Archive
Final images (Kathryn)
As we all return to our lives in the United States i leave you with pictures from the dedication of the new Hospitalito, and general images of this very beautiful country and its people
The days leading up to the November 19th dedication of the hospital were madly busy, with construction workers, staff and volunteers from around the world pitching in to help. The morning of the dedication an obstetrician and CNM from Oregon, a UK surgeon, a Fulbright scholar grant writer from Pennsylvania and a North Carolina bio-engineer and I use our advanced skills! But we and dozens of others pulled it off!
A sunny day celebrated with speeches (and then more speeches, and even more), music, tamales and horchata, and tours of the new hospital and clinics.
Local VIPs, donors and friends from around the globe, and the Santiago Atitalan community celebrated. Christina and Melissa flank a painting of mother and child in one of the birth rooms, donated by Frontier School. Dr. Juan Manuel Chuc is the medical director of the hospital. Lyn Dickey and Karin Bergstresser (gringas in traditional traje), are 2 of the board members of this independent non-profit hospital, and instrumental in raising the donations and overseeing construction of the new hospital.
The new Hospitalito has a clinic with 5 exam rooms, a dental clinic, pharmacy and lab, an emergency room, 2 labor and birth rooms, 2 operating rooms, and soon 6 inpatient rooms. In the plans (pending funding) is a Maternity Casita where local midwives will be invited to work with hospital staff for low risk births.
And finally, some images from Lake Atitlan, taken by my dear husband Martin Levowitz: photographer, Hospitalito volunteer carpenter, and supporter of me and our students in our travels to Guatemala:
Kathryn with one of the women in the weaving collective where we buy textiles to sell at school, to make money to give back to our partners in Guatemala, where a little goes so very far: be prepared to shop!!
Maltiyoox (Melissa)
Christina and I arrived back in the U.S. early Monday morning. Everyone is preparing for Christmas: decorating, shopping, playing Christmas carols. Life’s worries are so different here. They seem so trivial compared to what troubles we left behind. On this Thanksgiving, I have so much more for which to be thankful. It leaves me to ponder what all transpired over the last few weeks.
Working with the people of Santiago Atitlan was both a privilege and a challenge. The people have learned from centuries of repression to guard themselves against outsiders. It was, therefore, not easy to earn their trust. As Tz’utujil Mayans, theirs is a very unique culture, found only in the communities lining the southern side of Lake Atitlan. Their language varies slightly from village to village. For nearly all, Spanish is their second language, and many speak only Tz’utujil. Given their very specific cultural background, communication and understanding was definitely a challenge.
However, one of my favorite aspects of nursing and midwifery is making a connection with the families I serve. Labor and birth is a time of intense physical sensations and emotions. It is a rite of passage and a mark in the history of a family. Such intensity makes this an opportune time to bridge the cultural divide and connect to a woman to support her through this special moment.
I had the privilege of attending five births in Santiago and assisting with four more. It was fascinating to observe the Tz’utujil customs and rituals surrounding birth. First of all, it is a family affair. The woman is usually accompanied by her spouse, sisters, mother, father, in-laws, and, occasionally, her comadrona (indigenous midwife). The room can become quite crowded and warm, womb-like, and full of love and concern for mother and baby. The woman confines herself to the warmth of this room, avoiding any cold air or drafts. She prefers to drink warm liquids, such as hot tea, water, chocolate, or atol (a hot corn gruel). Many women prefer to be upright, walking or pacing, sitting, leaning, squatting, or on hands and knees through most of the labor. However, near the end of their labor some, out of pain and sheer exhaustion, can no longer support themselves. It is during this time that Tz’utujil husbands, if asked, are all too happy to take off their shoes and jump in bed with the woman, sitting behind her to support her in an upright position for birth. She leans her weight into him and rests her head on his shoulder while he whispers encouragement into her ear. This is perhaps one of the most touching scenes in the births I’ve witnessed in Santiago. At one birth, the woman was surrounded my family, with a sister, aunt, mother, or mother-in-law at each extremity, laying hands on her and whispering advice.
