Adios

I'm going to miss this place.

Delivering babies: fun.
Living on the border: amazing.
Working in a hospital that serves this for lunch: best job ever.

Of course, the only thing that softens the blow of coming down from one adventure is planning the next one, and that process has already started. Of course, I'll need to tend to some of the more routine adventures of adulthood first, but it won't be too long before I'm back on the trail. I can't wait.

Crossing the line

I ventured into Mexico yesterday, and I'm tempted to weave a harrowing story about bandidos and coyotes. The truth, however, is a lot less interesting. Despite its reputation, the other side of Nogales is just as calm as our side. The trip was almost disappointingly easy!

I didn't have much of a travel agenda. My loose plan was to explore the medical tourism industry and have a nice meal. Other than that, I just wanted to walk the streets and see the city in person.

But first, I had to talk my travel buddy into coming down from Tucson.

It wasn't very difficult.

Crossing into Mexico is pretty easy. You literally just walk right in. Occasionally, the country uses a stoplight system to randomly check bags, but even that's not too hard. You just press a button as you walk past the customs desk and a stoplight activates. If it turns green, you keep on walking. If it turns red, you open your bags for the agent. But yesterday, they weren't even doing that. It was a sleepy Sunday morning, and the Mexican customs agent just eyeballed the few people trickling across. We didn't even have to show our ID.

And just like that, we were in another country.

We only had to walk another twenty or thirty feet before the activity started to pick way up. But the bars, restaurants, and shops that the area is known for have almost entirely been replaced by pharmacies and dental offices.

Now, you may be picturing one or two pharmacias dotting the streets, but literally every storefront for the first two blocks into Mexico was for a medical tourism operation of some sort.

Gone are the street hustlers beckoning you in for a cerveza, amigo. They've been replaced by well-dressed professionals offering amoxicillin, CPAP machines, and tooth cleanings at very competitive prices. It was surreal.

The Sonoran government has been heavily promoting medical tourism along the border, and it's a smart move. For a variety of reasons, the stream of southbound leisure travelers has dried up, but people are more willing to head across the border if they can save hundreds of dollars on medical or dental care.

It's no secret that the cost of care has been skyrocketing in the US. There are many reasons for that, but a major one is that drug and device companies see the well-insured, highly-subsidised US patients as their primary profit centers. It's not at all uncommon for a pill that costs $.02 to manufacture to be sold for $10-50 each here in the US. In other countries (even developed ones), the profit margins are far more reasonable. Of course, it's entirely reasonable for the drug companies to make profit from their developments, but charging hundreds of dollars per dose seems a little exploitative.

I don't want to go too far down the health policy rabbit hole today, but I think it's important to know that  in 2003, Congress passed a law that prevents Medicare from negotiating drug prices. It was a huge win for Pharma lobbyists. No other country or private business has tied its own hands so tightly, and that's reflected in the price we're paying for our medications. The same pills that sell for hundreds of dollars in the US are available for pennies across the border. Literally the same pills made in the same factories. I can't blame people for seeking a better deal across the line. In fact, until we get a better handle on drug prices here in the US, I strongly support it.

Ok, that wasn't too bad. Just a two paragraph detour. Now back to the adventure.

Aimee and I were more in the market for a margarita than a medication, so we kept walking south. After you clear the first few blocks of pharmacies, the streets start to look more classically Sonoran.

We continued forward towards our main goal: good food. Although the number of restaurants has dropped dramatically since Nogales' tourism heyday, there are still plenty of world class establishments. La Roca is arguably the best and most famous. We're inclined to agree.

The restaurant was built into a rock cliff (hence the name), and is the kind of place that could easily cost $100 per plate in the US. But this isn't the US. We had multiple courses of some of the best food we've ever eaten, and washed it all down with a few beers and margaritas. The service was impeccable, and the price was entirely reasonable.

And that's it. No crime witnessed, no maps misread, no diarrhea suffered. I don't even know if I can count this as international travel. But it was a wonderful way to spend the afternoon, and a surprisingly easy escape from the Arizona heat. We'll definitely be back.

The Wall

I can see another country from my bedroom.

I've only been here for a few weeks, but that still amazes me.

This really is just one big city that happens to straddle two countries. Even though the official population is only 20,000 people, Nogales is the largest border town in Arizona. But the official census count is deceiving. It's not at all uncommon for a US citizen to reside in Nogales, Sonora for the cheaper cost of living, and then cross the border every day for work.

Of course, the border crossing is more than just lines of commuters. Freight trucks, ambulances, and even trains cross the border on a daily basis, and monitoring them is unfathomably complex work.

Tracks bringing freight trains from Mexico. The gate itself is in the background.

Train car Xray equipment a few hundred yards into the US.

