An enlightening encounter

If you have ever traveled to a developing country, you have probably experienced local street vendors. They are the population that sustains itself through the tourist economy. They are usually poor, extremely poor, and, while some have a preconstructed place to bring tourists to shop, others travel with their products in hand, approaching as many tourists as possible.

The population mostly consists of women and children - tourists are less likely to buy from adult men. While the education and social standing of these street vendors is usually low, the breath of their language abilities can be striking. A friend recounted a story where, when traveling in Central America, he would speak in french - to try to avoid the nagging of the street vendors. Of course, his french consisted of only a few words - enough to fool most but far less than needed to carry a conversation. Many times, his plan worked - street vendors would start speaking in spanish, then switch to english - and, when he shrugged and muttered his french phrase, they would usually leave. However, he was astonished by how many times the vendors would start in spanish - then english - then continue in french. At that point, the gig was up, since the local poor street vendor knew more french than he did, and he had to give in.

Traveling for any amount of time here, you become accustomed to the presence of vendors. You learn ways to avoid them. You never make eye contact if you can avoid it - never. You learn to walk behind the most obvious tourist (middle age, short shorts, fanny pack) hoping that they will divert the onslaught. You learn the quick phrase to stem their efforts (no quiero comprar nada hoy, lo siento). And, shamefully, as you grow accustomed, you dehumaninize and treat them more as a nusiance than people.

A few weeks ago, I ventured to Panajachel - another town on the lake - affectionately known as "Gringo-tenango" for obvious reasons. Unfortunately, it is necessary to pass through Pana to get to the city, the airport, etc. And so, I went to Pana and was instantly bombarded with the street vendors. "Buy this purse" "Buy this necklace" "Buy this throw for your table". And so, I put on my experienced tourist face and employed my strategies. - eyes down, behind tourists, "No lo quiero, gracias".

I continued my strategy when I sat for dinner - I sat next to a large, painfully obvious family of tourists, I politely kept my head down and said no thank you.

During the course of my meal (45 minutes), I had between 5-10 people ask me to buy goods. Always the same things, nothing I would ever need, always the same lines - "Compre algo" "Buen precio" "Barrato"

Towards the end of my meal, a boy, not more than 9 years old, climbed the steps to attempt a sale. He was small, but, then again, everyone here is small. He had the same features, dark, ruffled, greasy hair, dark skin, dirt around the edges - that almost all the vendors have. He wore a Chicago Bears jersey - again, not uncommon - most clothes are donations from the States. In his arms he carried the usual suspects: homeade necklaces, bracelets, scarves, etc.

He held is arms up and asked me to buy something. I said no thank you and went down to my book, not paying him another thought. He stood behind me, waiting - not uncommon, kids can be persistant and want to try to sell to you again. After a minute, I turned around, ready to say no once again...and he caught me off guard.

(in Spanish) "Is that English you are reading"

An interesting question - not the usual, "Yeah, it is a book I picked up...Can you read English?"

A slight giggle and a shake of the head

"Your shirt has English on it, it says Chicago Bears - a football team in the US"

He looks down with a newfound respect for his shirt - something he has probably been wearing every day for a long time.

I repeated my question "Can you read English"

"No"

"What about Spanish"

"No." Sadl, yet, unfortunately expected

Seeing as the boy was around 9 or 10 and couldn't read, I asked a semi obvious question "Do you go to school?"

"No, it is too expensive"

I knew this too, public school is not free here, even the worst schools you have to pay for. I asked, " How much does it cost to go to school"

"75 Quetzales...a semester"

This blew my mind, 75 Quetzales a semester - $10 US - too expensive. His chance to escape poverty, to open countless opportunities, to help himself and his family - all thwarted for 10$. It is heartbreaking - he has a natural curiosity, a air about him that could be something better than what he is- but, because of 10$ a semester, he is restricted to his current life.

Of course, there are other factors. More than likely, no one in his family went to school - in fact, he later told me that his two older brothers also sell goods on the street. His family probably has no understanding of the power of education. They are poor, they are uneducated; by selling goods on the street, he is able to help keep his family afloat...at the expense of his future.

I wondered about his business - how many hours did he work, how many sales did he make, how much did he earn a day?