This family involvement is inspiring. In a culture where family and community come before the individual, family participation is paramount. One patient told me she chose to give birth at Hospitalito because her family would be allowed to accompany her, a privilege that is not enjoyed at most Guatemalan health institutions. However, sometimes the family can be overbearing, deciding where the woman will give birth and who will attend her without seeking the woman’s opinion on the matter. Overall, though, their support was welcomed and helpful, and many women went home to a house full of relatives ready to cook, clean, and help with childcare so that the woman could recover and nurse her newborn.
Although we often did not speak the same language, the women and I were able to communicate. I learned to read their facial expressions, their body language, and their eyes. I learned the hard way that Tz’utujil women are stoic, more so even than other Latin cultures, and often will hardly show an outward sign that birth is imminent. I had to really tune into the woman to read her subtle clues in order to be prepared for the birth.
Arriving back in the States this week has been difficult, learning to throw toilet paper back in toilet, brushing my teeth with tap water, and trying to impart what I experienced to friends and family. People want to know what you did, what you gave, how you contributed, but what they have trouble grasping, and, indeed, what I had trouble understanding, is that I received so much more than I gave. It was certainly a lesson in humility to realize that we had so much more to learn than to teach. In my three weeks in Santiago Atitlan, I only learned one word in Tz’utujil: “maltiyoox,” or “thank you.” Of all the words in a language, this is perhaps the most important. I doubt, however, that it adequately expresses my gratitude for this experience.
The Language of Health
The Language of Health
My experience at Hospitalito, a hospital supported primarily on donations in Santiago Atitlan, Guatemala, has been extraordinary. While at Hospitalito I have had the opportunity to see many interesting patients. In the process of caring for these patients I learned a great amount about the Guatemalan health care system, resourceful management of medical conditions, and the ongoing struggle to improve healthy living conditions as well as health care. I also learned that the co-existing emotions related to the value of health our shared intra-culturally; the tears that are shed at the bedside of loved ones are the same in every language. I was disheartened by the circumstances of large amounts of young infants hospitialized for pneumonia. Their distress was obvious as they came in with difficulty breathing, fevers, and adventitious lungs sounds. Many children endured the fumes of burning wood that was used to cook in a house with poor ventilation. Some were even wrapped on their mothers backs while she cooked through the fumes of the burning wood smoke. The consequences of such trauma to their lungs was worrisome, and required a long course of intense care; but there was optimism in that we had the resources to treat them, and it was nice seeing the recovery seal of a smile as they went home. However there were other intense situations that we were less equiped to manage and in those situations it was harder to predict the outcome.
There was a sixteen year old boy whose grandfather brought him into the emergency room unresponsive, after a suicide attempt. The young boy had tried to hang himself with a rope, feeling the hopelessness of the struggling through life independently, without his father who died fifteen days prior. During my assessment of him, I found that his neurological functioning had returned, he had severe bruising and swelling around his neck, but the most capturing findings was the pain that I saw when I looked in his eyes (although he tried to avoid eye contact). I recognized this as an emergent need to find him support, I wasn’t just nervous, I was certain that he would try again if he didn’t get help. His psychologist referral was hopeful, but there were no local specialist, and the referral was to a doctor that was located hours away. Getting him there would mean daily wages lost for the family who survived from day to day wages; it was a stressful decision that I could tell the people had a hard time making. Therefore, there was uncertainy about if they would make it, and as he left I was a little tense wondering if he would find help. I wished I could follow the outcome of his course, but I knew there would probably be no follow-up visits. This situation is an example of how inadequate resources in Guatemala compromise the health of people who need a fighting chance. This is why the progression of health care access is so vital to these people. This is why we celebrated the opening of the new hospital building for Hospitalito with so much joy; as we know each phase that brings us closer to meeting all their health care needs is so precious.
Hospitalito photos (Kathryn)
- Within weeks of the mudslide the hospital was functioning again, in an empty hotel, where it functions until the new building is completed later this year. It is a humble place with 3 clinic rooms, an OR, and ER room, a labor/birth room, and 3 tiny inpatient rooms.