Not surprisingly, the border is the main economic driver in the region. Nearly everyone here either works for the warehousing/freight industry that brings produce and goods across the border, or is a federal agent keeping watch. There are a lot of politics wrapped up in those two industries, and it's a delicate balance between flow of commerce and preventing unwelcome elements. There isn't a person in this country that wants to see criminal enterprises taking advantage of a porous border. But not only is an impermeable wall logistically impossible, it's against our country's best interest. $30 billion of trade crosses the border every year, and we'd be foolish to let that dry up.

As an aside, I also believe that it's a shame to block the healthy flow of people and wildlife on its own merits, but that's not the argument that I want to make here. Our economy can't support a closed border, and a closed border doesn't really do much to prevent the crime that we're actually concerned about, anyway.

One of the political struggles over the past decade has been finding the right balance of security and rationality along the US-Mexico border. Despite the headlines, both Nogales' are incredibly safe. They have lower rates of both serious and petty crime than most other US cities, and the crime that they do have is almost exclusively gang on gang. The rhetoric just doesn't fit the facts.

Tall walls invite taller ladders (or deeper tunnels), and don't really do much to stem the tide of drugs or people. Ironically, the only thing that has stemmed the flow of immigrants has been economic improvement in Mexico coupled with a recession here in the US. It's not that anybody really wants to uproot their family, move out of their homeland, and face walls, guns, and deserts. They're just not left with many other choices.

Similarly, the only thing that shows promise in stemming the drug trade (and the violence it brings) is a recalibrated drug policy here and in Mexico. "Securing the border" plays well in Washington, but it misses the issue. More guns and more fences don't solve the real problems, and they can actually create some of their own. In fact, the escalation of enforcement has led some observers to now call this a militarized border.

I'll anger some friends by saying this, but that's a bit of a stretch. This isn't Checkpoint Charlie, and there aren't tanks posted on the hills. But there are SUVs up there with well-armed agents inside of them. This is one of the most heavily policed regions in the world, and while that isn't a bad thing on its face, we need to balance the pros with the cons. Border agents have an exceedingly difficult job, and we should make sure that the danger we place them in is contributing to a better, safer United States.

Is a heavy police presence a provocation in its own right? What crimes do we actually want to tailor our interventions against? What components of a prevention strategy ultimately make people safer?

I don't have any answers to these questions, and there are probably several correct ones. People far more qualified than I am are setting border security policy here and in DC. I just want to make sure that we're asking them the right questions.

Border Town

On a map, the US-Mexico border is about a quarter-inch wide. But in all actuality, it's really more like 50 miles wide. The fence itself is just a few inches, but the transition from one country to another requires quite a bit more space. You can't walk ten feet in this town without a reminder that you're living on the border. From the language to the food to the music, this is clearly a town that straddles two different worlds.

But these images don't tell the whole story. Nogales is has a rich history that is reflected in its architecture. It's still a transportation powerhouse, connecting Mexican farms, factories, and the deep sea port of Guaymas with the rest of the United States. But these days, most of the freight (and revenue) passes straight through the town and heads for the freeway. But not that long ago, the town was a bustling hub for tourism and trade. A bit of that turn-of-the-century charm persists throughout the city.

This is the historic Santa Cruz County courthouse. As a bit of trivia, Lady Justice on the dome isn't wearing a blindfold. So along the border, justice isn't blind. I don't know what that means. It's just interesting.

The Woolworth's facade is a relic of Nogales' former glory, but the For Sale sign is a bit more representative of the current state of affairs.

If you look closely, the actual border is right at the end of this street. The fence cuts right through the middle of town, and it is such a part of day-to-day life here that it almost melts into the background.

In fact, it's so easy to miss the border, that you (well, I) could make an innocent left turn at a stoplight and find yourself myself in the entry line to Mexico.

I let out an audible "Holy Shit" before noticing the "Last U-turn Before Entering Mexico" sign. That was a close one. This isn't my best photo, but it's not bad for having a heart rate of 150 BPM.

This is an amazing region of both countries, and Ambos Nogales shows that borders are so much more than just lines in the sand. But the region is as polarizing as it is beautiful, and the area isn't without it's own controversies. I'll dive deeper into border politics in my next post, so get your pitchforks ready.

Push!

I have a patient laboring right now, which is the calm before the storm around here. Anybody who has had a baby knows that pregnancy is one big waiting game.  First, you wait nine months for the baby to grow. After about eight and a half months, the baby is generally safe to come out. But most women will have to wait another two or three weeks for their body to say that it's time. And for a lot of pregnant women, waiting two weeks with an eight-pound, heartburn-causing, bladder-squishing weight hanging off of your chest feels about as long as the 37 weeks leading up to it.

