Gaspar, the Driver of the Black Tuk Tuk

5 April 2013

One afternoon in clinic I asked the supervising physician, a long-term foreign volunteer, to see my patient so that he could finally sign off on her and she could go home.  I urged him to hurry.  The patient had arrived in the morning and told me that she’d come from “far away”.  It did take a while for the lab to send down the results of the tests I’d asked for, but still I felt that the physician was prioritizing his patients and not mine.

He glanced at her chart then scolded me for rushing him.

“She lives in San Lucas Toliman.  That’s close by.  Most of our nurses commute from there.”

While waiting for him I checked Google maps.  San Lucas Toliman is no more than 10 miles away from Santiago, where Hospitalito Atitlan is located.  Ok, fine, that’s not far.  But I was new to the area.  I didn’t he should have been so harsh.

—

A few days later I was on call with David, a different doctor, and like me a short-term foreign volunteer.  At about 3pm two-year-old Abigail arrived, brought to the Emergency Room by her parents.  She had been having mild diarrhea and vomiting for a day.

In children with diarrheal illnesses, the most important thing is to make sure they stay hydrated.  If they can tolerate liquids orally, that is drink enough to meet their daily fluid requirements as well as replace what they lose in diarrhea and vomit, they do not need to be in the hospital.  Most of these illnesses are self-limited and pass on their own.  If the child can drink, they can drink and recover at home.

Our plan for Abigail, who appeared well, was to watch her for a few hours and make sure that she could drink enough liquids.  We gave her parents a bottle of pedialyte, a syringe, and instructions that she should get at least 10mL for every 15 minutes.

It was a difficult shift.  Crisis after crisis kept Abigail from the forefront of our minds for several hours.  Finally, at 7pm, we checked in on her.  Her parents had successfully followed our instructions.  We told them that they could go home, where they should continue the same regimen with the addition of a cup of fluid for each diarrhea.

“Pero no podemos.”  But we can’t.  “It’s too late.  There’s no transportation.”

A Lake Atitlan tuk tuk and it’s driver.

The public transportation to go between towns is pickup trucks, the beds outfitted with a cage-like structure with bars that you can hold onto as you stand up in the back.  To go within a town, instead of taxis, there are autorickshaws or tuk tuks.  Small, red vehicles that feel like someone stuck a cab and an extra wheel onto a motorcycle.

 

The family lived in a small community called Cerro de Oro, which is even closer to Santiago than San Lucas Toliman.  They had taken a pickup to get to the hospital.  Which apparently stop running at about 6-6:30 in the evening.

Crap.  Well that would have been good to know.  I wish they had mentioned that in the new volunteer orientation.

We had limited options.  The family couldn’t stay the night in the ER; the nurses would get upset.  We could admit Abigail, but that was going to cost money that the family didn’t want to spend if they didn’t have to.  And they really wanted to go home.

“Querrían tomar un tuk tuk?”  Would you be willing to take a tuk tuk, I asked.  The tuk tuks stop running at 10pm.

“Sí, pero pienso que no se puede.”  Yes, but I don’t think it can be done.  “The Santiago tuk tuks aren’t permitted to go to Cerro de Oro and vice versa.”

You’ve got to be kidding me, I thought.  But it occurred to me that anything can be done for a price.

The phone number of a tuk tuk driver, Diego, was programmed into my cell phone.  David and I called him to see what he would charge.

“Ay, la cosa es que con mucho gusto yo llevaría la familia a Cerro.  Pero no es permisible.  Lo siento.”  The thing is I would gladly take the family to Cerro.  But it’s not allowed.  I’m sorry.

We were shocked.  It was the first time in Guatemala that we were told flat-out no.  Based on our experience, we expected that Diego would at least start by stating a high price.

“Here, Nicki,” said David.  “I have a number for Gaspar.  He drives the only black tuk tuk in town.  Maybe he’ll take them.”

“Based on the fact that he drives a black tuk tuk instead of a red one?”

“Hey, he’s a rebel.”

I called Gaspar.  He was willing to take the family for 40 Quetzales or about USD $5.

He arrived surprisingly fast.  So fast that the family wasn’t ready to leave yet, as the nurses were still finalizing their paperwork.  After several minutes driver of the black tuk tuk was starting to get antsy.  This worried me and David.  We personally decided to give him an extra 20 Quetzales, under the table, to make sure that he stuck around.  And because we felt guilty since it was our fault the family had missed the last pickup.

—

It’s a doctor’s business to understand the barriers, physical and otherwise, to healthcare for his or her patients.  The situation in which the patient lives, how far away they live, and what transportation is available, definitely count.

In my opinion a town is absolutely far away from a hospital if you stop being able to get home, or to the hospital, after 6pm.

 

Ins and Outs

14 Mar 2013

On the surgery rotation one of the medical students’ main duties and first orders of business of each day is to tally the ins and outs of their team’s patients.  The most important of these is urine output over the past 24 hours.  It is not an arduous task.  All it requires is simple math, the addition of numbers entered by the nursing staff into a nice spreadsheet format on the computer.  It takes 10-20 minutes, depending on how many patients the team has.

A surgery is a shock to your system.  Depending on the type, it may take the body some time to recover.  This is time during which the surgical team monitors the patient for complications. We watch urine output for many reasons.  It is an important indicator of fluid status, especially in a post-surgical patient who may have lost blood.  If someone is peeing less than they should it could mean that they are blood down from the surgery but still too weak to self-hydrated, so we should give them IV fluids.  If someone is peeing much less than they should, or not at all, it could suggest kidney damage – that while blood vessels were being pressed on or clamped during the operation the kidneys did not receive enough blood flow.  Or perhaps something else was damaged, accidentally “nicked” during the surgery – such as the urethra or both ureters.

