Mobile Clinics (at schools)

One of the unique and special things about the Primeros Pasos clinic, where I am volunteering, is that they do “mobile clinics” to local schools. Today we treated 4 classrooms of children. Each child was weighed, (ideally) came prepared with a stool sample for parasite testing, and was given an approximately 10-minute consult with a doctor, nurse practitioner, or medical student, and a short health lesson. The child was sent home with a piece of paper describing his health, and how to take any medications we gave him. We treated every child for intestinal worms, and gave them soap and a toothbrush to take home. About half of the children I saw had GI complaints, and were given an anti-parasitic medication. We also treated the URIs and other infections that we encountered. It was a totally new model of school health for me, and was fascinating. The mobile clinic process will continue, and we will go back on Monday to see the rest of the kids. It was incredible to see how many children were able to receive education and treatment in a short period of time, and children who would otherwise likely not have been treated (at least not quickly).

These are the pictures from the school. The location is very rural, and the ride up to the school in the rain was a little rough in the re-vamped American school bus. The ride home was even more eventful...!



These last two pictures are of the assessment and educational part of the encounters. Cody B is the other recipient of the Frist Global Health Leaders fellowship that is allowing me to be here. He and I are shown here working with some of the kids.

A Happy Ending

I'm getting the feeling that we don't get to see a lot of follow-up in the clinic. But today I was lucky enough to have some of that gift. One of the children I saw last week (the 3 year old with a bad ear infection, lots of drainage, and mastoid tenderness starting) came in today for follow up. I had been worried about him, because he was on the verge of getting worse, and his mom was going to have to go through a lot to get him the help he needed. Today, the little guy came running up to meet me when I called his name, and was running around the room, playing. His ears looked much better, and overall he looked great.

The mom thanked me a couple of times as we were saying goodbye, and I told her that it made me so happy to see him playing and happy, I wanted to thank her just as much for letting us see that. It certainly isn't my child I see there, but it makes me so happy to see that he recovered, and that we were able to help. I was so happy to see that the family was able to give so much, to--the family had bought the (somewhat expensive) medicine, found a neighbor to do the injections, and returned for 2 follow-up appointments, and missed a lot of work because of it. That level of devotion from the mom did a lot for him.

But in the end, I think the best part was the big wet kiss on the cheek I got when they left. :)

Quiché home, and traditional weaving

Today I journeyed to a nearby town of Momostenango, generally known as Momos. All of the towns here seem to have short nicknames that make it much easier for a foreigner to get around (though I am sure it is not the purpose!). I arranged my homestay here in Xela through ICA, one of the local Spanish Schools. On the weekends, they offer trips to nearby towns, and allowed me to tag along.

One of the weavers from Momos showed us around her home where she does the weaving, with the wool, yarn, dyes, looms, and finished products all in one place. She was kind enough to let us try it out, too. All of their dyes use natural leaves, berries, and rocks, adhered with ash (remind anyone of tie dye, using soda ash?). The work area is a part of the home, so you can see the clothes drying right next to the yarn hanging. And naturally, the children hang around during the work times.






We also got to snack on some tortillas cooked over a wood stove. The photo doesn't do the process justice, because the smoke was so thick and so strong that you could smell it from far away, and EVERYTHING on my smelled like smoke even after walking in the rain. Despite the potential respiratory difficulties, I was anxious to help out, and practice making tortillas by hand. My tortilla press at home is great, but leaves me without a seemingly vital skill. I have to admit my handmade tortillas are looking better and better these days. : )


And naturally, no town in Latin America is complete without a church, and this is the one place our guide took us. The thing that amazed me about the church, though, was that it had a Mayan flare, with beautiful carved stone at the back where hundreds of candles were burning, and people were gathering for silent prayer. I didn't photograph that out of respect for the people praying there.

Chicken Bus/Camioneta

Many foreign travelers consider “Chicken Buses” to be representative of travel in Central America. They are old school buses from the U.S., painted, decorated, and somehow converted into a local bus for a set route. The owners go all out on decorating, including everything from painting the outside, to decorating the inside, and of course, adorning each with (often several) blessings or religious sentiments. Guatemala is no exception to this tradition.

In addition to the beautiful color, they are also known for being quite the experience. First of all, it’s crowded. Remember your old school bus, where two kids would sit on each seat, with an aisle between two seats? Well in the new life of these buses, three adults and seemingly limitless amounts of children can sit in each seat, leaving no aisle room, because the last person only puts half of their butt on the seat, the other half in the aisle. The area above the seats can be full of packages, and the cargo area on top of the bus may also be full of furniture, bags, boxes, etc. Passengers are let on and off, and bags are dropped practically (and sometimes) while the bus is still moving. Two people run the operation, a driver and an assistant. The assistant climbs around wherever is necessary to do his job, shouting in a singsong voice the name of the destination at each major stop to herd people onto the bus. When the bus is navigating a difficult curve, he hops out and guides, then hops back on while the bus is still moving. Every 15 minutes or so, vendors are let on and off to offer you nuts, candy, ice cream, or whatever plastic junk they are selling.