Then the contractions start getting more painful, and maybe your water breaks, so you come into the hospital expecting to have a baby. No, no, my friend. You still have to wait for your cervix to dilate 10 centimeters to make room for the baby. For a first time-mom (like the one laboring today), it can take hours. And in at least one occasion, it has taken 24 hours, as I'm often reminded by my mother.

This last stage of the pregnancy can be wildly different from one woman to another. Most deliveries in the US occur in a hospital, but not all of them. Other options include births at home, births in a birthing center, and of course births in the ambulance on the way in. Two of those options are not ideal, but birthing centers are an under-appreciated option for most women. They're generally run by midwives, and have a much more comfortable approach. Couches, bathtubs, and giant exercise balls replace the stirrups, sterile drapes, and face masks of a hospital birth.

But that's not to say that giving birth in a hospital is an unpleasant experience. Many hospitals have taken big strides to make the process of giving birth feel less like the process of giving a kidney. Rooms are getting bigger and more comfortable, and the standard of care has changed a lot over the past 20 years.

The studies that defined how long labor should take were first done in the 1950s, and that set the tone for hospital births. If you were taking longer than the labor curve said you should take, you were given medicine to speed up the process. If you were taking a lot longer, you got a C-section. Period. But several of the more recent studies have shown that labor can safely take a lot longer than we initially thought.

But with all the progress made in de-escalating hospital births, there is still one pervasive element that we can't quite kick: fear. Fear of bad outcomes, fear of upset patients, and unfortunately, fear of lawsuits. Thankfully, all three of these occur incredibly rarely, but it's the fear of them (especially the last one) that sets the tone of what's done in a hospital.

This fear leads to a lot of hyper-vigilance. To keep an extra close eye on the baby, many hospitals strap a fetal heart rate monitor to each mom's belly. It's a pretty nifty device that uses ultrasound to monitor the baby's heart rate in realtime. It was heralded as a lifesaver when it came out in the 1960s, since we can tell a lot from the baby's heart rate. If the rate is too slow or too fast, we can assume that the baby is struggling and needs to come out.

That seems pretty reasonable right? But in the fifty years since continuous fetal heart monitoring has been around, we haven't seen any real decreases in most bad outcomes. This is probably because truly bad outcomes are rare, and many, many, many babies are going to show concerning heart rates without any serious underlying disease. But we can't tell which babies are truly under stress, and which ones are just getting excited about coming out. So we get extra aggressive with labor induction and C-sections, which of course, have their own risks associated with them.

One of the maternal/newborn nurses here used to be a doula (birthing aide), and says that it's just a difference of approach. Doulas assist mothers in both birthing centers and hospital births, so this nurse has seen a lot. Her take is that birthing centers are slightly more comfortable with a relaxed approach, since most babies will be born without any major issues. The birth centers send their high-risk patients to the hospital, and don't place the remaining ones on continuous fetal monitoring. The outcomes aren't any different, and a falsely concerning monitor strip won't result in a rushed labor or emergency C-section.

Obstetricians have one more tool available to them: the C-section. Their approach is that if there is any risk at all to mother or baby, they will both benefit from a rapid birth to get through the most dangerous phase quickly. C-sections are often derided, but they have phenomenally good outcomes. Yes, it's a scar on mom and a non-typical birthing process for baby, but both generally do great afterwards. Of course, there's no way to know if they would have been fine without the surgery, but obstetricians don't want to take the chance.

To their credit, obstetricians are the people you want taking care of high-risk pregnancies. They have tools, procedures, and medicines available to them that other birthing professionals do not. But after you've seen enough scary pregnancies, it's hard to remember that most women will be just fine. I get that.

For example, I took care of eight laboring patients in the last 48 hours. Three or four had concerning fetal monitoring strips, and one of them was scary enough that we gave the mom some medicines to speed up the labor. Of the eight, seven patients gave birth to seven very healthy babies, even the ones with scary monitoring strips. But the eighth women had an entirely different outcome. She had some health problems that complicated the pregnancy, and even though she was fine a few days ago, the fetus had died before the patient even got to the hospital. So at 3am, I had to tell a mother that was excited about having another child that it was not going to happen with this pregnancy.

That was a heartbreaking conversation, and one that I don't want to repeat any time soon. So maybe that will be on my mind when I decide whether or not to monitor the next mom's fetal heart rate or consider induction. But I hope it isn't.

I think that my training as a Family Physician is a good balance between the two approaches. We're often thought of as General Practitioners, but we're a completely different specialty. GPs get one year of training after medical school and take care of mostly adults in an outpatient (clinic) setting. FPs, like me, go through three years of training after medical school (the same as internists and pediatricians) and are qualified to deliver babies, take care of kids, and treat people in a variety of settings. We're equally comfortable in the birthing center and the hospital, and although we have access to many of the same tools and medicines as obstetricians, we're a little less likely to use them. We know that most laboring women will be just fine, and we're willing to spend a bit more time before going to the OR.

