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!

Dia de los muertos: market and fair

Today is a holiday in Guatemala--Dia de los muertos, or day of the dead. The day is a celebration remembering the dead, and interestingly, is a lively celebration rather than a mourning day. The streets fill with people heading off the cemetery, families get together, kids fly kites, and music is heard in the streets. I asked 3 armed men (one military guy and two local police toting giant rifles and lots of ammunition) why they were standing in a particular place, if they were guarding a particular grave or something. But they said, no, everyone deserves protection, dead or alive. As crazy as it was for me to approach three heavily armed men (can you picture this, because it still makes me feel a little queasy), his response was pretty telling to the way things seem to go here.
Right outside the cemetery is a carnival and street fair, with food vendors, music, shopping, and all sorts of floral arrangements to bring to the cemetery.

New Apartment

About a week ago I felt like I had hit an emotional wall with my host family, and decided it was time to move out. As kind as they were, I wanted to be able to have my own space, cook for myself, and be closer to the center of town. I moved on Friday. That's where my blogging energy went--I have been setting up my new apartment. Aside from one small repair that had to be done (thanks Cody!), and massive kitchen-cleaning, the place has been nice. I've been able to cook every day, and have plenty of space to do my work, and relax. The building is a sort of strange old colonial building, with a courtyard in the middle, and lots of patio space. My computer and camera had a disagreement, so all I have is a photo of the corridor leading to my place. The entrance to my apartment is on the left.