In theory I understood the importance of checking urine output on a post-op patient.  But the practice simply became rote.  I did it every day, at 5am, for two months.  And I never had a single patient with a problem.

I was on a shift at the hospitalito when María, almost 50, had a hysterectomy.  She had her uterus removed because a huge fibroid was growing in it, down low close to her bladder.  The operation began at 8am and was over by 9:30.  When Jane, the doctor on call, and went to check on María.  It was just before 11am.  The first things we looked at were María’s vital signs and urine output.

As in the US, these values are measured and entered into the patient’s chart by the nursing staff.  Unlike the modern hospital in the US where I had my surgery rotation, the hospitalito charts are on paper.  Jane and I looked at the piece of paper that itemized María’s urine outputs in a long list.  We (thought we) saw that she had already made 200mL of urine after the surgery.  After checking on her – she had some pain but otherwise no complaints – we declared her to be fine.

At 3pm the nurse found us, worried about María because she had only made about 80cc of urine.  The measurement wasn’t exact because her foley had fallen out.  Thinking that she might be dehydrated, we gave her a liter of fluid.  An hour later the nurse said that she still hadn’t made any urine.  We put the foley back in, hoping that all she had was a below-the-bladder obstruction.  Nothing came out.  Now we were worried.

Looking back over María’s chart we found that we made a colossal mistake.  María had been admitted the day before her surgery, which is when the nurses began tracking her urine output.  She already had one and a half pages worth of urine output listed.  We thought that the second page, the 200mL, was all from after her surgery.  But it wasn’t.  It was from the early morning hours, before.

The gynecologist Antonio who performed the operation was in clinic.  We pulled him out to consult.  By this time it was close to 5pm, the end of the day at the hospitalito for everyone except the doctor and two nurses on the night shift.  The laboratory technicians were about to leave.  We couldn’t even check María’s kidney function and electrolytes.

Antonio was clearly concerned.  He stayed until 6:30, something the nurses later told me that he never does.  Jane and I thought that he would send the patient to Sololá, to the large national hospital that is our hospital of reference.  But it wasn’t.  He opted to keep the patient in our small hospital until 7am the next morning, when he would take her back to the OR and reopen her to find the problem.  As the surgeon, the patient and the decision were technically his.  At first Jane didn’t fight him on the decision.  He is permanent staff, she was a temporary volunteer.  He is Guatemalan, she is foreign.

But by 8pm, when María hadn’t made urine in over 12 hours, Jane felt she could no longer stand by the decision.  The kidneys are in charge of removing certain wastes from the body by placing them in the urine to be expelled.  They are also responsible for electrolyte balance – they reabsorb them from the urine when body levels are low, and place them in the urine when body levels are too high.  When someone isn’t making urine, the buildup of wastes and electrolytes can be very dangerous.  Even deadly.

Jane called Antonio at home to convince him to let her send María to Sololá.  Antonio was resistant.  He said that the surgeons in Sololá wouldn’t do anything until 7am either.  And perhaps he was worried about exposing his possible surgical mistake to others.  But Jane insisted, and Antonio said that he wouldn’t stop her.

As she filled out the reference paperwork Jane vented, “He said that Sololá wouldn’t do anything until 7am when the day staff arrives.  But I can’t believe that.”

I agreed.  Sololá has 24-hour surgical staff and does emergent surgeries.  What else could this be for if not a patient like María?

“And even if they don’t take her to the OR, at least they can do labs there at night.  And if her values are bad, they can do dialysis.”

Our ambulance left with María, and Jane and I both half-released the breaths we’d been holding.

Later we learned that Antonio was (mostly) right.  Nothing was done for María until the next morning.  They didn’t even check her labs.  But they did have urologist who repaired her two “nicked” ureters.

The principal new lesson for me:  In going to new places as a healthcare worker, I must adapt to different methods of record-keeping.  Especially in the developing world where charts may not be as organized, are often on paper and not laid out nicely on the computer, and could be in another language.

A lesson I’ve learned many times, reinforced in a new context by Jane:  Fight for the best care for your patients.  Even if you are the outsider.

 

Their Concern is Not Your Concern

12 Mar 2013

Concepción was a 5-month old girl whom I met on the second day of her hospital stay.  Her parents had brought her in because of trouble breathing and a cough.  When Alexis, our pediatrician, checked her oxygen saturation it was below 80%.  This is bad, especially in a young child that needs good oxygenation for proper brain development.  Normal saturation in someone with healthy lungs is 97% or more.

Alexis diagnosed Concepción with bronchiolitis and admitted her to the hospital.  Bronchiolitis is a common illness that affects children less than two years of age.  Often it is caused by respiratory syncytial virus, leading to inflammation of the bronchioles or the small passages.  Treatment is supportive.  The most important thing is to keep the child’s oxygenation level up with supplemental oxygen administration.

In the early afternoon Concepción’s parents approached me.  Their daughter seemed much improved to them and they wanted to go home.  I went to Cathy, the doctor that I was on call with.  We turned off Concepción’s supplemental oxygen and checked her saturation.  It fell to 85%.  Not good enough.

“Los pasajes a sus pulmones todavía están inflamadas.”  The passageways to her lungs are still inflamed.  “Her body won’t get enough oxygen without the extra she’s getting here.  She has to stay until she no longer needs extra oxygen.”

“But her cough is gone.  And she’s breathing much better.”

They didn’t get it.

I’d forgotten how complex the body can be.  The idea of giving someone a higher percentage of oxygen (the air we breathe is 21% O₂) so that, through their ill lungs, their body will still receive the amount that it needs – the amount that healthy lungs would pull out of the air – is a difficult one.  And it can be a distinctly foreign one to someone from a different system of education and a different way of life.

We were struggling to explain, not getting anywhere.  Finally, we asked the family to speak with our social worker.  Once they learned that sliding scale payment system was available to them, based on their income, they agreed to stay.