So if you have underlying medical issues or a more serious pregnancy complication, you should deliver under the care of an obstetrician. If you already have a Family Physician that you know and trust, that's who should deliver your baby and take care of him or her after the birth. Most other women should see if a birth center is right for them.

But I've spent far longer talking about this than I thought I would. I should go check on my laboring patient, although she really doesn't need it. She will probably deliver a perfectly healthy baby without much intervention on my part.

Update: She did.

Border Hospital

Holy Cross is a very interesting place to work.

As a rule, small hospitals have a really nice feel to them. Probably because everyone knows each other. The housekeeper is cousins with the charge nurse, the security guard is in night school with the cafeteria worker, and the laboring patient in room three is the surgical tech's daughter-in-law. I hear "good morning, Dr. Stone" ten times between my car and the hospital.

Like any critical access hospital, there is a basic lab and radiology department. But ordering anything beyond that requires us to transfer the patient or send out the lab.  It's good training in resourcefulness. Patients with a cough require a bit more from my stethoscope and from my brain than they would at a big university hospital. An automatic knee-jerk xray isn't feasible when the technician needs to be called in from home, and ordering a CAT scan will get me laughed out of the hospital.

In addition to the usual small hospital charms, Holy Cross has its own set of eccentricities. It was built in the 1960s, and working there can feel like going back in time. The patient care areas have the usual modern equipment, but there's a strange little wing off to the side of the hospital where the call rooms and offices are.

The first thing you'll notice is that it's carpeted.  You just don't see that in hospitals, and for good reason. There's a bathroom in each office, and a shower at the end of the hall. It feels like a college dorm, minus the college. The wing seemed completely out of place in the hospital, until I realized that this isn't just any hospital. It's a Catholic hospital built when they still had convents attached to them. So I am, by far, the most sinful person to have slept in these halls.

The Catholic element brings another uniqueness to Holy Cross. Working in a big university hospital teaches you to be mindful of a wide variety of patient beliefs. But when it comes to medical advice, we're trained to present all options as objectively as possible. So, calling on that training, I checked up on my first few moms the day after their deliveries, and asked each one of them my standard list of questions.

How are you feeling? 

Good.

Are you still bleeding? 

No.

Has your appetite returned?

Yes.

What would you like to use for birth control?

(Crickets)

Birth control is an important part of helping a new mom's body heal and recover.  Prescribing it is just what you do. Except when you work in a Catholic hospital.

In all fairness, the vast majority of the OB patients here use birth control, and most of their pregnancies are planned. But the patients just don't seem comfortable talking about birth control in God's house.

And this is very much God's house. As you pull up to the front entrance, the door to the hospital is on your right, and the door to the chapel is on your left. Choose wisely.

Some other apparitions:

Your nurse today will be Mary.

What would Jesus eat?

Culture shock aside, Catholic hospitals play an important role in the US healthcare system. It's far too common for patients to lack any type of health coverage--citizens and migrants alike. And although Catholic hospitals are increasingly being run like other large health care corporations, the Church has joined government and private hospitals to find room in their hearts and in their budgets to provide care for people who just can't get it anywhere else.

Another unique aspect of Holy Cross is the role that it plays in emergency healthcare. The term Critical Access Hospital isn't just descriptive, it's financial. It signifies to government payors (Medicare, Medicaid, etc.) that this hospital plays a more outsized role in the community than its numbers might imply. A big university hospital can care for hundreds of patients each day, and even if some of them don't have insurance, the income from the ones that do can pay for the hospital staff, laboratory, radiology equipment, etc. However, a Critical Access Hospital may only see a few dozen patients each day, but the hospital still needs to pay the bills that keep the doors open. Even though the hospital may not be financially viable within a strict fee-for-service model, it's role in the community is very important, and its loss would be devastating. So clearly there's a value to that service that requires a slightly different funding method.

As the political dust settles around the Affordable Care Act, it's pretty clear that most of the provisions are doing a lot of good for a lot of people. But there is one part of the ACA that is having an unintentionally adverse effect on Critical Access Hospitals. The extra funding for CAHs was significantly decreased by the ACA, with the expectation being that the funds would be less necessary as more of their patients were covered by insurance. But the increasing amount of insured patients isn't keeping up with the decreasing amount of federal funding, especially at hospitals along the border. But thankfully, the funding cuts have been pushed back until next year, and this is an area of active debate.

And speaking of the border, that's another one of the more striking differences between Holy Cross and most every other hospital in the US.

I took that photo while standing on hospital grounds. If we were any closer, I'd need a Mexican medical license.

I'll go into detail about the border in a later post, but it's one of the more amazing parts about being down here. Holy Cross is a very interesting place to work.