Return to the US

I have been home for about a week now. There are a few things that I miss about living in Guatemala, but mostly there are things that I wish we did differently here. I'm not going to pretend that I don't enjoy the hot luxurious shower, or the warm water in the kitchen sink, but the excess here is pretty shocking. Mid-December, with all of the holiday excitement, is probably one of the most difficult times to return to the country after being in a poverty-stricken place.

My friend Becca described my feeling as "materialism guilt." I'm simultaneously torn between wanting the pretty shiny things and the peppermint mochas, but I'm also acutely aware of the items that I'm buying. I had no problem gift shopping in Guatemala, Cody will certainly tell you that. But half the stuff I bought there I bought because I wanted to give the money to the vendors and artisans. I enjoyed shopping at Fair Trade stores, and buying things on the streets. But here, it's back to the Wal-Mart style shopping, that makes me a little bit sad. It's hard not to think "oh, the cost of that necklace could feed 'x' number of people..."

This isn't the first time I have gone through this before. In fact, about 6 or even 9 months ago I remember telling myself that it was time for me to get out of the country again, because I was starting to want too many new sweaters and shoes and stuff. It comes and goes, and hanging out where I do I easily can slip back into the appreciation for pretty, new things.

Have you seen those ads from non-profits that suggest that you give someone the gift of a charitable donation in their name? I have done those a couple of times for people, and this year was the first time that someone did one for me. It might seem silly to someone who so thoroughly enjoys the latest and greatest, but it actually made me really happy. Opening that email telling me that a gift had been made in my honor made me smile that sort of smile that comes from deep within. I still feel warm and fuzzy as I think back to it. My friend was right, this was something I'd enjoy much more than a new pair of earrings. There is satisfaction in knowing that someone was given something that he or she really needed, instead of something (admittedly fun) that I don't really need.

I struggle with wondering if this materialism guilt is a good thing (a realistic thing) or not. I have no doubt that some awareness of our spending habits and our wealth is important. Now comes the question of what to do about it. Maybe I'm not going to sell my diamond ring and feed the hungry, (but then again, should I...?), but I think that a conscious effort to literally share the wealth is important.

This brings me to another important lesson. I have always felt that we have an obligation to do our absolute best to make the world a better place. In Jewish tradition this principle is called Tikkun Olam (translated: repairing the world). I take this principle to mean more than just spending wisely and being responsible consumers. To me, this obligation extends to using more than financial resources, but whatever skills and knowledge we have. At this time, I am searching for a pediatric nurse practitioner job in the Boston area. I am not too far into the job hunt (I've sent out about a dozen applications), but the stress that I am starting to feel is actually not financial. I am stressed because I feel like I have a skill to be offering the world, and I have nowhere to use it. I feel like being idle with any resource, even skills, is wasteful.

After all these heavy thoughts, the question becomes what to do. Well, first and foremost, I have to find a job. But obviously it goes beyond this. I'm an advocate for responsible consumerism, including both spending wisely, and buying fair trade, local, and organic as much as possible. I'm not saying don't buy the stuff, but think about how much you need it, and when there is a choice about the source, take into consideration fair trade, organic, etc! As for materialism guilt, I'm not writing it off, nor am I going to let it take over my shopping. It's a good reminder to help you slow down and buy responsibly, but even responsible consumerism isn't going to change the world. It's going to have to take some Tikkun Olam, and careful work.

If you are interested in donating to the clinic where I was working in Guatemala, here is the link. http://www.primerospasos.org/donate.html They offer an option to donate in someone's name as a gift, and there is other information about donating. I definitely care a lot about this organization, and I think they use their money wisely, but there are plenty of places that are worthy of donations.

Goodbye Dinner with Friends at Cafe R.E.D.

I wrote about Cafe RED in a previous blog post. The owner, Willy, offered us to have our goodbye party there. Cody and I both left the clinic at the same time, so we decided to do an event together. Neither of us wanted much of a party, and we didn't want to make it into such a big deal. Willy offered that we could buy a bunch of food and cook it there for our friends. It turned out really well, and we had 6 people cooking and doing food prep! It was great to get people involved, and have a nice place to hang out all afternoon while we made dinner. My favorite kind of party! We had indonesian coconut pineapple rice, and a tofu peanut sirfry. I also made a chickpea spread for an appetizer, and we had homemade bread and some tasty cheese. It was some good eating!

At the end of the dinner we had a little moment of thanks from the clinic. They kindly made us these certificates honoring us for the work we have done at the clinic. This is Margarita (and her son), presenting them to us. Margarita is the clinic's director.

Last Day at the Clinic

Saying goodbye is tough, but the last day at the clinic was much more than that for me. Half of the day consisted of wrapping up the projects that I had been working on, and the other half of my time was filled by seeing patients.

I took pictures with my second to last patients, and they were very sweet about it being my last day. I just wish I got some action shots, but the smiles are pretty great, too. :)


Read the blog I wrote about the suero project, and you can get a sense of some of the wrapping-up we were doing. It was a busy day, but it was exciting to see how much work we had been able to accomplish. It was nice to take a moment and reflect on what was done. We were given many thank-yous, and very sweet goodbyes.

I counted up my totals, for the figures I have to report back to Hope Through Healing Hands, and I saw 293 patients with the clinic, and did formal and informal training sessions, which included 42 people. Cody and I left the clinic with materials to treat malnutrition and prevent and treat dehydration. It has been a really valuable experience, hopefully for everyone involved.