He told me that, on an average day, he works from 8AM until around 11PM. He asks hundreds of tourists every day, but, over the course of 14 hours, only makes 5-6 sales for around 30-40 Quetzales a day (about 5 dollars US).

5 dollars a day - enough for their family to survive, but never enough to escape poverty. They can never save money, they can never invest, they can never advance. If they have some sort of emergency - medical or otherwise - they will never have a backup - their decisions will have to be based on the little they can scrape together and they will plunge deeper into poverty.

I asked him when the last time he had eaten - 8AM. I glanced at my watch and saw that it was 8 --PM - a long day of work having only had a breakfast of tortillas. And there I was, sitting down to a full dinner, after a full lunch and a full breakfast -- suddenly my fish soup lost its flavor.

I asked the boy about his favorite food. He laughed again - you could tell he doesnt usually interact with tourists like this. He said the usual; tortillas, rice, beans - all staples, all things he has every day. So I pushed a bit, "What is the one food that you like above all others, your most favorite food to eat". He finally admitted it was fried chicken and french fries.

And so, I paid for the bill and accompanied the little boy down to a local fried food vendor. I squashed the little medical voice in my head screaming "fried food is bad" and, for the mere cost of 15 Quetzales - about 2 dollars, bought him some fried chicken and french fries.

We chatted for a bit more -- it is incredibly hard to chat when, really, your lives have nothing in common. He thanked me for the chicken and went on his way - more than likely to continue to try to sell his goods.

There are times in our lives when we become accustomed to what we once thought was impossible. In medicine, there are countless examples - your first patient that dies is horrible, but, sad to say, the 100th just doesnt have the same edge. It is then , when you least expect it, that you sometimes get hit with an occurance that serves to re-awaken your senses. I had been in guatemala for 5 months, I had passed hundreds of vendors, I had perfected the art of ignoring. And then, one little kid comes along and reminds you that all those people are very much human.

I did not make a difference in that kids life - he will still wake up then next morning, have a meager breakfast and go about his 14 hour, 5$ day. His path is still set, I was a mere speed bump, a quick diversion to break the monotony.

But, whether he knows it or not, his contribution was much more lasting. He broke the paradigm, made me see deeper than the superficial causes I had resigned myself to. And, although I will still probably do my best to avoid the onslaught of the vendors (after all, I still have to get where I need to go), his memory will hopefully bring me pause a little more often.

A Change of Scenery

In mid November, I ended my rotation in San Juan and, after a brief hiatus in Costa Rica, I moved to Santiago Atitlan. Situated on the south coast of Atitlan – 11 km wide lake, - Santiago is home to approximately 40,000 people. As one of the 12 towns around Lake Atitlan - each of which is named after one of the 12 Apostles (Santiago = Saint James), Santiago is known for its painters / weavers and the half Mayan / half Christian god Mashimon. If you ever visit Santiago, you will be inundated with requests from people of all ages to see both – for a small fee, of course.

Medically, Santiago is similar to San Juan Sac – both areas are extremely poor, with limited education, security and work opportunities. Diseases common to both cities include Asthma / COPD, Gastritis, Alcoholism – as well as all different types of trauma and obstetrical complications.

However, there are many significant differences between Santiago and San Juan Sac. An important difference is the location of each town. At first glance, Santiago has the advantage – away from pollution / crime filled Guatemala City, surrounded by tranquil forest, hugging what may be one of the most beautiful lakes in the western hemisphere. But, on closer examination, the more remote location of Santiago holds certain drawbacks.

First, being 3.5 hours away from Guatemala City means that the population is 3.5 hours away from the nearest large government hospital – Roosevelt. The Roosevelt Hospital system – actually a series of 3 public hospitals – are all located in Guatemala City. They represent the most advanced free care available to the public. However, besides being extremely overcrowded, patients must travel from all parts of Guatemala to reach Roosevelt. My first day on call, a 7 year old boy came in after being hit by a Tuk-Tuk – local taxi - (see picture). We stabilized and, when he was not improving, we transferred to Roosevelt – the closest hospital with a CT scanner and neurosurgeon. We later learned that our boy died before he was able to make it to surgery – a consequence of the location of Santiago.