The next morning at signout, the change-of-shift meeting where healthcare workers hand over their patients, Cathy and I expressed our frustration.  We didn’t understand how parents could still want to remove their child from the hospital when her doctors are clearly telling them it is dangerous.

Nearing the end of his one-and-a-half-year stint with the hospitalito, Andy had much more experience with the patient population than we.  He chimed in with some of the most important words of healthcare wisdom I’ve heard.

“It’s because their concern is not your concern.”

I think I actually stopped breathing for a second, so deep was their impact on me.

“They’re concerned about a cough.  And about paying.  Where you’re concerned about a saturation of 80%.”

 

He went on, bringing up a related topic with, “It’s the same when we try to get patients to go to Sololá.”

El Hospital Nacional de Sololá is our hospital of reference.  It is where we send patients whose conditions our small hospital is not equipped to handle, such as surgical emergencies (we do not have a surgeon at all times, and only do elective surgeries).

Patients and their families are very resistant to being sent.  A patient with an acute abdomen, doubled over with severe abdominal pain, was refusing to go and his family was agreeing with him.  “No doc. *groan*  I’m fine. *groan*  I don’t need to go.”

I wanted to tell his family, “If you thought he was sick enough to bring him here, why won’t you take him a hospital with more resources??”

Andy had good insight on this phenomenon too.  “You’re concerned about the (severe) illness and getting the patient appropriate care.  They’re concerned about different things, and several factors feed in to this.”

The first is family structure.  Decisions here are a family affair.  You have to check with everyone: parents, siblings, cousins, great aunts, your uncle’s friend’s minister’s pet chicken.  Also, when a woman gets married she basically leaves her family and becomes part of her husbands.  Most of her important decisions are discussed with her husband and in-laws.  Once Andy had a mother tell him that she couldn’t make a health decision about her child without first consulting her mother-in-law.  Could you imagine an American woman not making a decision without her mother-in-law?

The second is language.  The language here, along the south shore of Lake Atitlan, is Tz’utujil.  At the hospitalito our nurses speak Tz’utujil and can serve as translators.  Sololá is on the north shore.  The language spoken there is Kaqchikel.  It must be terrifying for patients to entrust their health to people they cannot understand.

The third is economics.  “Can I afford to pay?” is a heavy question.  Technically services at public health centers that are part of the national system are free.  However there are still things that patients and their families end up having to pay for:  transportation, medicines, certain tests, transportation to certain tests if they’re not offered at the national hospital.

The ultimate is cultural.  There is still a significant amount of distrust of western medicine and the big hospitals in particular.  This is partially circumstantial.  A lot of people who go to the national hospitals come back dead.  Because they do not go unless, or until, they are very sick.

 

Along the Southern Shore of Lake Atitlan

6 March 2013

I have left Xela, a place which has come to feel like home, for places and realms unknown.  For two months I’ll be in Santiago, a small town on the southern shore of a large caldera lake, where I will volunteer with Hospitalito Atitlan.

I’m always anxious before something new.  Even when it’s fairly obvious that everything will work out ok, that the experience will probably be good for me.  Which working in a hospital, after several months of a primary care clinic, will be.  Hospital medicine is different from clinical medicine.  Patients are more ill, so what one does and learns are not quite the same.

Hospitalito Atitlan is a small, private, non-profit hospital.  It is the only provider of emergency, obstetric, inpatient, and surgical care within a two-hour radius.  The hospitalito has a long history tied to the Tz’utujil Maya of Lake Atitlan.

After a measles epidemic in the 1960s the Archdiocese of Oklahoma City decided to support a small hospital and opened the first Hospitalito Atitlan.  It survived through most of Guatemala’s 36-year civil war (1960-1996), only closing in 1991 when the war environment made it too dangerous to continue operations.

Twelve years later in 2003 a small group of residents and extranjeros decided it was time to bring the hospitalito back to life.  After much work the grand reopening took place in April 2005.  Hundreds of people received medical care each month.

Then Hurricane Stan hit six months later.  The torrential rain caused a massive landslide that hit the community on October 5th.  Hundreds died.  Thousands were left homeless.  And the hospitalito was not spared from the destruction.

A backpacker’s hostel was quickly turned into an emergency hospital so that staff could continue to serve the victims of the landslide.  Foreign and local healthcare volunteers arrived to care for patients.  But this solution could only be temporary.  The hospitalito needed a permanent home.

Weather and land experts recommended against returning to the original location.  The board and supporters worked tirelessly to fundraise for a new building.  Two years later in October 2007 the new facility, finally, was opened.

I learned most of the above during my orientation to the hospitalito from an old fundraising video narrated by Isabelle Allende.  I remain impressed that one of my favourite authors was recruited to help with the fundraising effort.

 

Unlike in Xela, where Spanish is native to most, a Mayan tongue is the first language here.  Tz’utujil is the primary language of most of the patient population.  Three languages will be present in most of my interactions:  the Tz’utujil of the patient and their family, the translator’s Spanish, and my English and Spanish.  The people here cling strongly to Mayan traditions, including traditional healing practices and often choose to go to hueseros instead of doctors when they fall and hurt a bone.

My new host family in Santiago is an interesting reflection of the general population of Lake Atitlan, albeit slightly more well off.  The mother Candelaria barely speaks Spanish.  For Santiago’s big market days she and her sisters in law prepare vegetables to be sold.  We communicate with basic Spanish words and sign language.  She taught me how to say “stomach” in Tz’utujil so that I can indicate to her when I am hungry.  The father Juan came from a poor background but has done relatively well for himself.  He looks after the lake house of a rich businessman and volunteers as a fireman.  Juan pushed education in his grown sons.  The men in the family all speak Spanish, the sons better than the father.