Suero Project: Making ORS with easy to obtain, locally available ingredients

Dehydration from diarrheal illnesses is one of the leading causes of death in the developing world. We have fewer diarrheal illnesses in the US (mostly due to clean water and food), but in places like Guatemala, gastrointestinal infections are very common. In order to prevent and treat dehydration for these people, oral rehydration solution (ORS), or as they say here, suero, is used. Suero isn't everyone's favorite thing to drink, but it can be life saving!

One of the things that Cody and I noticed at the clinic was that there is rarely enough suero to go around. We did the calculations, and it seemed like we were only giving out about a tenth of what we should be distributing. We often run low, despite the rather frequent pharmacy deliveries. The supply was clearly in need of some help.

Cody decided that we should try to make our own suero at the clinic. I could see that this was going to be big, so I asked him if I could help out on it, too. We looked into a few methods, and decided that it was feasible. In some parts of the world people make a very basic ORS out of sugar, salt, and clean water. This is pretty basic, and the World Health Organization (WHO) has specific guidelines about how to make an even better version. The only problem was, when we looked at the WHO recipe, it became clear that we were not going to be able to obtain a key ingredient: potassium chloride. We looked into various ways of buying it abroad, and getting it transported to the clinic with volunteers, but decided that wasn't a sustainable (or very feasible) option.

We looked into our possibilities here, and ways to get potassium into the suero. In some of my research I discovered that unrefined brown sugar actually has a lot of potassium in it. By chance, we were able to find a bag of ground panela, or piloncillo in a store. This artisanal product is not only flavorful and sweet, but also has a whole lot of vitamins and minerals in it. Cody worked closely with his friend Jonathan to come up with a recipe that would allow us to do the best we could with the ingredients we had available here.

In the end, we came up with a recipe for suero that we can make at the clinic! Through Willy's help at Cafe R.E.D. we were able to get in touch with a cooperative of local farmers, who grow panela organically. We now have a regional, organic source of panela, that we can purchase through an organization that we respect. We also got several pounds of salt and bicarbonate. All items are in containers at the clinic, and can easily be measured into liter-sized amounts of suero mix, and given to patients in little plastic bags.

And the best part is, Cody did the math, and it turns out that this recipe is 1/10 the cost of the old suero packets we were buying at the clinic! Now for the same cost, we can treat 100% of the patients who need suero, instead of just 1/10!

Cody has been working on writing up a report and presenting it to the clinic's board in both the US and Guatemala. But the reception at the clinic has been overwhelmingly positive.

Here we are showing off our supplies, about to teach people at the clinic how to mix up the batches of suero mix.

A Place of Inspiration: Cafe R.E.D.

One of the great things about being in Xela is being surrounded by so many inspired people. The city seems to collect young idealistic people looking to change the world. As cheesey as that may sound, it is great to get the chance to meet so many interesting people.

One of the coolest people I have met here is a Guatemala guy named Willy. He runs Cafe R.E.D., which is located about 2 blocks from my house. Cafe R.E.D. is way more than just a restaurant, it's an educational program and a source for fair trade goods and organic veggies. The walls are currently half covered in murals, and the other half in a photo exhibit trying to help young women improve their self esteem. Half the time I go to visit there's some board meeting or class going on. It's a really neat multi-functional space. They host cool events, have art shows, fair-trade/organic/crafts markets, and a whole bunch of interesting people gather there. One of the reasons I have been working with them was to get connected to a co-op of organic farmers that sells panela (unrefined sugar) in powder, which we are using for the ORS/suero project. Willy introduced me to the head of sales at Kuchub'al, and we were able to make that happen.

This is the place where I went to make pumpkin pies.
They actually posted some pictures of the final product, the Thanksgiving dinner. I didn't attend, because I headed off to Antigua with Luis, but I heard it turned out well.

Here is a link to Cafe R.E.D.'s webpage. If anyone is ever in Xela, you should check them out.

Another reason why I like Cafe R.E.D. is the fair trade store. In there, I found a documentary about a coffee farm a couple hours away called Santa Anita. The documentary talked about the events leading up to the start of this farm. The tragic past, tied with the conflict/revolution here gives meaning to what the families there are doing today.
The film is available on youtube, from this website, if anyone is interested in seeing it. After all of my project-work at the clinic, it made me realize that no matter how much I try to treat symptoms of social problems, they will always return unless we treat the source of these problems. True preventative medicine is much more about social issues and politics, helping people meet their needs, rather than prescribing vitamins and such. It's pretty thought-provoking to see what people here have lived through, and perhaps even how little has changed since the start of the conflict here decades ago.

Willy is doing a great favor for me and my friends, allowing us to come and cook on my last night in Xela. It's halfway between a restaurant and a home-made goodbye party, and I think it will be great! Plus it's a great way to support an organization I care about.

Quilt Project

One of the things that constantly impresses me here is the indigenous clothing. Women have gorgeous, intricate clothing, embroidered and woven. As much as I love the fruits and vegetables sold in the market, my favorite part is still the dress shops, where whole families go to shop for an outfit for one child, or one of the women. I have decided that I would like to take some fabric home to make a quilt.

All of the fabrics that I chose were some of the traditional weavings. Most of these fabrics are what the women here use for skirts. I have two more intricate cloths, one is actually a little girl's shirt, hand embroidered with flowers and other designs.

