Thursday, April 30, 2009

A Letter From Mexico

I wanted to share this e-mail from a Doctor in Mexico. He is a member of an emergency management mail list and has been letting us know how things are going down there. Some lessons for all of us up here in the states.

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Hello everybody, there have been long days these days. To make it different I will begin to just throw my ideas, I don't know if it is helpful for you... but might give you and idea on how I am living it here. I need some kind of catharsis. At the end I will sumarize if you want to skip the rest.Today just before comming back to home my wife told me my two year old son was warm. I came home he was on this bed, he was sweating but he was ok, his temperature was 37.o C... I hope you can make the translation to Farenheit... (Editor: 98.6F) but had no fever. He is OK and I am pretty sure he will be. I think fear is more contagious than flu.My wife is kind of mad: when I am home I am tired, making phone calls trying to get a hospital for a non Flu/cold patient who has an infarction and is not able to get attention in the public hospitals because they are packed with flu-like symptoms, most of them colds, or just the idea of being sick.

Once I have the opportunity to be with her, I am so tired that the only thing I can do is sleeping, to get a phone call from one of my patients just an hour later... "No, madam, no, if she has no fever, no sore throat, no aches, etc it is quite possible is not -The Flu- ... you want me to check her, of course is your daughter, I put on my jeans go, check the girl with a common cold and then come back home". Nevertheless I have the feeling the number of calls was lower today.On the other hand I am called by the physicians at the local General Hospital: "Juan, there are many patients comming, one out of 10 or 20 is suspicious, but the epidemiologist doesn't take a swab on those that are only symptomatic and doesn't have hospitalization criteria.

They are only testing... and treating, patients that have respiratory failure or some reason to put them into the hospital. What do we do". ... Nevertheless they tell me they have the feeling the numbers are lower. Fewer patients are coming, and less of them that can be classified as suspicious. And I think that is only happening in the local general hospital, not in the other two hospitals here where they have treatments. On monday, some of my med students called me from Mexico City, there are 6 of our students doing their internship there. "Doctor Fraga, the students from other universities have already left... they are asking us to stay and to do our job and their job... we want to stay and help, but there is a lot to do here" later during the day the University asked the hospital to let our students leave if they wanted too without any academic punishment. There is no written word on what is the duty of an intern, but generally speaking interns from public universities are still there, interns from private universities are not working during these days... ¿?

At the local red cross we have a small hospital, more like a clinic... we don't have spaces to have patients isolated, so we agreed with the local Health Ministry to send the suspicious cases to the general hospital, I call the following day to the state's epidemiology director to see if the patients were confirmed. We have refered around 10 patients... none of the patients have had a sample taken.... were they misdiagnosed at hour hospital or finally the test was not done to them because of another reason?? I don't really know. The thing is that I personally checked today one of our physicians... he had 38.5o C, Strong headache, Astenia, coughing, myalgias, artralgias... I gave him the treatment, but the only place he was able to test was the health secretariat. Finally he had the swab taken at 19:30 we will now if he had influenza A in a couple of days.

Apparently tomorrow we might be able to get quick tests from the health secretariat and be able to treat the open population that doesn't need to be hospitalized.... in compensations to what is happening at the local general hospital.I am watching the news, the national Health Minister is smiling and saying that things are not as big (apparently) they have got confirmation from the first cases and they can say that there have only been (until now) 99 confirmed cases of swine flu (not only type A influenza but N1H1) and from these confirmation 91 are OK and 8 died... obviously there are many confirmations pending... There are anouncing a presidential message on the TV: He is repeating most of the information that you have seen in the news, including the recommendations that have been around the media since the weekend: avoid public places, use face mask on the public transport, use hanckerchiefs, etc. We have some free days coming and he is recommending the population not to go on holidays, to stay at home (good I think).

