Archive
Vamos Adelante
Health Promoters at the Clinic
Nicole and I hit the road at 0540 on Tuesday, May 16 and finished our day well after darkeness had fallen. We had some amazing opportunites with Vamos Adelante, first in the clinic at Zapote, and later in some remote villages. In Zapote I had the opportunity to work with Nicole and with Dr. Renee. I continue to be in awe of Nicole’s midwifery knowledge and aspire to incorporate all of the things that I have learned from her.
After a delicious lunch, we walked several miles of beautiful mountainous terrain with one of the main promotoras 
(health promoter), Sara. It seemed a crime to be stepping on so many fallen mangos that are so expensive in the U.S. Sara guided us through the bush, greeting all in her path. It was obvious that she was well-known and respected by all with whom she came in contact.
As those of you who have had international clinical experiences know, this can be a heart-wrenching experience. Malnutrition is at the top of the healthcare problem list, along with dehydration, anemia, fetal growth restriction, and nausea and vomiting. Several of the medications that we would routinely prescribe are illegal to prescribe, and medications in general are not given to pregnant women here, for fear of fetal harm. On one hand we felt like, “Are we really helping?”, as we consulted with a pregnant, malnourished 15 year old who lives in a very dark enclosed dirt-floor home, shares a room with several family members, and sleeps on thin boards. Wow-a far cry from our pillow top mattresses and body pillows that many women in the States see as a necessity during pregnancy. On the other hand, we were able to share education on positions for comfort for an occiput posterior baby, what to do during labor to relieve back pressure if the baby’s position doesn’t change, how to decrease nausea and ensure adequate intake within the family’s meager means of nutrition.
Words don’t really describe the depth of the encounters, so I will attempt to summarize our day: In total, we were involved in 24 visits: 2 pediatric visits, 1 newborn, 1 postpartum/lactation, 4 primary care, 6 prenatal in the clinic, and 10 prenatal in the villages/pueblos. We also did a couple of hours of training with Sara, one of the main promotoras after our visits. Nicole was instrumental in her teaching of fundal height measurements, Leopold’s maneuvers, and care of the pregnant client. I worked with Sara for quite sometime on how to count and calculate heart rate and fetal heart rate. She initially had a hard time wrapping her brain around this concept but I laid down as the patient and she practiced and demonstrated by checking my pulse, my blood pressure, and using the fetoscope and stethoscope. This was overall a humbling opportunity to be a part of the lives and the culture here in some of the most remote areas of Guatemala.
Last Day at Hospitalito Atitlán
Smile Network Surgeon at Work
Yesterday marked our last day at Hospitalito and the last day of cleft lip/cleft palate surgeries. We started off the day with a “charrla”, presentation from Carolina, a medical resident from Belgium. Her presentation was on diarrhea and it was prompted by two deaths from dehydration and loss of fluid related to prolonged diarrhea in this area; one was a child under 5 years of age and the other was a young patient in her 20’s. The malnutrition here really compromises the body and places the patient in such a fragile state so that when sickness does hit, it can be devastating.
After the presentation I was able to assist with a Skype call to a French immersion school in Minneapolis, MN. This school had raised $5,000. for the cleft lip/cleft palate surgeries, and the children were excited to meet the family and talk with them. The call was moving; the family that you see pictured told the students that they thanked them, the Smile Network team, and thanked God for their son’s surgery. They were so happy because kids used to make fun of him and now, “Jeffery is beautiful” .
I was fortunate to be able to see the Canadian surgeon at work, as well as the anesthesiologist from Oregon, and nurses from various states. What a great team of people! It was so rewarding to see a group of healthcare people focused on a common goal, operating smoothly and creating such a transforming outcome for patients and families. The surgery that I watched was that of the youngest and smallest patient, Josue, 4 months old and weighing in at 5.2 kg, barely meeting the 10 pound requirment!
After the surgery I had the opportunity to see Dr. Jennifer in action as she assisted Dr. Luis with applying a plaster cast for a young boy’s arm fracture after falling out of a tree, she then ran from the ED to the clinic where she saw a pediatric patient and a gynecological patient. The husband-wife team, Dr. Brent and Dr. Jennifer are truly amazing and such a blessing to the people here.
We ended off our day with Brent and Jennifer and their four children, as well as Emily (OB resident from Omaha, NE), Dawn (OB resident from OR) and her husband David, Adonna from the women’s weaving coop in Solala, and Diane from NY. We hosted the event at Casa Susana and had home veggie-soup, guacamole, tostadas, bean dip, tuna salad, tamales, black berry cobbler, and a great time visiting with new friends and reminiscing about our time here in Santiago Atitlán. Now, it is off to Antigua and adventures with Vamos Adelante!
Our last week in Santiago Atitlan
As Leah and I prepare to leave Santiago tomorrow to work in villages south of Antigua, I’d like to share some of my favorite pics (next post) and some of the more touching moments.