I am really looking forward to going home and piecing all of this together. If anyone has any quilt design ideas, let me know! :)

Implementation of the new Malnutrition Protocol at the Clinic

This morning I went into the clinic with a back-pack full of stuff. I brought in the 150 copies of the nutrition record for the charts, 150 copies of the patient info handouts, 5 laminated copies of the color-food pyramid/nutrition info sheet, the stuff to make folders, handouts for my class, and a sample of an appetite stimulant we can use. When I got to the clinic in the morning, I set out to organizing all the folders, posting the information, and making a spreadsheet to keep track of patient data.


We got busy towards the end of the day, so I was a little nervous we weren't going to have time to hold the little training session class for the clinic staff. But in the end we were able to fit it in. We held the class in the classroom space the clinic saves just for this purpose (and for office-parties).

I went over a little bit of info on why malnutrition is important to treat even when it's mild or moderate, how to treat it, what paperwork we can use to keep track of tests and stuff, distributed protocol, went over dosing of some medications, talked about what sort of educational info we should use, and how to help motivate people to get involved in such long-term treatment.


The protocol includes:
-screening for malnutrition at every visit, and prompt treatment
-education for students, volunteers, and staff
-documentation specific to the needs of malnourished kids

Treatment includes:
-monthly weight checks, and exams
-lab testing for parasitic infections and anemia, and treatment for any infection
-multivitamins
-educational plan with info about nutritional requirements, supplements, health/hygiene, etc.
Everything is kept track of in the patient's chart, and a spreadsheet at the front desk. The parents also are given a chart where they can keep track of the information themselves.

It has been really exciting to work with the clinic on this, and get input from various people. I'm looking forward to keeping track of the progress of the children at the clinic over time.

All in all it was a good day. It felt nice to finally get to do something with the work I have been doing, and I think it was all pretty well-received.

Malnutrition Work for the Clinic: Patient Education

As my work in Xela is coming to end, I am trying to wrap up my projects and share the things I have learned with the clinic community. I am also going to try to train the medical students in primary care treatment and screening of Grade 1 and Grade 2 malnutrition.

One of the parts of my treatment plan is a strong educational component for the patients and families. I made up food pyramids with some more nutritional info for the patients to take home, and some to keep in the clinic for quick reference. I'm also including some basic malnutrition info, and a couple of forms of keeping track of weights and lab values both for the clinic and the families.

Here's what the food pyramid looks like:


I printed paperwork for 150 charts, and double-sided handouts for the same number of patients. I am hoping this is a good way to get things started. We're still working in finding enough money to support the protocol (which includes tests for anemia, tests for parasites, treatment for any GI infections, appetite stimulants when needed, multivitamins, possible iron supplementation, and monthly weight checks). But in the meantime I'm trying to get things going with whatever resources we have.

Hopefully after tomorrow's class and getting the papers in place at the clinic I can start focusing on the ORS project this weekend, to get that set into place.

Calle del Arco, Antigua

I found this photo on my camera, and thought it was beautiful. This is one of the main streets off of the plaza/park in the center of Antigua. The arch, or bridge, was apparently built to allow nuns to cross the street from the convent without being seen. Through the arch you can see the Merced Church.

Lots of Transitions

The Primeros Pasos Clinic is always bustling with change (forgive the cliche, but it's true). The medical director has generally been a one year post, and the administrative people are shifting in and out. International volunteers may come for as little as a week or a month, though few stay for longer. The most influential group of transitioning people is the medical students from the local university. They rotate about every 2 months, and each time they change we have to train a new group of people. The med students get this as their family medicine rotation, which comes before their pediatric rotation. Our clinic sees mostly pediatric patients, so this leaves them with a lot of catching up! This means that they have been spending the last week learning dosage calculations, and what ages you can start using certain medications. After getting used to the previous group of students, it feels like a difficult transition to start all over again teaching the same things. But it's exciting to see when they pick things up, and start to remember the things we have gone over before. Since there is little orientation for people coming into the clinic, there is a lot of peer-peer teaching.

Working with people through all of these transitions, and coming into what seems like a lot of abruptly finished projects, it seems like there is little continuity. Not just in terms of protocol and procedures, but in terms of knowledge. If I have learned what a particular rash is, or what medications are not well tolerated my the population, then I leave with that knowledge and leave others to figure it out. But if I find a way to transition out, leaving information for people who will come in the future, I can use some of that information for the grater good. This is one of the things that I have been working on.

I started a list of medications to share with foreigners, and all newcomers to the clinic. As healthcare providers, sometimes it doesn't matter to us what particular medication from a group we use, as long as it's from that group, and safe for the patient. If a patient goes to the pharmacy and can't find a particular medication, there is often some flexibility, but the decision must be made carefully. At home, CVS or whatever pharmacy may call the person who prescribed it, but that doesn't happen here. When there is no dialogue after the one-time visit, there's no way we can adapt our choice of medications. Needless to say, we have to be very careful about what we write on a prescription. So I am writing a list of meds that can be prescribed for some relatively common conditions that are rare enough that we don't stock the meds in the clinic. This includes certain allergy medications, antbiotics, laxatives, asthma meds, and eczema meds. When I first got here, I had to make guesses on EVERY one of these drugs, hoping they happened to stock that kind here. Now that I have scoped it out, I can share that with future volunteers, and even post it in the pharmacy for easy access!

I am also going to work on sharing my protocol information for children with malnutrition. I am starting to write up a curriculum to review with the students soon.

The clinic has some protocol in place to make these sorts of transitions easier, but there's always room for improvement. I think that the only way to keep this consistency going is to have strong leadership and communication between the people in the environment. That's what I'm trying to help out with!