In Hospitalito Atitlan staffing by a few permanent Guatemalan physicians is supplemented by a steady influx of short and long-term foreign doctors.  The nursing staff is all Guatemalan – they do an impressive job for the little education they receive, many only 1 year post secondary school, and serve as Tz’utujil translators.  The support staff – the guardianes who function as both janitors and bodyguards/security, those who handle inventory and pharmacy – is also Guatemalan.  The administration and the board are split between Guatemalans and extranjeros.

Already I can see that the hospitalito is a unique place where cultures and languages meet and mesh and sometimes clash.

 

Un Cuento de Dos Pueblos

28 Feb 2013

High in the mountains, where the air is brisk and cold, lie the two most faraway communities that we visit.  The Pop Wuj mobile clinic comes to Xeabaj and Pujujil once every two months.  Always one right after the other such that you can’t avoid comparing the two.

Usually mobile clinic days are hustle bustle.  Community volunteers dash to and fro, organizing the line of waiting patients and setting up our clinic space and supplies.  The first time I went to Xeabaj I was met with eerie quiet.  For unknown reasons the mood spilled over with sombre.  The few people at the site walked slowly as if carrying something heavy on their backs, eyes cast towards the ground.

In Xeabaj we needed interpreters to translate the native K’iche’ into Spanish, which most of us mentally convert into English.  Three languages at work at once makes for an interesting patient visit.  Besides this, each time I started with a new patient I had to hunt another interpreter to translate for me.  They kept disappearing, leaving the grounds to go to the tienda, go home for a snack, congregate elsewhere and gossip.  By the end of the day there were still patients waiting but few interpreters left standing.

Later I learned that Xeabaj is a community displaced.  In 2005 the threat of Hurricane Stan was imminent and the town had to evacuate for fear of being covered by landslides.  Leaving with their children wrapped up to protect them from the storm and the few belongings they could carry, they were crowded together in a shelter.  Later they were relocated.  The location of Xeabaj II is further up the mountain, where the land is more rock than earth, dry and barely fertile.

The adjustment has been difficult for everyone.  The formerly agricultural town has had to look to other forms of industry – the women make candles and textiles while the men work as day labourers elsewhere – as their crops barely sustain them.  There are no extra to sell.  The hardship has taken its toll, bringing out disputes and grievances.  Dividing the community.

In my first visit to Pujujil I saw a sea of waiting people as the mobile van pulled up to the school auditorium.  Several young men dressed in black immediately began unloading our supplies.  I followed them into the auditorium.  Tables and chairs were already set-up.  More young men dressed in black were hanging curtains, creating private consult rooms in which we could see patients.

The native language of Pujujil is Kaqchikel.  Getting a translation was never a problem.  All those young men had come to volunteer as interpreters as well, wearing black so we could easily identify them.  They stayed close when they were between patients, gathering outside the curtained consult rooms, so we could easily find them.

Why were all the interpreters young, you may wonder.  Because the youth have learned more Spanish than their elderly grandparents, conceivably because of slowly improving access to education.  Why were all the interpreters male.  Because Spanish is learned in school, and boys are still kept in school longer than girls.

I was very grateful for those young men, eager and happy to help their fellow townspeople and us.  But this language situation can have complicated effects.  In the middle of the day I saw a young female patient.  I thought her clinic visit was almost over.  Then my interpreter had to step out for a second.  Immediately the patient began to tell me about vaginal discharge, of which she had been too shy to mention in front of the male interpreter. I had to scramble to find a woman in the village who could translate for me.

The town of Pujujil seemed very much a community.  They came together to help us bring health services to one another.  At the end of the day the volunteers and the patients were still on the grounds, gaily chattering away and helping us pack our supplies.  But so much togetherness can also be a bad thing.

Every few months Pop Wuj hosts a medical brigade from Timmy Global Health.  For brigade day we had given Pujujil community workers 100 tickets to distribute to patients.  The extranjero medical volunteers would see at least those 100, more if they had extra time.

They did.  Neighbouring communities caught wind;  some came and tried to line up for healthcare.  But the people of Pujujil physically blocked them from passing through the centre of town.

“No.  This is just for us.”

For the last few hours of the day, volunteers ended up just sitting around.

Yet Xeabaj and Pujujil can be very similar.  Especially when it comes to the illnesses that one sees.  The disease profiles are very different from those of more urban populations.  The city has seen an increase in rates of hypertension and diabetes, with a more sedentary lifestyle and the rising popularity of unhealthy food.  Whereas, in an entire morning of clinic at Xeabaj or Pujujil, I can go without seeing a single case of diabetes or high blood pressure.  Instead I see more infections like conjunctivitis or pneumonia.  More diseases that relate to hygiene like parasites and scabies*.

What scares me the most is the frequency of medically advanced diseases in rural areas:  infections like tuberculosis that has been ignored for a year, chronic conditions like hypertension where the patient’s blood pressure is dangerously high, even massive growths.

At the start of one mobile clinic I spotted Doña Noemi from across the auditorium.  She was sitting in the waiting area, several meters away, huddled in her seat beneath her layers.  My mother taught me not to stare but it was hard to stop gazing at the enormous growth on her right eye.

She didn’t end up being my patient.  But she did allow all of us to examine her mass.  It originated from below the upper eyelid, vascularized and tender.  When Noemi looked from side to side the mass would move with her glances.  We learned that it had been growing for two years, bleeds, and is painful.  Another sad thing is she went to a permanent clinic a few months beforehand.  However she was so turned off by the way she was treated – which could have been either a linguistic misunderstanding or physician rudeness – that she left.  We referred her to an ophthalmologist in the capital.

The communities are distant, so removed in multiple ways – isolated locations, language barriers, economic constraints – that patients do not seek care and instead wait for it to come to them.