Additionally, the location of Santiago plays a large role in the cultural attitudes. Being somewhat isolated, the people of Santiago have more tightly held on to their beliefs, customs, dress, language and other aspects of Mayan life. While this is a strength of the community, at times it means that more traditional healing is used, less formal education is available, and the understanding of the abilities and limits of modern medicine is poor. Again, in my first week, a woman in labor came to our emergency room after having continuous contractions for 20-30 minutes. Besides being painful, this is a dangerous condition because during a contraction muscles tighten the baby receives less oxygen rich blood from mom. We gave powerful drugs to relax the contraction and she soon delivered a healthy baby. We later learned that a local comodrona – local midwife – had bought an “injection” from the pharmacy, which, to the best of our knowledge, contained Vitamin B and oxytocin – a drug used to stimulate contractions. When oxytocin is used in the hospital, it is given IV and tightly controlled – if the woman has too many contractions, the IV can be turned down and the medicine quickly is cleared from the blood. When the midwife decided the labor was not progressing fast enough, she gave the injection. However, she gave a large dose intra-muscularly, meaning that there was no way to turn off the medicine. It is this lack of understanding, mixed with the availability of powerful drugs over the counter that can be a recipe for disaster.
In addition to location, language is another significant difference between Santiago and San Juan. In San Juan, because it is closer to the city, 95% of residents speak Spanish. However, here, farther from other towns, many residents only speak Tzu’tuil – a Mayan dialect spoken in the area around Santiago. Besides making patient interactions difficult – imagine some English speaking doctors needing translation – English – Spanish – Tzu’tuil and back – it also makes people more reluctant to leave Santiago, even just to go to an outside hospital.

These issues and more present challenges to my new supervising clinic – Hospitalito Atitlan. Begun before the civil war by church volunteers from Oaklahoma – the Hospitalito served as a clinic / resource for the town of Santiago. However, deaths during the war forced the hospital to close.

In the year 2003 – the community, working with a group of foreign volunteers, refurbished and reopened the Hospitalito. In April 2005, the clinic was welcomed by the community and was very successful – for about 3 months. Then, Hurricaine Stan brought a mudslide that wiped out the hospital and most of the town. For a first hand account of working in the mudslide, can read Dr. Mark Lepore’s story here. http://www.med.upenn.edu/ghi/documents/lepore.pdf

After the mudslide, the Hospitalito moved to an old backpackers hostel, where it currently resides, waiting for construction on a new, permanent structure.

The Hospitalito has emergency, surgical and outpatient capacity. We can stabilize patients, admit them for some advanced care, deliver babies, perform cesareans and other basic surgical procedures. Sadly, the limiting factor for many things at the Hospitalito is the availability of trained staff. There are 4 paid General Medicine Guatemalan doctors, as well as a full staff of nurses, lab technicians and other support staff. The hospital is then supplemented by volunteers – usually 2-3 supervisors – family or emergency medicine doctors, more sparse obstetric and surgical coverage, and a mix of residents and students to provide additional capacity.

For me, the Hospitalito is a return to a system of medicine more like the US. While I still have more responsibilities than in many hospitals in the States, we have the benefit of more resources, more complicated patients, and continuous supervision. It is a great mix and an incredible learning opportunity here in a small town on the edge of Lake Atitlan, Guatemala.

A hairy experience

Of course, such a serious blog needs to be chased with a bit of lighter fare...

Much like the 7 Holy Sacrements of the Catholic Church ( Baptism, Confirmation, the Eucharist, Penance, the Anointing of the Sick, Holy Orders and Matrimony- for my non Catholic friends or those who, like me, slept through most of Sunday school) - anyway, much like the 7 sacrements, there are certain rituals that all males must sucessfully navigate to be granted full access into the wonderful world of "manlihood." Important "manly" customs such as learning to pee standing up, having your voice break in front of the girl you like, discovering the wonder of all the different bodily sounds - these must be achieved if one wants to evolve from a boy to a man.

Here in Guatemala, I have chosen to undertake yet another of these sacred quests - about the 4th or 5th Sacrement - the sacrement of growing facial hair.

True, it started as a touch of laziness. With no available razor (thank you TSA) and little knowledge of the correct word in spanish, it was only a matter of time before things started to get a bit scruffy - see photo 1

After expanding my vocab and knowledge of SJS - I finally purchased a razor. However, that morning, as I trying out the different types of "manditory shaving cream beards", I paused at my white goatee, thinking to myself "hey, that's not bad". Then, the next step...shaving everything but the goatee and taking a moment, still in the bathroom, of course, to survey the scene. Sure, it had only been a week, which for me signals the mere beginning of facial hair - but, I thought to myself - what the heck - foreign country, blurry photos, who's to know the difference.