Asthma without ICS

One of the mainstays of asthma treatment at home is the use of inhaled corticosteroids (ICS). They are so effective that we even branch out to using them for asthma-like symptoms on infants and toddlers during the cold season. We use them in nebulizers in the office, and prescribe them for use at home. Once kids are needing a lot of albuterol this is how we can treat asthma and breathing problems from another direction. Used short term, or in low doses, there aren't a whole lot of side effects to worry about, making them a much safer choice than systemic steroids, which can have a whole bunch of nasty adverse reactions.

In school and in practice we are taught that when a person is having a certain number of exacerbations, and needing albuterol at certain intervals, we need to bump them up to the use of ICS. From there we can manage the dose, and get them on any combination or taper necessary.

But what do you do when the pharmacy only carries albuterol and Advair (a combination, not first line)? And not just in inhaler form, there seems to be nothing but saline and albuterol for the neb, too.

Twice in the last week I have seen two children who I would consider using ICS for, but I had nothing to offer. So today I went to two pharmacies after clinic to fully research the options. This is something that I try to do every once in a while, because I need to be able to accurately tell my patients what to buy, and how to get it cheapest. Many of the families are unable to afford an expensive medication, but when I find that a pharmacy sells the old generic (CFC containing) version of albuterol, I send them there where it costs about 2/3 of the price at the other pharmacies.

Today's pharmacy results:
Albuterol inhalers cost about $6, which is expensive, but not entirely unreasonable.
Pulmocort is available in nebulized form, but costs $3 per dose, which adds up fast!
There's one combination ICS with albuterol, pretty pricey at around $18 per inhaler. Other combos with LABAs like Advair are well over $20.
Spacers w/ and w/o masks cost about $15
There's no inhaled ICS in inhaler form that is not combined with anything.



My new ideas are that it's possible to consider that one combination ICS if really truly needed, and prescriber a spacer, too, for the young ones. I checked out the pharmacies so that I can recommend the right places to go, and wrote it all out on a list to share with the clinic. If someone really needs pulmocort it's possible that we could have them come into the clinic 5 days a week, and they could buy it and bring it to put in the nebulizer we have. But I'm going to try to pursue routes of asking for donations from the US to both fund purchases here, and bring us some goods from home that are not being used.

A baby's funeral

This week has brought many challenges, from big to small. But one of the most striking events this week happened yesterday, on Thursday. A young Guatemalan woman who works at the clinic has been absent for the past week, having her first baby, at the age of 18. We were all excited to hear the news, as when she approached her due date we all half-expected her not to show up anymore, thinking maybe that was the day she'd gone into labor! Her sisters and mom brought the baby into the clinic to be checked out when he was just 1 day old. The doc examined him and gave the report that all was well. The grandmother was full of smiles, and so proud of the little guy that when I missed my chance to hold him, she ran outside to grab them for me. I held the little guy, wrapped in a bundle of a half dozen blankets.

Somehow things changed in the next 48 hours, because on Thursday morning (yesterday) the young mom woke up and the baby had died, at just 3 days old, and with no warning. The news traveled fast, and within a couple of hours, when the clinic was scheduled to open, everyone knew. The whole day at the clinic was affected by it, from our speculations to the cause of the baby's death to the fact that the woman who cleans and opens the clinic every day is the grandmother of this baby, and therefore was not there. We all asked what we could to to help, and it seemed that the only request was money--for the burial, and whatever other expenses were necessary. At the end of the day, we were all invited to the burial at the city cemetery.

There were few questions asked about the cause of the baby's death among the non-medical community, or at least that we heard. There was no discussion of an autopsy, and I heard no one try to place blame on anyone. Of course we all wondered was it some sort of hemorrhage, was it a cardiac problem, was it SIDS? But the overwhelming emotion everywhere was sadness.

The burial was intense. We waited outside in the cold for the procession of people down from the rural area (one of the communities where we did mobile clinics). 4 pick-ups trucks packed full of people passed by, and the 50 of us who were waiting on the steps stumbled over to join. The first truck carried the baby-sized coffin. From what I could see from the short distance, it was a white, ruffly, padded box, rectangular. It looked more like an ornate accessory than a coffin. It was propped on a stand made of metal rods. A group of men carried the coffin as pallbearers would, though it was small enough to be carried by just one.

As soon as they pulled into the cemetery one woman started to sob. Loudly. Like nothing I have ever heard before. It was pure anguish. There was no holding back. Occasionally she would shout out some term of endearment, or flail her arms and body toward the coffin, and her companions would hold her back. As she fell to the ground only a few yards into the cemetery, and stayed back for a while with two younger women, I learned that she had been drinking. When she rejoined the rest of the group, she continued with her sobs.

There was a fascinating contrast between the numerous children, the women selling candy and snacks at the burial, and the pure, honest grief in peoples' faces, posture, and sounds. About 25 of the 150 people present were wearing strips of white cloth--tied over babies on their backs, on their heads, as ties around their necks. These were to signify that they were family members. Most of the women were in indigenous dress, except for a few younger folks, and the 2 foreign women. Then men were mainly in jeans and a jacket, though a few were in suits, and almost half had cowboy hats. I heard that white was the chosen color, because it was a baby who had died, not an adult. White is the color of angels, which is what he was said to have been--a little angel called back to God.