 

*The scabies mite can infect anyone, regardless of personal hygiene.  However it is more often seen in crowded living conditions with poor sanitation.  Hygiene also plays an important role in prevention and control.

 

Clinic- Don Agosto

13 Feb 2013

Maximón (pronounced Moshimohn) is a Mayan folk saint/god blended with influences form Catholicism. A very human figure, the faithful offer him alcohol and cigarettes when asking for blessings on their health and relationships.

In the highlands of Guatemala people are fiercely protective of their traditions.  Despite the more affordable prices of modern apparel, women continue to wear traditional clothes. The views on the street are a dance of colour.  Corte Mayan skirts fanning out like ballgowns or rolled tight like tacos.  Huipil Mayan blouses embroidered with flowers, birds, patterns depending on where you come from.

But not the men.  To overcome discrimination against indigenous backgrounds in the workplace (where men have made more ground while most women have remained at home), they abandoned traditional wear.  A man wearing elaborately made pants, held up with a belt, and a figure-adorned shirt is a rare sight.  If you see such a man on a non-celebration day you’re probably in a smaller town.  He is certainly elderly and more likely to be poor.

Don Agosto was a patient I saw in mobile clinic.  He hobbled up towards me, using his walking stick and dressed in traditional Kaqchikel Mayan clothes.  I complimented him on the rich embroidery.

“Gracias.  My wife made them a long time ago.”

The knee pain of his osteoarthritis had been bothering him.  As a secondary complaint he mentioned he’d had trouble breathing and a cough, on and off, for a year.  When asked, he responded affirmatively to sometimes having fevers at night.

Through a stethoscope his left lung was different from the right.  The breath sounds were deeper and harsher.  I percussed his lungs, tapped on them like a drum, and found that his left lower lobe was dull instead of the normal resonant that lungs should be.  There was something there, solid or water, but not the mostly air that it should have been.

I asked Carmen Rosa, one of the clinic’s new physicians, to check my findings.  She did.  We were both worried about tuberculosis.

As I listened Carmen explained to Don Agosto that he should go to Hospital Rodolfo Robles in Xela.  Named for a famous Guatemalan doctor, it is a national hospital that offers specialized care for pulmonary diseases and especially TB.  Their physicians would do the diagnostic workup then offer treatment if necessary, for an affordable price.

After we mentioned that – if he had the disease – he could spread TB to his family, Don Agosto agreed to go.  But, fidgeting in his seat, in an anxious voice he asked us to please give him clear directions on how to get there.

“Es que yo no viajo mucho.”  I don’t travel much.  “And I’m worried about getting lost.”

Don Agosto’s community was more than an hour away in the private van that we took.  He’d have to walk to the nearest bus stop, probably not close by.  Once in Xela he’d have to transfer, finding the right local microbús.

As a point of reference:  It took me more than a month to figure out the microbús public transportation in Xela.  There are no printed schedules, no maps of routes.  I got my information from repeatedly asking locals.

By how worried he was, he probably didn’t have anyone in Xela.  No one to ask directions from.  No one to stay the night with.  To make lining up in the early morning easier, or in case the processes at the hospital took all day.

One of things I like the least about developing country life are the “travel politics”.  With no published prices, as an extranjera I’m constantly taken an advantage of.

“She doesn’t know any better.  And she’s a gringa, she has money.  Let’s try to charge her twice as much.”

Never mind that I’m a volunteer at non-profits, not making and in fact losing money by being here.

With no obvious routes, early on I was told, “Never ask a bus driver if he’s going to ___.  He will say yes, and you could end up in the middle of nowhere.  Always ask where he’s going.”

This was the first time I saw how deeply these “travel politics” could affect health care.

Carmen Rosa and I wrote directions on a piece of scratch paper.  After giving them to Don Agosto, he stood up to leave.  He was my last patient of the morning.  I snacked on a granola bar while watching him make his way through the village.  A gust of wind blew up, throwing dust on the rich pattern at the bottom of his white trousers.  He tread away unnoticing, supported by his walking stick.

 

Isaias Asks for an Answer

7 Feb 2013

When one of our doctors noticed that Isaías’ heart murmur had gotten stronger he became one of Pop Wuj’s chronic patients.  Because of his family’s limited means, for specialty cardiology care his mother Gloria was instructed to take him to the university/public hospital clinic where an appointment costs less than USD $1.  Dr. Garrías, their cardiologist, recommended that Isaías receive an echocardiogram.  There was one hiccup.  The university’s equipment was out of service.

“No problem.  Bring Isaías to my private clinic.  As a university patient he’ll get a discounted rate,” Dr. Garrías told Gloria.  All this was before I began working with the family.

When I became his de facto health advocate I took Isaías to the private clinic for the echo.  The cardiologist was, in a word, unprofessional.  He arrived an hour and a half after the start of his posted clinic hours, did not apologize, clearly didn’t remember Isaías and Gloria.

The worst part: After he performed the echo he handed the report to his secretary in a sealed envelope.  He then went into his office, shutting the door behind him.  The secretary called me over to give me the report and tell me how much to pay for the visit.

“Pero doesn’t the doctor want to talk with us?” I asked.

“La cosa es que this visit just covers the test.  You should take the results back to the doctor who originally referred you.”

First, it’s basic protocol for a physician to discuss test results with his/her patient.  Second, just because we’re paying a discounted rate doesn’t mean we should get treatment that’s below the standard of care.  Finally, he’s the referring doctor.  He’s one who told us to come here.

But I didn’t argue.  I didn’t know the system well enough and I didn’t want to burn any bridges.  Instead I brought the report back to Pop Wuj.  The Christmas holidays were coming up so it sat for a little while.  Finally Carmen, the director of Pop Wuj’s social outreach programs, became sufficiently non-busy to have a great idea. “Nicki, why don’t you bring Isaías back to Dr. Garrías in his university clinic.  Then he’ll have to interpret the result for less than a dollar.”