Because these busses are so different, so vibrant, and full of color, strange sites, sounds, and smells, many travelers like to experience them, saying they have seen the “real” culture. My first time on one of these buses was in Costa Rica, and it's fun to see it in another location. I have to say, the painted colors remind me a lot of the trucks in India. They are decorated with such care!

I took the bus pictures at the start of the route, because when the bus got full, there was hardly room to move my arm, let alone try to take a picture.

Food

Here are some of the foods we at yesterday--tortilla soup and sopes. There are a lot of similarities between Mexican and Guatemalan food, and many "Mexican" foods are common here.





I have been trying to be careful with eating fresh fruits and veggies here for a couple of weeks. But when I saw beautiful strawberries and blackberries (at 25cents/lb!) in the market, I all of the sudden didn’t want to wait those couple of weeks. I decided to buy them anyway, and cook them. There is a little Mennonite bakery here where they sell fresh granola and yogurt, among other things. Xela is pretty well known for its Spanish schools, and there are at least 2 dozen, if not more language schools in town. This, combined with all of the volunteer/non-profit work here means there are a lot of foreigners in town. I would classify the resources here for foreigners as being somewhere between amazing, and over-the-top.

Wash

This morning I dropped off my clothes to be washed and dried by a nearby woman. It took all of 5 minutes, and will cost me 16 quetzales, or $2 (less than my cost for the washer and dryer at home!). However little this may seem to us, this is a luxury that few people have. I was told that I could only bring clothes, not sheets or towels, but could try another day for those things if I wanted. So I set out to washing my towel like everyone else here—-by hand. After setting it to soak in cold water with (American) detergent, I asked if I could boil some water, in order to have hot water to wash it in. I got a quizzical look. Gas is expensive here, why would you waste it on a towel? I explained that I wanted to be able to kill bacteria. In the end, after using the cold water, boiling more water, washing in hot water, scrubbing on the washboard, wringing it dry, and hanging it, the whole process took 30 minutes. In the rainy season, it won’t be dry until tomorrow, if I’m lucky, possibly another day or two. Imagine doing that for all your laundry…

Tortilla Smoke

Walking along the street today in the grey foggy drizzly weather, I smelled smoke. That's actually not an uncommon smell here, even some of the kids in the clinic smell like smoke, from the cooking fires at home. But for some reason I looked up to see what it was. I am not sure why, but this struck me as kind of funny. I thought it deserved a picture. This chimney, or pipe for the tortilla smoke seemed so charming to me in some way. I am sorry the thick black smoke didn't come out well in the photo, with all the wind.

Education

What would you do if you wanted to teach a community to wash their hands? Would you start with the children or the adults? And how do you not make it seem incredibly elementary?

I have been asking myself how to teach health lessons to a community, and I have been wondering something in particular. Maybe the best way is to teach the mothers, stressing the importance that it is for the benefit of the children. I think the desire for wanting a better life for your child extends far enough to actually break down some of a person’s pride. Starting from the beginning, perhaps one can teach lessons of basic sanitation (or whatever the topic may be: health, illness prevention, infant development) to a community. The mothers can then enforce it with their children, and ultimately even share it with their husbands.

As I start to consider options for my projects here, this has been one of my ideas. Many educational initiatives already exist working with women (for health, pregnancy, and various things) and children (for overall health education), but few programs address children through the minds/hands/eyes of the mothers.

A Clinical Post

I saw a baby today, 7 months, weighing 7.5 lbs today. It is unclear what the birthweight was, though they thought he was 7 lbs. A normal 2 month old with that birth weight should weight abut 11 lbs. He was brought in for conjunctivitis, which he has had almost since birth (no, not for the lack of weight-gain). There were no birth/hospital records. He also cried a lot and was constipated, though he was breastfed.

When I looked at his eyes, he had a white reflex in both eyes (instead of red). This could be a sign of a tumor called retinoblastoma, though it could be something else. Two other volunteers actually asked me to come in because of the weight issue, but when I saw that, I went to get the Dr immediately. We sent him for a CT immediately, and will continue to evaluate and treat, presuming that the family follows up. Certainly an interesting case, and scary. But also sad to see such a malnourished baby at only 2 months!

Contrast

The contrast between the roads in the city of Xela, and the area where the clinic is located. The rural area is beautiful, with a bunch of curious smiling kids running around. The city is much busier, much more developed, and probably a bit dirtier from the pollution.

