Today in clinic, I delivered some bad news to a patient. I told him and his wife that he had liver cancer. Three weeks ago, he came to clinic after being referred for gallstones. When I examined him then, his liver felt really rubbery and weird, to use technical terms, and when I showed Dr. Pott, he thought it worthy of an MRI. The guy had been a heavy drinker, and also had signs of chronic illness - temporal wasting, weight loss, etc.

Today, the patient came back with the results of the MRI, which confirmed hepatocellular carcinoma. After Dr. Pott and I had a hushed discussion while examining the MRI, Dr. Pott left the room briefly. I was left with the patient and his wife, and I asked them if they had been told the results of the MRI. They hadn’t. To me, it seemed obvious that the patient needed to be told that he had cancer, so I told the patient and his wife, as compassionately as I could, that he had cancer of the liver. They looked at me, stunned and confused. As a medical student, I probably overstepped my role, to tell them this without the attending doctor in the room. However, I felt that the information should be relayed to the patient and assumed Dr. Pott was about to do just that.

Dr. Pott came back in the room, but didn’t know I had told them the news. He asked the patient to leave the room so he could talk to the wife. After the patient left the room, Dr. Pott told the wife that the patient had liver cancer, for which there was no treatment in Belize, and that he had 6-12 months to live. The woman was clearly holding back tears. Dr. Pott, not knowing that I had already broken the news to the patient, asked the wife how much information she would like him to tell the patient. She replied that she would like him to say he had liver cancer, and that’s all. The patient was called back in the room, and Dr. Pott told him he had liver cancer.

In the U.S., the way this scenario played out would have been a violation of the patient’s right to privacy. Dr. Pott may have had a reason for telling the wife and not the patient the full story, e.g. perhaps Dr. Pott knew the patient well enough to know that the patient wouldn’t want to hear he had cancer and would rather have his wife make all medical decisions. I think this is unlikely. In this culture, it is likely that the way Dr. Pott handled the situation is the norm. In retrospect, before I broke the news, I should have asked the patient how much he wanted to know about his illness. Nonetheless, it was a moving experience, and I will never forget it.

Photo: Man fishing in Hopkins, Belize

I am taking a trip back to Rochester for 4 days. I’m looking forward to cool weather, as the heat index in Belize for September and the first few weeks of October was between 100-110F daily. I’m also excited to have a break from the bugs. In my apartment, no matter how much I scrub the place, there are bugs on me constantly. If I make a sandwich and leave it, or a utensil, on the counter unattended, there will be ants on it within minutes. Ants are in the bed, and on me if I’m in bed! Each morning I wake up with new mosquito bites though I apply DEET bugspray each night.

Admittedly, I’ve been getting frustrated with these physical discomforts, as well as feeling helpless in the face of the poverty that surrounds me. As an example, the family across the road from me, when I was living next to Judy, was selling the daughters for sex in order to put food on the table, (which of course resulted in more babies to feed). In the house I moved to on the north side of Hopkins, another neighbor just started a job cleaning at one of the Hopkins resorts, for what she considers a good wage of about $30Bz/day ($15 US dollars/day) to support herself and her daughter.

Since hotel and flight prices are currently cheap in Cancun, I’m spending a couple days here in Cancun, en route to Rochester. What a way to jolt me out of my third world existence! Cancun is the antithesis to Hopkins. Despite all of the complaints I’ve just detailed above, I’d choose Hopkins over Cancun any day. The people I’ve met in Hopkins are the most open-hearted and generous people I’ve ever come across. Most are down-to-earth, they look me in the eye when they talk to me, and they are genuine in what they say, even if it might offend me. Here in Cancun, humanism has been sacrificed for the sake of commercialism. Yesterday, I was looking at some silver earrings in a market, and when I told the shop-owner that I was going to think about it and maybe come back later, he followed me out of the store and yelled after me, “You’re a liar, you’re all liars!” Then I made the mistake of getting suckered into attending a time-share sales pitch, which was a colossal waste of time and energy. So today, I plan to go to the beach and try to forget about the inequities in the world. I’m already looking forward to returning to Hopkins!

Today, the village (Hopkins) ran out of water. Again. This happens all the time (about once every 1-2 weeks), and the village sometimes goes 4 days with no running water. The water I drink, I buy in 5-gallon jugs. I definitely have a renewed appreciation for clean water since I moved here.