The poverty and needs continue to be overwhelming and sobering. What does one do with the sense that a step forward is a wonderful thing, but a “drop in the bucket” ? There have been times when I have felt the most honest response would be to burst into tears, maybe even sob in response to the sadness of the lack of education, nourishment, basic resources, or access to the most basic healthcare. Right in front of us. Everywhere. Given this is not an appropriate response (especially not a culturally appropriate one!), I remind myself we are making a difference here, no matter the size. There was the morning with the community health nurses where Leah and I helped the women understand the few but available contraceptive options in their community. Visiting in the narrow, dusty alley that was the meeting place of two women’s homes, tattered clothes drying on the lines above our heads, I watched one of their young boys, hair thin, head too large for his body with large tired eyes, and knew there were so many others like him. In truth, I have never seen a malnourished child. This mother was interested in contraception. Maybe our time with her that day will help her obtain it, use it successfully, and be able to best care for her family.
There was the 39 year old woman with her 8th pregnancy at the hospital at 38 weeks by a 24 week ultrasound with definitive signs and symptoms of intrahepatic cholestasis (ICP). For us as providers, what a difficult situation — was she term? preterm? Was she 35 weeks and an induction of labor would put her baby in jeapordy due to lack of resources here to support the needs of a baby if premature? Or, if she did have ICP would continuing her pregnancy be potentially fatal to her baby, especially if she was 38+ wks? As I spoke spanish to the translator, who relayed the inforamtion to her in her indigenous language, it was clear that with her level of education and the literally foreign concept of what I was offering, there was no way I could successfully transfer this information about abstract medical options, risks, benefits, and treatment. She wanted nothing to do with interventions, so that provided our “answer”, but I was left with a sense of, “how do we do this”? and hoping and praying that her baby would be safe and born healthy.
There have been several opportunities to pass on education, information and demonstration on intermittent monitoring in labor (as opposed to continuous or not enough), the benefits of maternal position changes, and skin to skin after the baby is born. There is a long way to go, but I am hopeful. My greatest lesson in this area carries a familiar ring, that we must all work together — the midwives, docs, nurses, and staff — to make it work for the mothers and babies. I believe we can do this, and do this together.
There are many more stories, including the worst from today’s report from the night call MD — the one year old who died from acute diarrhea. Yet, I am once again inspired by the efforts made here by many both locally and from all over the world. Hospitalito is able to provide services from birth to emergency and surgery to this community – a rare and unique service in these more remote areas. Not to mention provide a site for medical missions such as Smile Network. Que Milagros! Then there are the Community Health nurses from El Centro de salud get right into the homes to help those that may not be able to make it to the health center for food, antidiarrheals for their children, or vaccines, or who might not be aware that contraception is available. And there are peace corps volunteers, Europeans, Americans and Canadians starting libraries and cooperatives, and many medical missions that local people have built and rebuilt after devastating mudslides. Especially inspiring is the relationship between the local midwives (comadronas) and the medical community who seem to understand the need for collaboration. Leah and I attended the monthly meeting this week where a local doctor from the community health center taught the midwives to recognize danger signs and when to transfer. The comadronas were interested, responsive and engaged and the doctor supportive, committed, and respectful. We were asked to give a presentation at the next meeting. Que suerte! While we will not be here, I hope to do so with the students during our November trip.
Needless to say, these are people who know how to move forward. So, what does one do with the sense that a step forward is a “drop in the bucket” but to keep moving forward? I am reminded of our Dean’s famous sayings, “onward”. And so here we go, onward, into this wide neighborhood full of beauty, need, sadness, miracles, desperation, and always, birth.
Favorite pics from Santiago Atitlan
Leah helps woman with difficulty breastfeeding. Success!
boy with cleft lip and palate scheduled 4 surgery today!
woman in annual procession to relocate Santiago saint
OR at Hospitalito, Smile Network's site for cleft lift & palate repairs
working with community nurses - what an honor!
Martin (Volunteer Spanish translator) with baby scheduled for surgery
Woman carrying firewood - load are often much heavier & larger than this
Traditional Midwives-Santiago Atitlán
An Educational Session for Traditional
- Nicole and Vincenta
- Leah Talking with Delores-the Lead Midwife at El Centro de Salud
This morning after a fabulous training with the Smile Network International surgeons at Hospitalito (more on that later), the social worker, Vincenta, invited us to a “capitacion de las comadrones”, which was like an inservice for the traditional midwives. More than thirty midwives came in their traditional Mayan dress to learn from each other, and from doctors and nurses from El Centro de Salud (the health department). Dr. Maynor Toc gave a power point presentation, along with his nurses, describing danger signs during pregnancy, birth, and postpartum. It was so inspiring to see health professionals respecting the tradition of the midwives and acknowledging their experience, yet bringing forth important medical information in a very respectful way. Vincenta brought a list from Hospitalito Atitlán of high risk pregnant women who have not been at their prenatal appointments. The names were read aloud so that the community midwives could get in contact with the women to check on their health status and to reinforce the importance of their prenatal appointments. The midwives broke up into small groups to facilitate a learning activity about danger signs during the pregnancy & birth. Nicole was asked to give a presentation for the comadrones in the future. How exciting that Frontier has such open opportunites in Santiago Atitlán! As most of us in the states can attest to, the cohesiveness between community providers and hospital providers is so important for continuity of patient care. It was great to hear the comodrones The group was very welcoming of our presence and we were honored to be representing Hospitalito Atitlán with Vincente and FSMFN.