Paying for Care

The same child with the murmur actually had to be sent to the local public hospital to receive further tests and studies because of a suspected coagulopathy. The part that worries me is that we sent them from an almost free clinic (less than a dollar to treat a child) to a hospital where they may have to pay for relatively expensive tests and medicines. I spent a while convincing the mother that it was worth it, because it could save the child’s life. At the end of the day, I am left wondering if they ever made it to the hospital, and if they are going to be able to treat him. I am a huge advocate for the free clinics, but now each case that may not get the proper care when we can’t give it breaks my heart.

Similarly, a 3 year old boy who was starting to show signs of complications of otitis media (mastoid tenderness and severe otorrhea, worse than I have ever seen!) was sent to the pharmacy with a prescription for Rocephin, and asked to find someone to inject it in him for the next 5 days, because there was none at the clinic. This is a fairly common practice, especially in the clinics or hospitals where patients have to pay for their own medicine. But this is a child who we want to treat fast, in a family who may not have the means to buy the medicine (we discussed this with the mother) may delay it, when the child clearly needed treatment.

In the end, perhaps it comes down to something of a control issue. If there is something I can sort of fix, I want it to be fixed, even if not by my doing. I just want the control of fixing it or knowing it will be fixed. In reality, I suppose that level of hope may be over-stepping my bounds, but I always want the kids to get better fast. Here, things seem to be more complex.

The Student Within

Being a student is really more of a state of mind than an enrollment status, I think. As a PNP student, much of my life was about the clinical aspect, not just the books. There’s a huge part of me that is always learning, and somehow seeking validation from someone saying that I have done something right. Maybe that is childish, but I feel like it also ensures that I can give safe care. As a new grad, there are a lot of things that I know in theory, but haven’t actually seen in a clinical situation yet.

One of the main challenges for me as a PNP student last year was learning to hear murmurs. I got so excited when I started to hear them on my own, and even more proud when I heard the faint ones. Well today I heard my first diastolic murmur. For those who don’t usually think about types of murmurs, these are murmurs heard on the second heart sound, and often indicate a problem. My first reaction, was fear for this boy’s health, because I actually listened to his heart because I suspected he had a complex problem affecting multiple systems. But then I realized with excitement that this was my first diastolic murmur, and it was faint! My elation disappeared when I spoke with the doctor, and I realized that I didn’t know the word for murmur in Spanish, I just said “something bad, in the diastolic part.” When he said the word for murmur, I looked at him kind of funny, because it was a word I didn’t know. So there went any chances I had of passing as a good healthcare provider in Guatemala, nearly denying a murmur because of a lack of vocabulary… But I was proud when he agreed that there was a faint diastolic murmur. In the end I am not quite sure what is going on with the murmur, but the boy was sent off to experts to evaluate everything.

Varicella (Chicken Pox) -- Day 1

To a new pediatric clinician at home, Varicella is something you probably had yourself as a child, and something you hear about in class, or read in a book. When our class of 40-something students at Vanderbilt was asked if we had seen a case of varicella in clinic, none of us raised our hands! But here in Guatemala, it’s very common. Occasionally kids get one dose of the vaccine, but most kids don’t get any. Recently, it seems, a wave of it hit the local schools.

On my first day at the clinic, a girl came into the clinic with a fever, headache, vomiting, and a few hundred vesicles and papules all over her body. I checked for complications, and she was fine. We sent her home with some acetaminophen, and told the mom to wash her hands before touching the baby (that's another story, but handwashing here may require some improvement).

I was working with a Guatemalan medical student, in her 4th year. When I told her it was my first case of Varicella, she smiled and asked (kindly, not making fun) if I wanted to grab my camera. No HIPPA laws here… But I thought about it, and realized that as time goes on, there won't be too many more chances to see chicken pox at home. It’s truly amazing how quickly we have eradicated this disease from the pediatric population at home, though. I feel strangely good knowing that after seeing this girl helped me to be able to recognize it in case I ever encounter the disease at home.

Guatemala -- first impresions

Other than India, this is the busiest, dirtiest, and most colorful place I have traveled. For some reason I thought Guatemala would be very similar to Mexico, Costa Rica, and Nicaragua. In some ways it is, but in most it is totally different. My mainstays of food here have been rice, beans, tortillas, bananas, and packaged crackers. Lots of carbs, sometimes a whole plate-full! Everyone has been incredibly kind to me, offering me assistance whenever I am lost, or need to know something about a place. I have been at the mercy of strangers a few times, and have been in good hands.

I am learning that there’s no use in trying to get any sort of business done at lunch-time, unless you go to the huge chain-style grocery store, because everyone closes and goes home. The few people you see working may decide it’s the time to hang out with their children. Every day I learn more than I think I will manage to remember (where to take the bus, when to get off the bus, pay when getting off the bus, not getting on the bus, where I live, where certain streets go, what the word is for something, who people are that I have met before, etc.). I think after a few days it will all start to sink in to something more uniform and natural. Right now it feels like a constant chaos of new experience. In a good way. Very good.