The emergency room and labor/delivery is staffed 24/7 with one doctor and 2 local nurses. The hospital has 4 Guatemalan physicians who are supplemented with volunteer doctors, nurse practitioners, PA’s, and since Frontier has been coming, nurse-midwives. In addition to all of working in the clinics, Christina has been spending time in the ED, and Melissa/Kathryn have been on call for labor/births. 
Birth is a family affair in Guatemala; in this community more than 90% of women give birth at home with traditional birth attendants. Here is a happy Melissa, a new mom, her baby boy, her husband, and her mother. 
Although we are here as NPs and NM’s, in the spirit of being of service, Melissa offers to be “baby nurse” for a C/Section for a breech presentation. This OR has a fireplace in the corner; probably the living room of this old house/hotel. 
- The Old and the New: every morning at 7:30 the doctor going off call meets with all the providers to give report, and for all of us to plan the day. This day it was raining, so the hospital laundry was hanging out to dry in the meeting room. The providers are passing around a camera with a digital picture of an unusual foot lesion on a patient who presented the evening before; it will likely be sent electronically to consultants in the capital, or to contacts of the volunteers from around the world for their opinions! Distance medicine here on the shores of Lake Atitlan. Doctora Suzana who is looking at the camera is one of the core physicians. The woman to her left is a family practice resident in Seattle who works with one our midwfe preceptors!!
Many Hands (Melissa)
Our first week at Hospitalito in Santiago Atitlan has passed. We went from working in a humble one-room clinic with Vamos Adelante and seeing patients out of the health promoter’s home to helping Hospitalito prepare to open a gleaming new facility, probably the biggest building in town. Hospitalito is the only hospital within a reasonable driving distance for the people of Santiago. Therefore, the complexity of problems presented is much more acute than those we saw at the Vamos Adelante clinic. Children and the elderly with pneumonia, falls and broken bones, heart attacks, uncontrolled diabetes and hypertension, and many women’s health issues are some of the more common health problems seen on a regular basis at Hospitalito. Obstetrical and gynecological problems that are promptly and relatively easily treated in the States, such as a dermoid ovarian cyst or a molar pregnancy, are complex problems here requiring many referrals. Hospitalito has provided an important service to Santiago Atitlan, but without the proper surgeons or specialists, anesthesia, medications, and equipment, these cases, which would be simple problems in the States, become potentially life-threatening emergencies. Treatment is sometimes impossible or out of reach for the community. If Hospitalito does not have the resources to provide the service, patients are referred to the national health care system, which is free but notorious for poor standards of care. When referred to the national health system, many patients and their families refuse care there. They would rather suffer and even die before resorting to the public health system in the area. The national Centro de Salud in town offers contraception, prenatal care, and intrapartum care, but does not even have oxygen in the event of a neonatal resuscitation. The nearest national hospital with such resources as a blood bank and ventilators is a harrowing 2-hour journey by boat over a choppy lake that has already claimed at least 2 lives since we arrived. Roads around the lake have been nearly washed away by the heavy rainy season, making many communities inaccessible and cutting off access to the national hospital.
One example made me realize just how desperate the health care situation is here. A young woman, pregnant with her first child presented to the ER Monday morning with abdominal pain and leaking fluid. She was 32 weeks and 5 days into her pregnancy, and was found to be prematurely ruptured and contracting every 2-3 minutes. Hospitalito does not have the necessary equipment to care for a newborn with respiratory distress, so it was arranged that the local firefighters would transport the woman around the lake to the national hospital. When the situation was explained to the woman and her family, the woman burst into tears and a somber tone came over the family. They had virtually accepted the death of the baby. Even the doctors working at Hospitalito did not offer the woman much hope. First of all, she would have to make a 3 or 4 hour journey around the lake to the nearest national hospital, and once she arrived, the quality of care she and her baby would receive was in doubt. On top of all these worries, her family was scrambling to find a way to pay for the transport. If this woman had been my patient in the facility where I am employed, her nearly 33 week baby would have an excellent prognosis and would probably only spend a few weeks in the hospital. Yet here in Guatemala we would have to watch this baby die! This is just one disturbing example of many.