There was little order to the process. As we walked to the far end of the cemetery (beyond the fancy monuments and such, to where space is given to people free of charge), we turned off to the right, then stopped while some men discussed the location, and we all turned around and walked to the left. We stood in the narrow spaces between the graves. There was a space already dug in the ground when we arrived. I'm not sure who dug it and when. A man in street clothes and dark sunglasses held his hat in his hands, and said a few religious words, and the entire crowd--minus the 4 foreigners there--crossed themselves. The speech focused on the idea of a little angel being returned to God.

After a moment, the coffin was lowered carefully into the ground, and the sobs became louder. The coffin wasn't just set into the earth, with a ceremonial placement of a shovel-full of dirt. The coffin was actually buried. Shovel-after-shovel-full, the crowd watched as two men took turns shoveling. They only stopped when there was a mound of dirt over the grave, and they had dug holes for four cut-off soda bottles to hold the white calla lilies they had brought. The grave was adorned in white flowers, and tiny plastic cups of soda were distributed to the crowd. Some of the women bought snacks for their kids, from the vendors who followed us to the grave sites.

Two of the women had almost identical cries in the crowd. The other woman was the grandmother. These women were in the throes of grief, they weren't burying it deep inside. Neither were the men who freely letting tears pour down their faces. Psychologists say that people have to experience grief, or the pent-up emption will cause some sort of explosion or harm later on. But many people struggle with how they should grieve, in a culture where displays of extreme emotions are not considered acceptable, especially in public. These women have a skill that is not often found, at least not back home. There were no negative repercussions for their sobs. I would imagine there may have been a quiet whisper about the woman drinking so much, but I heard none, and saw no disapproval.

The baby's mother did not attend the burial, because she was unwell, her face swollen, likely from so much crying, but possibly more. This is a place where temperature plays a significant role in health, and the family thought it would be harmful for her to be out in the cold, so she stayed home. She missed her own son's burial, but the baby's father shed some tears for her, standing right over the grave.

At the end of the burial, a group of us 3 foreigners walked away together. I thought we wouldn't say a word, because we were all so deep in our heads about what we had just witnessed. But it took surprisingly little time to cross over into conversation--sharing the observations, and questions that we had. It was surreal for me to imagine that within the span of 24 hours the mother probably spent 10 hours comforting and feeding a crying child, put him to sleep, woke up a couple of hours to find him dead, call her family, call the clinic, get arrangements made, hold a funeral and a burial, and have him in the ground 12 hours from the time she had woken up thinking he was ready to feed again. And after all that, after the day she had, and all of her family, we were going to go home to the comfort of our homes where no sobs were being let out, and have a peaceful evening.

Cough Syrup

One of the things we struggle with upon occasion is the idea that patients expect to receive something when the come into the clinic--basically, they expect medicine even when they do not need it. This doesn't happen much, because most of the kids we see are genuinely pretty ill, but we see our share of common colds, too. Now the desire to leave the clinic with something in hand is not the most absurd of ideas. I think patients do it at home, too, expecting a prescription to make the visit worth it. Every provider has her own way to deal with this issue. I have decided that this is the purpose of the cough syrup at the clinic. It's not an antitussive, but rather we have 3 different liquid formulations of expectorants. The families become accustomed to receiving a bottle each time the child is sick with even the slightest and driest of coughs. This has become the culture at the clinic (and perhaps in the greater area).

Lately there have been a few occasions when I have sent the family home with a bottle of tylenol for fever, and instructions that the child's cold should pass in a week or so, and warning signs for a more serious illness. As they are leaving, I've heard something like "Excuse me, you didn't give me anything for his cough." Even when I explain that an expectorant does nothing for an occasional dry cough, they insist. I go back and forth about what to do in these situations. Is it a belief that the syrup will truly cure a cough? Or does it just feel better to go home with SOMETHING in these visits? And what happens when they already have something, but still want something specifically for the cough?

I was pleased to see that the mom of one of my patients today seems to have caught on that guayacolate doesn't do much to get rid of a cough. But she's been the first one to admit this to me. Some moms smile and nod, and seem to accept my explanation as to why I am the only one who won't give them the stuff. But many outright disagree, because every other doc here gives it out like candy whenever there's a cough.

This comes in light of learning that because of certain budget restrictions, we are short on important supplies (like vitamins for malnourished children). I look at the wasted expectorants, and wonder why we're really spending all that money on something that doesn't do much anyway. There's a time and a place for expectorants, certainly, but is this it?

But despite the preference for prescribing expectorants, I'm going to take matters into my own hands for my last couple of weeks here, and I think I'm going to start giving out bars of soap to these kids instead...

Antigua

This is an image of one of the churches seen on the side of the road. There's no sign explaining the history, but it is quite an understated beauty. It's just one of many such sites in Antigua.

When Luis came to visit I figured it was cruel to make him do too much traveling on his only "vacation" of his semester, so I had us stop for a couple of days in Antigua, the colonial city in Guatemala. I wrote briefly about Antigua when I went with Jean. Luis and I spent a little more time relaxing there, and went into some more historical sites (and did less shopping). It seems like every street corner has an old broken down church, or some interesting ruin. Most things are religious in nature (convents, churches, etc.).

One of my favorite places was the Colegio de San Geronimo, which was once used as a religious school, then attacked by indigenous protestors, taken away due to lack of authorization by the Spanish crown, and then used as a royal customs house. It was gorgeous, and reasonably well-taken care of, with grass and gardens and public trash cans, all available for a small fee, just off the side of the road and market. You can climb up and see the volcanoes, though we went on a rather cloudy day.


Another famous site in the area is the Merced church. One cool thing about it is that there are some images of the gods prominent in the local religion, mixing the indigenous with the colonial. After being destroyed in 2 earthquakes it has been restored to this pale yellow beauty.