And so, I stepped out of the bathroom, with basically what looked like a bit of dirt on my lip and possibly some on my chin. And so began my journey

Time passed by - hair continued to grow - sparsly, irregularly, but grow nonetheless. Soon the little smudge of dirt turned into a larger smudge and, before you knew it, one month later, people began noticing I had facial hair.

Then, one month later, the first trial, the meeting with the girlfriend. We had planned to meet in Miami for a weekend - a quick encounter for a momentary return to reality. She, of course, had heard about my attempt, she had even seen grainy pictures via Skype, but this was different, this was real life. This was a huge test - anyone can grow scraggly scruff - however, when the girlfriend admits it looks good, you have completed your quest for true facial hair. What would she say?? What would be her reaction??

The picture pretty much sums it up. I believed it was phraised something like this "Yikes! - I mean, it could have potential, if you kept growing..." And so, my quest continued, as the decision was made to come to my full facial hair potential before making permanent judgements.

And so, time continued - taking call, working in puestos, going out in Guatemala. Another month passed. During that time I became used to having soup and other liquids drip from my upper lip. I tried to stregthen the hair, systematically pulling on different parts to "toughen up the roots" - of course, this just left a few more bald spaces, making things even more awkward.

Then the second test - Costa Rica. Another chance to impress the girlfriend. This time, she would have 5 days with the facial hair - a decision would have to be made...

And the decision..."I am kind of getting used to it, it doesnt bother me as much..." SUCESS!!! Yes! Partial acceptance of facial hair! This was a huge moment, much like the Game 6 of the Sox v Yankees ACLS Championship in 2004, for the first time, I thought, I had a chance. Of course, with this renewed enthusiasm, I couldn't stop my quest. No, I needed to push on for the ultimate test - presenting to the Family.

Another month passed. I finished in SJS and began working in Santiago Atitlan. The facial hair was excepted with less pointing and suggestions to "wash my face". Time continued to pass on.

The holidays approached, and with it my imminent return to Boston, to Judy, to my family and to hers. This was the culmination - 3 month of unrestricted facial hair growth, eventual partial acceptance from the girlfriend - I was ready to unveil this upgraded, more manly self to the family. I arrived home late on the 19th - picked up by the girlfriend. I passed the time in silent reflection and meditation. Then next day, we drove to my parents house early in the morning. I got out of the car, walked in the door and...

There are few words to describe the love between such a close family as we are. Really, we have such as bond that there is almost no need for the subtletly of politeness or - well - subtletly. Yes, as you can imagine, from the moment in the door, the harrassment started. And, in fact, did not stop until I had, once again, been cleanly shaven.

And so, like the search for the holy grail, my quest had ultimately failed. However, it is about the journey, not the destination, right? Throughout my 3 months of facial hair, I learned much about myself and about the world - primarily that it will take me another 5-6 years and or testosterone injections to finally connect the upper and lower parts of my goatee - but also about life, responsibility, and acceptance of those who are different. Those are the lessions I will take with me, that, and, of course, if I ever do try to grow facial hair again, I will have to wait for the moustache to come back into style - that seems to be the only thing that I can grow.

Finishing in San Juan

Sorry for my hiatus - I doubt I will take up professional blogging as a career.

In mid November, I finished my time with the students of San Juan Sacatepequez. It was an incredible experience - an educational insight I never could have imagined coming from Boston. The clerkship taught me many aspects of practical medicine and responsibility. Most striking, however, was the experience of living and working with those in extreme poverty - seeing the factors beyond physical health that lock the population in poverty. In my final OEP (office of enrichment programs) report, I talked about some of those factors and how they affected 3 of my most memorable patients: Exerpts - along with some pictures, of course, are below.

“NON-HEALTH” FACTORS

The following are a handful of societal factors in SJS that, although not related to the health puestos or Centro de Salud Barbara, contribute to the morbility and mortality of the people of SJS.