Sneakily smart, Carmen.  Why didn’t I think of that sooner?

Medical students dressed in all white –pants with fully-buttoned coats – were the entire staff of the clinic.  They looked like chefs wearing thick white pajama pants.  The medical student working in reception asked me for Isaías yellow card with his patient number.  I had no idea what he was talking about.

“Perdón, pero no la tenemos.” I’m sorry but we don’t have one.

“Has he been seen here before?”

“Yes, he’s a patient of Dr. Garrías’.”

“Without the card, we won’t be able to find Isaías’ records.”

I put on my best pathetic face and said, “Could you please try looking by his name?”

He nodded his assent.  Standing up he walked over to the medical student working in records to explain what to look for, before directing us to one of the consult rooms.

After several minutes two different people dressed in white came in.  Angélica and Veronica.  It quickly became apparent that Angélica was the older medical student, Veronica the younger.

“They haven’t found Isaías’ chart yet, so were going to re-fill out parts of the new patient intake form.  First, why is he here?” Veronica asked.

“He’s had a heart murmur for a while but it recently got louder.  He was seen here by Dr. Garrías who had him to go his private clinic for an echo.  We just want to know what the doctor has to say about the echo.”

“But why is he here?”

“Um… ¿Cómo?”  I thought I just told you why.

“What symptoms does he have?”

“Uh, none.”  In my head:  But he doesn’t need to have symptoms.  He had a murmur that got louder, which should be enough of an indication to see a cardiologist.

She turned to Isaías.  “Do you have any breathlessness?  Get tired easily?  How about palpitations?”

Isaías glanced at me with a confused look, then back at Veronica.  “No.”

Veronica started to list more symptoms until Gloria, with Isaías’ half-sister on her back, stopped her.  She said, “Sometimes he gets tired when he runs and plays a lot.”

Well, who doesn’t?  I wondered if Gloria said that to satiate Veronica, or if the questions had made the mother in her more nervous than she already was.

Veronica finished her questions.  The two began to examine Isaías.  They were looking at his eyes with an ophthalmoscope when the student working at records popped in.  He had Isaías’ chart in hand.

Yes!  I thought.

Eventually, Veronica asked me about the echo again.  “So Dr. Garrías did the echo in his clinic?”

“Yes, would you like to see it,” I said as I reached into my bag.  It was a rhetorical question.  Her answer should have been yes.

“No, that’s okay.  As long as you have it.”

That’s odd.  In the US I’d get chewed out as a medical student if I didn’t look at all the information, especially available test results.

Veronica used the patient bed as a table while she refined her notes, with Angélica guiding her along.  It warmed my heart to see that some things cross international borders, including stressed-out medical students frantically putting together presentations for their attendings.

Eventually, only 45 minutes late this time, Dr. Garrías did arrive.

Veronica presented Isaías’ case.  She got through his history, was on to describing his physical exam, when Dr. Garrías interrupted her.  “Wait, why is he here.”

She explained his fatigability symptoms again.

“No, that would be why he first came.  You said that I had seen him before, so why did he come back.”

Veronica looked blankly at me.

I said, “You sent him to have an echo in your private clinic.  We’d like to know what your recommendations are based on the results.”

“Did you bring the echo report?”

“Yes.”

Turning back to Veronica he asked, “Did you look at it?”

Veronica mumbled, “Ehh…”

“Ay, Veronica.”  He bemusedly shook his head.  “You have to look at everything.”  Dr. Garrías took the echo from me.  “And who are you, exactly?” he asked.

“I’m a volunteer with a project that’s supporting the family.”

“You work in healthcare in the US?”

“Yes, I’m a medical student.”

After reading the report he pulled out his stethoscope to listen to Isaías’ heart.  When he finished he began to ask Isaías and Gloria more questions.

“So Isaías gets tired?”

“Sometimes,” replied Gloria.  “When he’s active.”

“But not all the time?”

“No.”

“If his heart were the cause the symptoms should happen consistently, all the time, not just sometimes.  Does Isaías have any issues at home or in school?  Are there problems in the family?  It may be worthwhile to take him to a psychiatrist.  But before we do that we can test his thyroid function…”

“Entonces doctor,” I interrupted, “based on the echo, you don’t think Isaías needs further treatment for his heart?  No surgery, no medications?”

“No, he’s fine.  The few things that came up on the echo were mild.  They should not be causing his symptoms.  Just keep following the murmur.”

Dr. Garrías wrote an order for thyroid function tests.  He then bid us goodbye and exited, the two students following behind him.

“Did you hear that, Isaías?  He said your heart is fine!”

Isaías smiled and raised his right arm.  We clapped hands loudly in a high-five.

As we checked out we were told we’d have to pay for a replacement yellow card.  I started to open my bag when Gloria stayed my hand with hers, paying the fee herself.

 

For details of the beginning of Isaias’s story, see: https://naranetacrossing.wordpress.com/2012/11/30/isaias/

 

Clinic- Laraí

1 Feb 2013

Laraí, a soft-spoken elderly woman with silver hair, waited for us in the patient room as we stepped outside get gloves.  Drew and I were seeing patients together that day, a rare treat for medical students in the clinic – where you get to bounce ideas off a partner without the stress that comes with working with a superior.

It was Laraí’s third time in our clinic in two months.  She had poorly-controlled diabetes (her blood glucose that day was over 200) and well-controlled blood pressure.  We thought all we’d do that day was increase her metformin.  But then she began to tell us that she’d been feeling out of sorts.

“No tengo ganas de comer.”  I don’t feel like eating.  “I’m tired.  Food makes me nauseated.  I just feel unwell all the time.”