Thanksgiving in Guatemala

I had almost forgotten about Thanksgiving this year, given that I had no holiday-oriented plans. My mom, kindly sent me a card to read today, but other than that, my only focus for Thursday the 25th of November was going into Guatemala City to meet Luis. So when I was subtly asked to help make some pumpkin pies, I was caught off guard, but agreed. Turns out, despite the fact that I offered an hour of my time, this turned into a real big baking deal. We made 6 pies, and had enough leftover cooked squash and filling for at least another dozen. Pumpkins were't available, so we used giant greenish squashes, which when cooked tasted pretty sweet like pumpkin. I want to write a whole new blog post on the restaurant that needed the 6 pies, but that's for another day.

Chuchitos

One of the things that I love to do when I travel is learn how to cook some local foods. It makes sense given that I love to cook, and love to eat good food. Cooking the foods at home sometimes is even better because you get to regulate the quality of the ingredients.

When Jean was here we took a cooking class in Antigua, and learned to make one of my favorite Guatemalan foods--chuchitos. Chuchitos are basically like tamales filled with a vegetable sauce. The first step of any good cooking adventure is going to the market. I did my shopping in two trips, because I forgot a vital ingredient. It was okay with me, because it meant I got to go on a treasure-hunt through another of the beautiful fresh food markets this morning.
I started off by cooking the veggie sauce. Then I soaked the corn husks, and made little ties out of strips of corn. I made the dough, assembled them with all sorts of goodies, and steamed them in a pot. I filled half with beans and sauce, and the other half with peas and sauce. I put cheese in most of them, too.


I thought they looked really cool lined up in the pot to steam.

The end result was good. Eaten with sour cream and some extra sauce, they were tasty!

Perhaps most importantly of all, I learned 6 things that I am going to do better next time. I can't wait to have eaten all of these so I can start on the next batch already! :)

Winning some trust

Those of you have ever seen or used a bronchodilator know how quickly and strongly it can take effect. Sometimes in clinic I like to use albuterol in nebulized form as some sort of instant gratification--as much for me as for the patients. It's nice to know within a couple of minutes that a medicine is going to work, especially when it reassures the families that the cost will be worth it. For someone whose trust is wavering, this can be the key to a successful treatment and relationship.

Working with the families at the clinic brings up some unique obstacles. Many of the families cannot read, though the often deny this. I try to ask the question a couple of times to make sure they don't need any extra help with things. But when they admit they can't read, I try to use symbols, explanations, and help them match things up. I'm still trying to figure out the best ways to do things. I'm tempted in the future to try a color-coded diagram of pills for a complex therapeutic regimen. It might sound crazy, but we have to do what we can to help. If they leave the clinic and don't know what to do with the 50 pills we've given them, they're just going to end up worse off.

Aside from the serious financial limitations in this population, the hardest barrier to address is the distrust of the medical system. Often people don't bring in their children until they are gravely ill, probably a combination of both of these problems. Earning a family's trust not only for yourself, but for the entire medical system is a huge task. I have heard horror stories, most of which I cannot confirm. I've heard that one of the barriers to birth control in this area is the major distrust that arose after the government gave Depo-Provera shots without telling people that they were a contraceptive. Needless to say, by the time our patients come to see us in the clinic, most of the families have already tried several herbal or natural remedies (including honey for infants).

On Thursday I had a very interesting experience. We were working with a 12-year old girl and her mother. The girl was having serious abdominal pain due to an ulcer. But she also had wheezing and a productive cough. The girl's expression was like that of any other adolescent who had been dragged to the doctor against her will, but with twice the disdain. Her mom looked desperate, seeing her daughter in so much pain, and was worried we wouldn't be able to help her. While considering using an antibiotic for the girl's respiratory situation, I wanted to see if she would respond to albuterol. When I explained the process to her, she gave me a blank stare and nodded, showing a certain amount of distrust. We gave her a nebulizer treatment in the clinic, and within minutes she felt better. She actually admitted to being able to breathe so much better.

For any patient it is helpful to be able to see immediate results, but for her, it was even better. Her ambivalence for treatment of her stomach pains, and her frustration with being at the clinic made her a difficult patient to treat. She left the clinic with 6 medicines, requiring her to take some sort of medication 4 times a day! In a patient like this, trust and compliance are vital to the success of the treatment.

I was lucky to have another foreigner working with me and this family, because the perspective was interesting. Cody was treating this patient with me, and he pointed out the drastic change in her expression after finally being able to breathe. It was incredible. She didn't look happy, but she finally looked like she was going to trust us to take care of her. I really believe that by demonstrating the effectiveness of the albuterol, we were able to gain some of this family's trust. I never would have thought of using a nebulizer in clinic like this, but it turns out to have been way more effective than I would have ever imagined.

Latest Blog Entry for HTHH: Battling Apathy and Appealing for Hope

Check out my latest blog post for Hope Through Healing Hands. The work here inspires me, but it can get overwhelming trying to battle such huge issues.
http://www.hopethroughhealinghands.org/blog?ContentRecord_id=38e5ce42-5418-455c-8287-b45a944cf4da&ContentType_id=7ee3f043-655a-41fd-ae51-d8cf19f29ba5&Group_id=135b9788-1130-4373-b931-a43d404be048

My Birthday -- A full day of fun!