However, despite all that can’t be done at Hospitalito, it is miraculous what can be done. On Tuesday, we helped with a c-section on a preeclamptic primip whose baby was a double footling breech. The woman’s blood pressure was closely monitored, and she was kept on a magnesium drip for seizure prophylaxis. Despite a difficult breech extraction, in the masterful hands of the 2 volunteer doctors at Hospitalito, the baby was vigorous at birth. By the next afternoon, the mother greeted me walking in the halls, asking me if she could go home yet. Another patient, a 60-year-old mother of 10, is dissatisfied with her pessary for uterine prolapse. When asked about her definition of quality of life, she stated that she only wanted “to be able to carry firewood, water, and laundry without feeling that her insides were falling out.” A visiting OB/GYN will tack her uterus back into place on Tuesday morning in a 45-minute outpatient procedure. For these women, and many others in Santiago, Hospitalito has been a blessing, but it would not be possible without the many hands of the staff and volunteers who donate their time to serve the community.
The Pursuit of Health (Christina)
The Pursuit of Health
My first week in Guatemala manifested a long process of reflection. Witnessing the power of strong will as it relates to the people’s fight for health in Guatemala has been inspiring. This was immediately recognized when we arrived at the clinic of Vamos Adelante at seven in the morning to a crowd of several patients waiting outside the clinic for our arrival. Apparently word had spread to the people in the villages that there was an opportunity to be evaluated by Dr Rene as well as faculty and students from Frontier School of Midwifery and Family Nursing at the clinic, and many people came. For many of them, the journey to get there consisted of a one hour bus ride and a two-hour walk from their small villages. They traveled in spite of being sick, one had chest and back pain, another foot pains, and another had abdominal pain from being brutally beaten by her husband; but incredibly, they still made the long journey. According to Felina, one of the health promoters employed by Vamos Adelante, access to the nearest hospital often required an even longer journey than the one to the clinic. Felina further explained that she remembers the times when a man walked several hours carry a laboring women in chair tied to his back, because that was the only way to get her to the hospital. I found this type of determination admirable; as it can be taken for granted the amenities of health care service that are easily accessible to us in the United States.
The difficult access to the hospital made the role of Vamos Adelante’s health promoters, a vital one. The health promoter’s function as primary care providers in their villages; they give out medications for acute and chronic illness (depending on whether they are available), care for wounds, and they are consultants for pregnant women. During our stay with Felina in the village of Ceylan, many people came to her house at all hours of the day seeking treatment for injuries and illnesses, and prenatal care. With motivation, compassion, and making the most out of everything she had; she stretched her wings to great lengths to serve them. Her skills and knowledge from much experience was impressive, yet she and the other health promoters still wanted to learn more from us. I found their desire to learn inspiring. For they had no motives of gaining a title or making more money; they wanted to learn because they understood the value of health and wanted to be able to service their community with a higher level of health care. With that said, I know we were there to try to help them, but I think they helped me more. They helped me understand that the pursuit of health is a commitment, to the people who made the trails, and I am humbled to be a part of it.
Christina King sFNP class 64
El Día de los Muertos (Melissa)
We were fortunate enough to witness the Day of the Dead ceremonies in Santiago Atitlán on November 2nd (All Soul’s Day). It is believed that, on this day, the separation between living and dead is thinnest and that the spirits of the deceased return to Earth.
Families spend weeks prior to the holiday cleaning and painting the graves of loved ones. The days prior to November 2nd are spent decorating with aromatic flowers, pine needles, and candles.
Día de los Muertos is not a day of mourning. Rather, it is a time of celebration. Vendors set up outside the cemetary to sell snacks to the crowds who gather there. Families will prepare the favorite foods of the deceased and share a meal with their dead loved one at the grave.
Families spend the entire day at the graveside of loved ones.
They light candles. The smells of food, candles, pine needles, and flowers are intended to attract the attention of the spirits and draw them down to Earth.
The Catholic priest is present to pray for the souls of the deceased.
Children fly kites (displayed here in the church after Día de los Muertos) to invite the spirts down from the sky.
Death is not feared or swept under the rug. It is as much a part of life as birth here. Loved ones are fondly remembered on this day.
Some R&R in beautiful Guatemala (Kathryn)
Volcan Fuego spewing fire and smoke, from the front of Felina's house in Celyan
Christina gets a mini facial with the macademian nut oil; "guaranteed" to make you look 10 years younger!