Smile Network International at Hospitalito Atitlàn
María After the Surgery
- María Before the Surgery
This morning I rounded with the Smile Network Nurses on post-surgical patients. María had just awakened with her “whiskers” (steri strips). She was a little disoriented, but her parents were thrilled with the surgery and happy to be taking her home today. Thanks to Smile Network International she will have a whole new face and a changed life. I plan to round on surgeries throughout the week and am glad to be here to help. For more on Smile Network International visit: http://www.smilenetwork.org/Smile_Network/About_Us.html
Puertas Abiertas
The Students and Teacher Working on Projects at Community Library-Puertas Abiertas
Nicole & Martin talking with Amanda at Puertas Abiertas
Community health & home visits in Santiago, Atitlan
Leah & the community health nurses in woman's home
This was one of our best days yet. Earier in the week Leah and I braved a surprise meeting to the public health center (El Centro De Salud). We were well received by the nurses and the comadrona (a local midwife) who invited us out to the home visits in the community first thing the next morning. Of course, we accepted and were thrilled! The day brought many lessons and an undeniable “en face” perspective of the cultural health disparities here. The good news first — these nurses are making progress, step by step, home by home, as they travel up and down the stone streets and pass through cement alleyways to assist women and families. We checked on a new young mother, just days post-partum (thank goodness all was well) and a woman who agreed to be vaccinated for tetanus (many decline the vaccines for concern of the side effects). We also visited a young malnourished child (the nurses will help connect the mother with a supplemental food program) and helped diagnose a women’s gynecological issues for which we then discovered there was no medication available. We will continue to foster this relationship with the health center — these are excellent opportunities to provide support, learn, and understand some of the true struggles these women and families face, which will then, hopefully, help us to be figure out how we can be of service.
Cleft Lip/Cleft Palate Surgeries
- Waiting to be Interviewed for Cleft Lip/Cleft Palate Surgery
- A Family Being Interviewed
- A Happy Ten Month Old
- A Little Girl Who Wants Surgery
- Mom is Happy That her Son Will Have Surgery
This week the mission team, Smile Network International, will begin cleft lip/cleft palate surgeries. On Saturday I had the opportunity to participate in the interview process for 37 families who were hopeful that their child/family member would be able to have surgery. It was very moving, as some of them had traveled as far as 15 hours for the interview, and many of the infants and children were kept hidden from view, masked by a cloth. What a bright new world this will open for these precious children! As of Saturday only one person didn’t qualify for the surgery and lab results were pending on some of the others. A team of surgeons, physiscians, nurses, and volunteers all came together to meet with families and bring joy to their lives. I am excited to see what will happen this week at Hospitalito Atitlàn, and I feel honored to be part of the process. For more information about Smile Network International visit: http://www.smilenetwork.org/Smile_Network/Mission_Calendar.html
Presentation on Birth Positions
- Upright Position with Support
- Relaxation of Muscles & Letting Go of Tension
The Double Hip Squeeze for Relief of Back Pain
A Slight Incline Shifts the Pelvis & the Flow of Gravity
Last Friday Nicole and I had the opportunity to present information to a group of physicinas at Hospitalito Atitlàn on varying birth positions in labor and the effect on the labor, birth outcome, mother’s comfort, and infant position. Nicole presented studies from the Cochrane Review data base , and she and I were able to demonstrate variations of labor/birth positions. Dr. Jennifer, who is here from the States with her husband, Dr. Brent, was there with her children, (the kiddos in the background). This family practice couple have been at Hospitalito Atitlàn for one year and plan to be here for another two years. Dr. Jennifer s aid that when she is on call and a woman is laboring, that she encourages the mother to move and vary her positions. The group included a third year resident OB, Dawn, who is completing her residency in Portland, OR, another resident OB, Carolina, from Belgium, Dr. Jennifer, and physicians from Hospitalito Atitlàn, Dr. Susana and Dr. Otto. Isabella, a nurse from the States who is here for a year with her husband was also in attendance. We were thankful for the opportunity and placed a copy of the power point, in Spanish, on the hospital computer for future use.
FSMFN Guatemala 