My friends here were very kind to me in humoring my love for my birthday. They made my coffee, got me my favorite cake, and took me out to do fun things. There was even a little surprise party at the clinic! We decided to use the holiday as an excuse to go up to Los Vahos, the thermal steam baths.

The walk up was gorgeous, through farms, hills, and trees.



The hike down was gorgeous on a whole different level. The fog had begun to roll in, and we could hardly see anything but the fog.

Trip to Lake Atitlan

I love my birthday, so in planning for my birthday, I tend to extend my plans to cover an entire week! While in Guatemala, this turns out to be a particularly good thing, because it serves as motivation to go out and do all the things I've been saying to want to go do. The weekend before my birthday, I went to Lake Atitlan with my friend Clare. Lake Atitlan is uniquely beautiful because of its gorgeous mountains and volcanoes that surround a volcanic lake. Charming towns are scattered around the edge, each known for particular attractions (hippie enclave, weaving co-ops, etc.). There's also a large coffee industry there, and some of the surrounding areas are particularly scared to the Mayans.


Transportation to the lake can be difficult, and this year seems to be particularly difficult. The rainy season this year (which just ended last month) was said to be especially harsh, and the landslides took a drastic toll on the roads here. The consequences are deadly in the time of the initial landslide, and during the rescues (which often kill more people than the landslide itself), but also spread to the transportation. Currently, the road to Panajachel is closed, so although everyone at the bus terminal in Xela claims that there are direct busses, this is nearly impossible. Going to Pana, we took 2 micro-buses (our first one got a flat tire), a bus to a nearby city, another bus to a lakeside city, a pickup truck to the lakeside, a motor boat to the town, and a tuk-tuk taxi to the hotel. But it was worth it, because when we finally got there it was gorgeous.



Due to our limited time there, we decided to take a boat tour, where we'd get to see 3 towns in half a day. It was great to get out on the water and see as much as we could, but since we were only in each place for an hour or two, we basically only got to the superficial tourist stuff.







If you are interested in seeing more photos, check out what I posted on facebook. I set the privacy settings on this album to allow anyone to see, so you don't need to have a facebook account.
http://www.facebook.com/album.php?aid=2011580&id=69000076&l=99b24d5ae2

An update on the girl with petechiae and the heart issues

I was glad to see that yesterday's 9-year old girl was back in the clinic. Her petechiae seemed even more noticeable as I walked into the room seeing her bare-chested for her repeat ECG.

She brought her labs back from yesterday, and here's what they showed.

Renal function (BUN, creatinine) normal.

Platelets 44
MPV 5.6
PCT: 0.025
PDW: 7.2

Coag time: 5 min 7 sec
Bleeding time: 3 in 21 sec
PT 18.3
PTT:33.2
INR: 1.54

RBCs 3.57
Hgb: 12.3
Hct: 34.1
MCH: 34.4
MCHC: 36.0
RDW: 11.1

WBCs and diff normal.

Fibrinogen: 532.

Fortunately her vomiting, diarrhea, and fever had resolved.

Her ECG today showed the same blockage, and some left ventricular hypertrophy.

We referred her to the hospital, mostly due to her ECG.

Despite the low platelets and the presence of petechiae, the mom and girl looked great, the mom was just trying to digest all the news. Apparently the mom's sister died at age 22 of an unknown cause. I hope they are able to find the resources to treat her effectively.

Local Medics

Being English-Speaking Nurse Practitioners, Cody and I were asked to teach a wilderness medicine class to a group of trekking/hiking guides. Not only was I intrigued by the opportunity, but I was also a little surprised, that the request came with about 5 hours of notice, on an already busy day. But there aren't too many English-speaking docs/NPs in the area to teach the course, and people often think that you know everything when you have some sort of medical training. So I set my own fears aside, and after a few minutes of internet research, we were ready to go. We got to the place, and found a group of foreigners who very kindly offered us fresh coffee and water served in recycled jars. It turns out, they had pretty flexible expectations, and let us teach pretty much whatever we thought was necessary. The course went well, and we adapted the content on-the-spot. We had a good time, and were invited to go back in a couple of weeks. I'm looking forward to it, and next time we'll be able to prepare beforehand!

Another interesting case: Vomiting, Petechiae and Cardiac Findings on Exam

I am sharing this story of a patient we saw today, mostly for those who might be interested by the case. Sorry that it's more of a medical one.

My first patient of the day was a 9 year old girl, who presented with a 2 day history of vomiting and diarrhea, 8-10 times a day. No visible blood in the diarrhea. Some stomach pain. No fever. 2 days ago she was diagnosed with a UTI and an intestinal infection by another clinic, and was given Bactrim and Metronidazole, but was still sick. They didn't do a stool sample. One day ago she developed petechiae on her trunk, shoulders, and legs.

On exam she had scattered petechiae, and some lower left quadrant tenderness. She also had a very unusual sounding heart. She had a grade III/VI murmur on expiration, heard best at the aortic, pulmonic, and tricuspid areas. The murmur was heart best while sitting. The Doc at the clinic said he heart a gallop, and Cody said he heard clicks. Peripheral pulses equal, BP 90/62, no cyanosis, cap refill <3 sec. Throat, ears, nose, lungs normal. No meningeal signs, sitting there smiling and even laughing a couple of times. And temp of 98 degrees F.

She had a history of being hospitalized for "purpura" but the family didn't know why. She was hospitalized 3 times in the past. This was her first time coming into our clinic. Apparently she had been given some sort of diagnosis in the past, but the parents couldn't remember what it was. Consistency in primary care and follow-up here are seriously lacking. There seems to have been some sort of other illness ("fever" according to the dad), at each of these times. No history of cardiac issues in the family. She has never been diagnosed with a murmur of a heart problem in the past, according to the parents. Parents deny any history of cyanosis, fainting, or weakness/tiring easily.