EDUCATION –education is divided into public and various private schools of varying quality. There are no laws for child schooling; many children of families in poverty have never attended school or had attended a low quality public school for only 2-3 years. As such the majority of patients we see cannot read and are unaware of any type of disease process or medication. For many, there is still abundant magical thinking regarding health – that the baby emerges from the belly button, like a flower, or that disease is due to “mal de ojo”, evil spirits cast from an enemy. Additionally, for many indigenous peoples, Spanish is a second language – without adequate schooling, their understanding of Spanish can be limited.

SECURITY – Security is poor in local communities. All police are based out of Guatemala City and have little overnight presence in SJS. Additionally, police are generally regarded as corrupt, occasionally more dangerous than robbers. Besides petty theft, Guatemala is experiencing an increase in gang activity, which is associated with drug trafficking, violence, and rape. To counteract this presence, some pueblos have taken to vigilante justice, forming mobs that capture and kill gang members. During my 8 weeks in SJS, approximately 5 gang members were lynched by roving mobs – lynching in Guatemala involves evisceration with a machete through the abdomen, dousing with an accelerant, and lighting on fire.

Additionally, and of important note is the high level of alcohol abuse and domestic violence inflicted upon women. There is still a strong culture of “machismo” where women are somewhat subservient to men; as such, rates of inter-relationship violence and abuse is high.

Because of the understaffed, corrupted legal system, many criminals never go to trial or are able to pay their way out of their punishment. During my time in SJS, we interviewed a woman who lost a baby due to spousal abuse – her husband, while drunk, repeatedly kicked her abdomen. According to the local officials, his only punishment was that he had to pay for the related medical costs.

WORK – Limited opportunities for well paying jobs promotes poverty and idle time. Many poor villages sell food or hand made goods. The average income in an impoverished community is anywhere between 100 Q (12$ a day) for those working for an established organization, to as low as 3-4 Q (50 cents) for the extremely poor, selling produce or other goods. There are few opportunities for work and even less to advance in the workplace.

RECREATION – There are few public spaces in pueblos for recreation. Some larger towns have organized soccer teams, and there is the occasional government sponsored holiday fair (during the “Dia de Ninos”, October 1st, the government set up trailers with video games). In general, the people work 6-7 days per week and have between 1 day and ½ day free.

HOME – Families live in a variety of homes. The richest in SJS have concrete homes with anywhere from 1 to 5 rooms and some of the basic amenities including gas, refrigeration, and television. The poorer populations have more poorly constructed houses, of lamina or straw, often with dirt floors. Many use fire / smoke stoves in their house, have only one room / one bed which the family share, and often live daily with livestock, other animals. Their houses are located farther away, in less desirable areas.

FOOD – The Guatemalan diet is based on mashed corn or “masa”. People prepare their corn using a process involving drying and lime, which removes the undigestable coat of the corn, allowing more of the proteins to be absorbed. All people, regardless of status, eat corn tortillas, which cost 0.20 Q per tortilla, about 0.02 cents. Those in extreme poverty will often supplement their diet with rice, frijoles negros (black beans) and coffee. With increasing resources comes increasing variety – potatoes, occasional chicken, less desirable parts of beef, vegetables including tomatoes, squash, plantains, and occasional fruits. Almost never seen in the diets of those in SJS include cheese or milk, fish, soy or other health food products.

Food is often bought at outdoor markets and is bartered. Because of water contamination, fruits and vegetables are occasionally contaminated and can cause illness. Meats are sold after slaughter and are not usually stored in refrigerators.

Additionally, there are increasing quantities of “comida de tienda”, junk food including chips, cookies and soda. In every pueblo, no matter how remote, there will be a small tienda or convenience store with all types of junk food. The food is cheap, chips usually 0.50Q (6 cents), soda between 1-2 Q (0.12-0.25 cents. Many people do not understand the health implications of eating such foods – some even believe that these foods are good for them, as they see advertisements with healthy people enjoying these foods. As such, there are increasing problems with cavities, malnourishment, and obesity in these poor populations.

Infrastructure

ELECTRICITY – those in extreme poverty have no access to electricity – those of a slightly higher status have access to electricity. However, the infrastructure is poor in SJS, and electricity is often cut by frequent power outages.

SANITATION – There is minimal access to public sanitation; most houses have no functioning bathrooms. As such, sanitation is extremely poor, with human and animal waste infecting most water sources, spreading a variety of diseases that have largely been abolished in the US.