Looking back at records from her previous visits, Laraí had lost weight.  Ten pounds over two months.

And then she said, “And the mark on my arm isn’t getting any better.”

She held up the back of her left forearm to show a large lesion, dark purple with whitish flecks around the edges.

My first thought was fungus, which is relatively common here.  But this looked unlike any fungus I’d ever seen.  Then another look at her chart showed that Laraí had already been treated for fungus.

“Le pica?” I asked.  Does it itch?

“No, but it hurts.  And sometimes it bleeds.”

That’s when Drew and I stepped out to get gloves, so we could take a closer look.

Shutting the door behind him, he said, “I think it might be melanoma.”

Melanoma is the deadliest form of skin cancer.  If caught early it is usually curable by surgical excision.  If not, it has a remarkable ability to metastasize.

Something clicked.  Drew’s statement released the same thought from the back of my head.  Oh dear, I said with my eyes.

We came back, ready with gloves, a ruler, and the ABCDE mnemonic for melanoma.

Asymmetry – with a concave surface on one side and a convex on the other, the lesion was definitely asymmetric.

Borders, irregular – Yes, they were.

Colors, multiple – It carried at least three colors: purple, red, and white.

Diameter, greater than 6mm – 40mm easy.

Evolution, or change over time – The patient said that it had been growing for at least a year.

We examined Laraí’s heart and lungs, and especially her abdomen.  With her lack of appetite and weight loss, we were worried about metastases to that area.  Everything was normal.  Her belly was not tender when we pushed on it, we couldn’t feel any masses, and her liver and spleen appeared normal.

Yet with the lesion’s growth over a year, which seemed fairly rapid, and Larai’s symptoms and weight loss, Drew and I remained almost certain that she had metastases.

We went outside to speak with the Guatemalan staff about what to do.  As with many of our patients with problems beyond our capabilities, we were to instruct her to go to the public hospital.  She would have to line up before 7am to get an appointment with an internal medicine doctor, who would then hopefully refer her to one of their dermatologists.

The level of education in the US on skin cancer is high.  If I had told a US patient that she likely had melanoma, possibly advanced, she probably would have been freaking out.  But Laraí sat there being her soft-spoken self.  She nodded occasionally, but her blank look cast doubt as to whether she fully understood the gravity of what we were trying to tell her.  I worried that she might not follow through with the public hospital.

I had never been more frustrated with not being tied in to the system.  Therein lies a big problem with being an outside, non-profit health clinic in Guatemala.  (Although it’s unlikely that the government Puestos de Salud could have done much better.)  I wanted so badly to be able to set up an appointment with the dermatologist myself.  So that Laraí wouldn’t have to wake up early, travel to only wait in line, then possibly get discouraged and leave.

But it might not have mattered anyway.  Our clinic coordinator, who is much more familiar with the system than I, told me that the hospital doctors would probably “leave it”.  Because private providers in Guatemala City (read: expensive and far away) are the only ones equipped to give the treatment that Laraí needs.  And because she’s “of age”.

 

Selection

9 Jan 2013

My eyes glance over a familiar gas station through the window of the car, an old land rover that has lost its shock absorbers.  I am accompanying Carmen, the director of Pop Wuj’s social outreach projects, as she does a home visit in Llanos del Pinal.  It is January and it is time for Pop Wuj to select a new group of families for our stove project.

Over the next few months volunteers will build safe stoves to replace open fires in the houses of carefully chosen families.  Carefully chosen because families must be, or at least appear to be, poor enough to merit our help.  We do a home visit to inspect houses.  If a house looks nicely built – with more than one floor, several rooms, or nice appliances – then we assume that the family ought to have enough resources to construct/buy their own stove.  If the family already has a stove they are, usually, automatically rejected.  Sometimes Carmen will make an exception for a family with a small gas stove – if they obviously only use it when they need to cook something quickly, and if it’s apparent from their house and circumstances that they are hurting for money.

The first home we pull up to is a cluster of three adobe constructions arranged as three sides of a square.  A sheet-metal gate forms the fourth side.  Ofelia lets us in by pulling back a section of sheet-metal that acts as the door in their gate.  She is the matriarch.  Our contact in the family is usually the matriarch.

Carmen introduces us and why we are here.  She is careful to explain who we are and even more careful to explain what we are not. “We’re a social cooperative funded by our Spanish school, all of which is run by Guatemalans.  We are not the government, a foreign or international organization, or a church.”  At each visit Carmen makes sure this is clear.  The government isn’t always trusted.  There are religious quarrels in Guatemala between Catholics and Evangelicals.  And she doesn’t want the families to see our American volunteers and assume that the organization has a lot of money.

Ofelia seems excited to see us.  Her whole family, including children who are probably grandkids and six chickens, come out into the small courtyard.  From here I see that the three constructions of the cluster are each a single room.  One is a bedroom, another a family room or a second bedroom, the last the kitchen.

We ask to see where Ofelia cooks, wanting to examine the space in which building will occur.  The roof of the room is especially important.  All holes should be patched so rain doesn’t damage the new stove.

The first item we see is a large gas stove.  I stop walking and look at Carmen.  My breath is held.  I know that in theory a rejection is coming, but I do not know how to deliver it.  She turns to Ofelia and gently asks, “You already have a stove?”

“Si, pero es caro.”  Yes, but [gas] is expensive.  “We were hoping for a wood-burning stove so we can collect firewood instead.”

“I see.  But I’m afraid we won’t be able to build you a stove.  We are a small organization with limited resources; we’re looking for those in the most need of our help.  For this project this is families that cook over open fires, because of the specific problems fires cause.  I’m afraid what your stove shows us is that you have enough means to solve these problems on your own.”

“Oh, but it’s not my stove.  It’s my daughter’s.  She’s lending it to me.”

