his vision diminishing further and he is running out of the medicine, which maintains the prolactin levels and prevents the tumor from growing back. Y.E. is going in for an MRI in January to get another visual of the area, but there is only one neurosurgeon in Xela, Guatemala to serve roughly 800.000 to a million people. He is 7 years post-operation and his sight out of his left eye is less than 10%, but thankfully his right eye is above 95%. The headaches and visual changes continue to ebb and flow as he struggles to pay for the medication that prevents the tumor from growing. Lauren and I are currently exploring treatment options and fundraising potential in order to get YE to his next MRI in January with his remaining vision intact. The challenges of medical treatments continue to persist in a resource limited setting. From the children with dangerous heart murmurs to pesticide intoxications and prolactin tumors, we are pursuing medical treatments amongst the perceived resource restrictions in order to restore health in Guatemala all while managing the indelible effects of memorable patients.