Antigua, the gorgeous old capital of Guatemala has been discovered by international travelers; here are 2 fine specimens from the USA!
Spanish colonial Antigua was the Central American epicenter of power in the 17th and 18th center, with no expense spared in its architecture. Repeated earthquakes crumbled most of the city and the capital was moved to Guatemala City in 1776 and the city was mostly abandoned. By the mid-1900's it was "rediscovered", declared a Unesco World Heritage site, and is gradually being restored
Guatemala is a semi-tropical with outrageous flowers, and bananas and pineapples and avocados and coffee (most of which is unaffordable and exported, while the average person lives on simple foods and instant Nescafe)
And then on to Santiago Atitlan, on the south shores of Lake Atitlan surrounded by 3 volcanoes, where we will spend three weeks working with Hospitalito Atitlan
Walking in Mary Breckinridge’s Shoes (Melissa)
After winding along bumpy stone and mud roads and crossing swollen rivers, we arrived in the village of Guadalupe el Zapote on Tuesday, October 26th in the early morning. After crossing the fourth and final river and seeing the water come up to the hood of our car, the motor steaming, I thought: “So this must have been how the Frontier Nursing Service nurses felt crossing the rivers on horseback.” Already, people waited outside the clinic where we were to see patients along with Dra. Rene, a retired Guatemalan doctor who is kind enough to volunteer her time to attend to this community once a week in the clinic. From 8am to 2pm we cared for 18 pregnant women seeking prenatal care and various primary care visits as well.
After a break for lunch, we headed up another winding, bumpy road through the hills to the small hamlet of Ceylan, where we were graciously welcomed into the home of Felina, one of the local health promoters. Health promoters are the foundation of the Guatemalan health care system. They are literate, educated, and respected members of their village who are trained in basic public health measures. Many of them are trained as nurses. Once again, I was reminded of the early public health work done by the Frontier Nursing service midwives. Vamos Adelante works with the health promoters from the villages surrounding El Rodeo to improve the health of the people, training and equipping them, but the hard work falls on the promoters themselves. Day and night people of the village would seek out Felina for her advice and any treatment she could give. Common maladies included upper respiratory infections, gastrointestinal infections, and malnutrition. Felina cares for the pregnant women in Ceylan as well, dispensing prenatal vitamins and recommending techniques to ensure a safe pregnancy and birth.
Wednesday morning we went with Felina to the house of her mother, who worked for Vamos Adelante in their nutritional program. There we observed the once daily meal prepared for the malnourished children and seniors of Ceylan and we listened to the miraculous stories of transformation brought about by proper nutrition. We helped served rice, beans, and incaparina (a hot, fortified, corn drink). However, before we could finish, Felina sent word that pregnant women from the village were gathering to seek care with us. By the time we returned home three of them were sitting on the front porch, waiting and chatting. More were soon to arrive. As the morning passed into afternoon, we offered to visit some of the women in their homes to spare them the long wait, but they refused, saying they preferred to be seen at Felina’s house, where there was more privacy. As Felina pointed out, they also had the rare opportunity to sit and do nothing but chat with neighbors. Others came too, children with diarrhea, a woman with an inguinal hernia, a man with a machete wound, and several cases of upper respiratory infections.
After finally finishing with all the patients for the day, we enjoyed the last remaining rays of sunlight by splashing in the stream behind Felina’s house with the neighborhood children. As the sun set, we returned to the house, but the children were not done with us yet. We turned Felina’s front porch into a discoteca, complete with Merengue and marimba music. We danced until we collapsed, exhausted, speckled with insect bites, and thoroughly satisfied with the day.
I fell asleep thinking of the parallels between our experiences with Vamos Adelante and those of Mary Breckinridge’s nurses on horseback, providing basic public health in an isolated place of few resources. I found it ironic that we had to travel to Guatemala to get a taste of what it must have been like for those nurses, and I must say: I like the taste. They may not travel by horse these days, but Mary Breckinridge’s nurses continue their work nearly a century later many miles from the Kentucky mountains.
-Melissa Poole, CNEP 59
FSMFN Guatemala 