This pulls my gaze from the ground towards Ofelia.  I believe her.  And the thrown together rooms with dirt floors and corrugated metal roofs show me they are far from a well-resourced family.  I know that I would make an exception.  But maybe I’m too much of a sap.

Carmen stays firm.  She echoes what she said a moment ago and adds, “I appreciate that you didn’t hide the stove from me.  Some families have tried that.”

The family is gracious as we leave.  The children are lined up shoulder-to-shoulder and follow me with their eyes.  Carmen thanks them for receiving us.  I secretly hope that we do not find enough families in this village (we build stoves in groups of ten) so that we can come back and give Ofelia some good news.

“Saying ‘no’ rarely happens, usually our filters before the home visit are good, but it is difficult.  And we have to be careful with exceptions.  If others catch wind of an exception, there could be trouble,” Carmen tells me while unlocking the land rover.  I learn that other organizations are doing stove building work in Guatemala, each with their set of (similar) requirements.

We drive for a few minutes to another home in Llanos that looks strikingly similar to the last one.  Luz de María is our contact here.  The door is opened by a middle-aged woman with teeth missing, wrinkles around her mouth, and braids on either side with purple thread laced through them.  She says that she is Luz and shows us into her small courtyard.

Sitting on the floor half in shade is a visibly old woman.  Her hair is arranged like Luz’s sans the purple thread.  All-but-two of her teeth are missing.  Luz introduces her as her mother Raisa, instructing us to yell because she’s hard of hearing.  I shout, “Hola! Soy Nicki!”  Raisa takes my outstretched hand and nods vigorously.  I’m not entirely sure if she understood what I said.

We are shown into the kitchen.  It is bare except for a small portable table upon which utensils are strewn-about.  On the ground the earth is scorched where the fire usually sits.  There is no sign of a gas stove.

In the courtyard we begin the interview.  I ask questions while Carmen writes notes and interrupts when necessary.  Luz has six children but only the youngest, unmarried and in his early 20s, still lives in the house.  However one other son lives in the house just to the north, one daughter in the house to the east.  The rest have not gone far; they all live in the same village.  All the sons went far enough in school to learn to read and write.  Two of the daughters did not.

Luz responds in the negative when we ask if she has a job.  But after careful prodding – Are you otherwise productive?  Do you work in the fields?  Wash clothes?  Sew?  Sell vegetables in the market? – she tells us that she has irregular work going to houses and doing other people’s laundry.  Here a “job” means steady, secure employment.  Luz’s husband and youngest find work in the fields when they can, other people’s fields.

We learn that, thank goodness, no one in the family has been burned by their open fire.  But the smoke does bother Luz.  It makes her eyes water and sometimes, she thinks, it causes her to cough.

Carmen makes some notes about the construction of the house.  After giving Luz more information about the stove project, including what the family is expected to contribute towards building materials (no more than USD $8), the interview is over.

On the way out I stop to ask Raisa if I can take her picture.  At 92 she is well into what is called la tercera edad, the third age, yet she is hard at work sorting corn kernels.  I’ve seen many like her in Guatemala.  Worn old bodies planting and harvesting in the sun, carrying heavy packages of goods to sell, leading a pack of sheep up a mountainside to where trees still stand and shelter grass on which animals can graze.  I am impressed, and I want to record the moment.

 

For more information about safe stoves that replace open fires, see: https://naranetacrossing.wordpress.com/2012/10/26/clinic-sin-respirar/

 

How is Suceli

29 Nov 2012

In September I wrote about a mother and daughter.  The first time I met them Sara and Suceli were on their way to UNICAR, a cardiac hospital in Guatemala City.  Four-year-old Suceli was to have an operation for a congenital heart condition.  Since then the two have stopped by Pop Wuj with relative frequency; Sara has occasional meetings with the director of our social outreach projects.  They remembered me from our first introduction and would often look for me to say hi.

In our further encounters I learned that Sara is a madre soltera.  Single mother.  Suceli’s father abandoned them while Sara was pregnant.  They are not, however, without support.  They live with Sara’s parents, four brothers, four sisters, and two grandmothers.  It was her brother who donated blood for Suceli’s operation.  Sara finds work sewing clothes to contribute to the family income.  Suceli is her only child.

In the summer of 2012 Sara took Suceli to a mobile clinic that Pop Wuj had scheduled near their town of Paraje Xek’axtun.  She was concerned; her daughter seemed to tire more easily than she should.  Dr. Wilder examined Suceli.  He noted a heart murmur that he thought warranted further workup.  Suceli was keyed in to our chronic patient program then referred to UNICAR.

Through UNICAR Suceli received all her care for her heart condition up through the surgery.  They evaluated her, did studies and imaging, made the diagnosis and recommendations.  The following September UNICAR doctors performed her surgery.  A few weeks later she came to Pop Wuj Clinic to have her stitches removed.

Since then it has been, shall we say, difficult to get in touch with UNICAR.  We still do not know what Suceli’s final diagnosis was nor what surgery was ultimately completed.  Wilder sent them a letter requesting her records, or at least the principal information, which went unanswered.

The fact that we don’t know the details of Suceli’s care is embarrassing.  As regards the health care projects Pop Wuj is accountable to Timmy Global Health, an organization based out of Indianapolis that partners with the clinic and generously supports the chronic patients. 

But an unsettling lack of information is not all we have to report back to Timmy.  “Ya no se queja del corazón”.  Now Suceli doesn’t complain about her heart, reveals Sara.  “She also eats more than before.”  Sara tells me Suceli no longer tires easily.  One fine day I find them on the roof of Pop Wuj where the four-year-old explorer is skipping around and marveling at the view.

For more backstory see: https://naranetacrossing.wordpress.com/2012/09/17/suceli-and-sara/