We did an ECG and a urinalysis on site at the clinic (tried to do a stool analysis, but didn't happen). The urinalysis showed slightly dark yellow urine with 4+ blood and 4+ protein, some casts in the urine, 1+ leukocytes, no nitrates, 1+ ketones, no glucose, bili neg. I didn't analyze it carefully, for lack of ECG experience, but she had "rabbit ears" on the ECG, which is a bad sign. We're asking her to come back tomorrow with the lab results (coag studies, platelets, CBC with diff, and BUN/creatinine). We have to choose labs here carefully and then explain the costs to the families. We may also repeat the ECG. We will determine the rest of our course of action then.

We're considering hemolytic uremic syndrome, idiopathic thrombocytopenic purpura, coagulation disorder, glomeronephritis, and/or a reaction to the Bactrim. And of course an intestinal infection, and other types of infections. We asked her to stop taking Metro and Bactrim, and explained that she should avoid Bactrim in the future. It is unclear if she had been taking Bactrim in the past when her petechiae/purpura showed up. She basically went home with a lab slip, a prescription for oral rehydration solution dosed by her weight, and instructions to come back.

If anyone has any thoughts, pass them along. This family seems concerned (I reassured the mother a lot throughout the cardiac exam, especially when 3 men came into the room to listen to her heart when I went for another opinion!). I am believing that this concern means that we will actually get to do some short-term follow-up. But even all that aside, this has been an interesting case to think through.

Just Another Clinic Day

November and December aren't very busy months. We stay busy when we're not with patients by practicing lab work, cleaning up, organizing the pharmacy, studying, and attending/teaching classes.
Ken, an American med student who's spending some time traveling, is currently running the clinic's lab. Today he taught me about testing for hemoglobnin and hematocrit, and we practiced taking blood and testing our own blood. It was really cool to see the process through, until the power went out and we had to stop.


I taught a class about pediatric examination techniques. I bought some dolls to practice on, which was good for some laughs, but was also a nice way to try out some exam techniques.

A view of Santa Maria

Every day when we drive on the bumpy old school bus to the clinic, we pass by this beautiful site. The Santa Maria Volcano is right outside of Xela, and is a favorite hike for visitors. Still haven't done the hike, but enjoying the view.

Jean's Visit and Antigua Trip

My aunt Jean came to visit for a few days, and we went to the colonial city of Antigua. Antigua was once the capital of Guatemala, and in the 1700's (and as early as the 1500's) it was a booming colonial city. These days it's a beautiful relic, designated as a UNESCO World Heritage Site, with what seems to be more tourists than locals (okay, that might be an exaggeration). It's only about 45 minutes away from Guatemala City, which means it's about 3.5 hours from Xela. It rivals Xela for the top Spanish school destination in the country, but if you ask me, they can have it! Lonely Planet guidebook describes Antigua as a place with buried power lines, where stray dogs disappear mysteriously in the night. I see it as a place where you can find public trash cans, gelato, and every single touristy craft thing imaginable.


Sadly, my camera fell victim to the unpredictability of Guatemalan travel. We had trouble finding acceptable transportation, so hired a cab driver to take us from Xela to Antigua. About 45 minutes into the ride, we got pulled over by some police, only to realize later that the engine was smoking. We had to get someone ELSE to take us the rest of the way. And it was in this transfer that my camera got left behind. Fortunately, I sort of knew the first driver, and he gave my camera back to me. But sadly, we have no pictures from Antigua.

We also got to hang out at the clinic for a couple of days, where Jean even got to help out!

More Cemetery Photos

After the big Day of the Dead celebration, I went back to the cemetery with Jean, when she came to visit. We went closer to dark, and things got a little creepy, but there was still plenty to see, and even more kites flying.

We were also able to find the Jewish part of the cemetery.

Dia de los muertos: cemetery

Entering the cemetery on Día de los muertos (day of the dead) in Guatemala is like exiting a busy concert. There are people everywhere, nearly (and sometimes) getting trampled, and so much noise and music that you can't even hear yourself think. Today is the day when everyone goes to the cemetery to visit their dead, and honor their memory. It's festive, fun, loud, and filled with children playing, and people eating. Yes, they even sell snack food inside the cemetery.
People go to great lengths to decorate the graves, leaving flowers, re-painting the stones, and planting grass and flowers for their loved ones. I even saw a marachi-type band playing and singing at some graves.
I think every single grave was decorated, even the ones with only a few flowers.
I was worried about being disrespectful taking pictures in the cemetery, but people seemed to have a different interpretation here about being respectful. Kite-flying is common at this time, supposedly as a way to communicate with ancestors, but it seems like a great way to get kids involved in the holiday. It wasn't just kites, though. There were makeshift soccer games, picnics, and there was loud dance music playing from a building in the middle of the cemetery. We actually stopped to talk with several families, and all were very welcoming and glad we were interested in the traditions here.
Much like other things here, the cemetary seemed to be sorted into areas with fancy expensive graves, and the ones with simple mounds of dirt with a headstone. All of the angels were head-less and hand-less, which I found to be a bit creepy. Apparently it's a common thing for the local gangs to go around stealing them.
We left as it was just getting dark, and I have to admit that even with all those flowers, it was starting to feel a little bit like time to go home!