He is saying that all hospitals and clinics are open to treat the people... mmm he might want to come to Queretaro, I think. He is saying that people should receive treatment since the first hours... I hope that our state's epidemiologists see the TV today.... More activites will stop tomorrow... mainly non critical federal government activites until may 5 but most of these days correspond to non laboral days (May 1, and 5 plus weekend). Well at the end he only said that they will continue with the efforts until next week.Sumarizing and adding some interesting points:-

There are clear indications on how to behave for the population, the health care facilities, etc... they can even be downloaded from the Health Ministry webpage: http://portal.salud.gob.mx/ soon they will place statistics there.- Data reporting is not consistent, some states report suspicious cases (based on symptoms), some states wait to have results on influenza type A results (48-72 hours), others (like mine) will wait to have H1N1 results (1 week). Remember this year is also an electoral year... (I feel awful admitting it can change the way they communicat things). I think a healthy behaviour would be to sumarize cases using the information on three columns: suspicious --> influenza A --> H1N1 it would also help estimating how good is each diagnostic strategy (clinical, inmunofluorescense, etc) for future experiences. People would understand a little bit more.- Monday and tuesday were tough days at the hospitals, today they are still busy but either more organized or with less patients, my colleagues don't complain as much as the other days. - Many cold cases, few flu-like cases... I have get tired of insisting it might be a good idea to open mobile clinics or check patients at their homes... day-to-day activities at the hospitals were many before this, now they have to work on both things... and extra effort needs to be placed to avoid overwhelming hospitals.-

Until now I have personally checked two health care providers, one was a bacterial infection (not flu) the other one is suspicious... I will have results in a couple of days... if he comes positive, that will mean that one of the patients he saw, sent to the general hospital and were not studied further, was also positive.... I really hope he comes negative.- Private hospitals (until today) were not included as part of the response here. Until today they would only detect suspicious cases, isolate them and call the health care authority to have the treatment and study brought to the patient. Apparently tomorrow they are beginning to do some diagnosis and might be able to get antivirals which are controlled by the government right now.-

On Monday you could get N95 masks at 9 pesos/piece (0.80 american dollars), today they are at 20 pesos (1.5 american dollars). Wouldn't it be a better business for 3M and similar companies on the long term to donate this masks? I mean, right now I think they are selling less of the rest of their products (paints, etc).- The people at the community level is behaving fine, they are responsible and do what the TV says: stay at home, increase your hygiene if you think you can have the flu go to the hospital.I am pretty sure that many of the suspicious cases will end up not being confirmed, nevertheless some kind of aproach should be established, I am with the early blind treatment people (remember treatment in the first 48 hours is better than later on) and then wait for the result. Some institutions are waiting for Influenza A confirmation between starting treatment. I think there is not an homogenous approach here. Speaking from many perspectives: communication, treatment, etc. I know some exercises were made at the federal level, but few at the local level. They are not considering much the EMS services as part of the response, I have to be quite proactive to communicate with the state's epidemiology director and honestly I don't have the feeling I got many answers there.Because of my words, you might have the feeling that things are worsening here, but honestly speaking I see people more calm, less visits to the hospitals, and the official numbers are not growing as fast, as well as the unofficial (colleague to colleague) impressions.

Today I am just kind of tired and a little bit frustrated knowing that some suspicious cases are not being treated nor studied further than the clinical testing at the local hospital. I really think most of this people doesn't have swine flu, but some of them might and if there is not an opportunity to run a test in every patient, then at least it might be good to offer them "empirical" treatment if it increases the patients' prognosis.Remember that I am only speaking about one small city, not the big picture...

I think that in Mexico City things are better with the response, but the hospitals are still busy.I am sorry I was not very objective today, I hope tomorrow I can send again some raw data...........My wife is sleeping now... she will be mad again.... I think I will have to by her flowers tomorrow :)I hope she allows me to open my computer again tomorrow at night to write you what's happening here... See you soon :)

1 comment:

  1. when discussing the issue of Pendamic planning in the past, we felt that bring people to one site was counter productive. We decided that a drive by situation would be better suited as it would reduce the exposure of other and also to the care giver. Think of it as going to a dive food fast food service but instead of getting food you get the shot.

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