This weekend, I've been invited to a birthday party tonight, and an anniversary party tomorrow night. I'm hoping we'll have water soon, so I can shower first!

Photos: Roadside Hawk (Buteo magnirostris); Great Egret (Casmerodius albus).

Our most recent telemedicine consult has an interesting twist. The patient is a Mayan man who has been having abdominal pain for a long time. He was treated for a bacteria as well as a parasite but has not gotten better. Because he's seen several doctors and they've been unable to help him, the people in his small village think he has a curse on him by a witch-doctor. There are two main families in his village, and the idea that he has a curse on him has repercussions for his entire family, as it is thought that the curse was placed because the family did something wrong. Small villages being what they are, the whole family is feeling shunned. Hopefully, one of the InterVol doctors will diagnose the real problem and we can spare the family this turmoil.

Today, I assisted Dr. Pott with another hernia repair, and Dr. Pott assisted me with the surgical removal of a wart from a woman's leg. I've also been getting practice putting casts on arms, and removing them. We have several kids per week with wrist/elbow/arm fractures.

Friday, the high school debate on the topic “Only those with serious mental illness should have access to health care professionals” went well. The students did a great job presenting their arguments. The team arguing the negative side of the argument won, and the photo (center) shows how excited the students of the winning team were.

Yesterday, I found a new passion, when I SCUBA dove for the first time. A friend in Hopkins, Luckie Nunez, is a SCUBA instructor, and began teaching me and two other of his friends to dive yesterday. After learning some skills in shallow water, we dove 20-25 feet deep in the coral reef off of South Water Caye. It was incredible! The colors and diversity were extraordinary, and the whole experience was otherworldly.

Photos: One of the students presenting her argument in the debate (top); students of the winning team after hearing that they won (center); those of us from Southern Regional Hospital who organized the event: Nurse Funky, Tina Gaud, Matron Valentine, Estella Humphries, Nurse Sinclair (bottom).

Last evening, shortly after I returned home from the hospital, one of my neighbors came running over to my house in a panic. Her nephew had apparently fallen while trying to pull a guava down from a tree, and badly cut his wrist on a piece of glass. When I looked at the boy, who was 12 years old, he had a deep cut and obviously needed to get to the hospital. With a tourniquet wrapped around his arm, I drove them to the hospital where things were quiet, and he was able to get cleaned up and sutured immediately, and he seems to be doing fine.

Today, I worked with Dr. Pott in the OR. We amputated a diabetic woman's finger, which had turned black and was oozing pus from a month-long infection -- not a very different scenario from many diabetic patients I've seen in the States. We had 2 other minor surgeries, one of which was a lymph node biopsy, and Dr. Pott let me do the incision, most of the dissecting, and the suturing. Exciting!

This afternoon Dr. Medieros, a breast surgeon at Rochester General Hospital, gave a teaching session on breast cancer to medical staff, via teleconferencing. The group was small, but people were grateful and found the session valuable.

Today, I gave a lecture on mood disorders (depression and bipolar disorder) to hospital staff. The lecture was scheduled for 1:00 PM, and at 1:10 when no one had shown up, I thought there must not have been any interest, and I almost left. However, the internet connection in the conference room is good (thanks to InterVol and Doran Mix, the med student here over the summer), so I decided to stay and do some work. Around 1:25, the nurse practitioner who had asked me to give the lecture came, and 10 minutes later, the room was packed with 20 people. I should have known -- the lecture was 1:00 PM *Belize time*. So, I gave my teaching session and it went great! The group had such a vivacious sense of humor that by the end, when people were asking questions, everybody was laughing big laughs, several people slapping their thighs. One staff member, as he left, said, “At first the people didn’t want to come, and now they don’t want to leave.”

A few nights ago, I was driving home from yoga around 6 PM. It had just gotten dark, but there was a full moon. I saw something I hadn’t seen before -- hundreds of crabs, crossing the road. Each one was about the size of my palm or slightly larger, and their eyes, sitting atop their eye-stalks, gleamed eerily in the light of the moon. A crustacean blanket across the road, it was impossible to avoid the crunch of a few unlucky ones under my tires. The road was still partially flooded, and suddenly I saw a slithering across the road -- a crocodile! It was probably about 5 feet long, and about 5 feet away from me. I’m glad I wasn’t on my bike that night.