ROADS / TRANSPORTATION – Many are in extremely poor condition. There are paved roads in and around the center of SJS, however, in pueblos, it is all dirt roads of varying structure and quality, weaving around the mountainous area. Most pueblos have only 1-2 main roads. With varying weather, especially during the rainy season, these roads can be washed out, temporarily stopping transportation.

WATER – All public sources of water are considered contaminated. Bottled water can be prohibitively expensive. Poor individuals, if they sanitize their water, either use sun, boiling or bleach.

CASE #1 – A 5 year old boy, accompanied by his mother, came to our rural health post with a chief complaint of productive cough and fever for 1-2 days. Immediately we sensed that something was wrong. It was not his current illness, he didn’t have a fever and his cough was benign. Instead, it was the way he acted – he didn’t speak – his mom said that he had never spoken, and rarely made eye contact. He appeared weak, he had trouble holding his head up, and could not walk without assistance. When he did walk, he stood on his toes and had a wide based gait, putting his arms up over his head, fingers extended – resembling a puppet. Most striking, he was overly happy throughout the examination. He would laugh, often randomly, occasionally inappropriately, in an unaware bliss.

His mother said that he had always been like this, that he had developed much slower than other children –this was not an acute change associated with his illness, rather, something they had adapted to. Born at home in a poor village, she never had enough money to see specialists in the city or pay for expensive tests to diagnose his condition. She hoped he would develop enough skills to live independently, but she seemed to know that she would always have to care for her son.

From a medical standpoint, it is almost impossible to diagnose such global, congenital cognitive problem in an office visit, especially for two medical students. We threw around ideas, such as Angelmans Syndrome, but, without testing, we could not be sure. Further, even with appropriate testing, there was probably little we could do to improve his outcome.

While congenital cognitive disorders happen in resource rich countries as well, the difficulty of having a disabled child in a poor community is striking. There are no government resources, no programs, no outside aid. Often, it is the sole responsibility of the family to care for the child, often with no education or knowledge of how to provide appropriate care. With increased susceptibility to disease, malnutrition, and abuse, these children often die much younger than their counterparts in developed countries.

For us at that particular visit, there was not much to do other than treat the underlying cold, make sure all vaccines / other healthy child measures were in place, and try to answer questions the best we could.
CASE #2 – A pickup truck arrives in the Emergency Department one afternoon carrying a 40 year old man in serious condition. Like many people around the villages of San Juan Sacatepequez, the man works by making fireworks, specifically the wics to be placed in various fireworks sold throughout the region. The wics can be made with few supplies, can be crafted from home, and require no particular skills. Additionally, many members of the family can work on the wics – especially young children, whose small hands can more easily manipulate the small fibers. This man had been making wics, when a spark somehow ignited his entire work area, causing a fierce explosion.

He was lying in the back of the truck, semi-conscious, groaning in pain, drenched in blood. A cloth was tied around his right wrist, and, where his right hand used to be, there was only random strands of tissue and blood. We brought him into the treatment room and immediately called for an ambulance to take him to Guatemala City, the closest place with trauma surgeons. We stripped his clothing and found he had 1st and 2nd degree burns over 70% of his body, his chest, arms, legs, and face. In fact, all the hair on his face had been burnt off – he had only charred remains of a moustache, eyebrows and had lost some of the hair closest to his forehead.

We quickly took vital signs – amazingly, his blood pressure was higher than expected 110/70 – most likely thanks to the clever individual who tied the tourniquet around his right wrist. I quickly assessed his airway, which can become damaged with the inhalation of hot gases, and gave oxygen, while the two other medical students skillfully inserted large bore needles into both his arms to quickly deliver fluids. After 5-10 minutes, the ambulance arrived, and we quickly transported our patient to a hospital where more could be done for him.

These accidents are not unique to developing countries, all countries have accidents in the workplace. However, the confluence of factors – poverty, little education, unregulated work environments, lack of medical resources, compound in countries like Guatemala and increase the morbility and mortality of such accidents dramatically. It is interesting to think what his outcome would have been if he had been working in a regulated environment, with safety precautions, adequate medical response and rehabilitation. If he did survive the trip to the public hospital in Guatemala, our patient will have no compensation for his family during his rehabilitation, and without a right hand, will have to find other work to support his family or risk homelessness and starvation.

CASE #3 – We were called out of one of our weekly Tuesday classes to assist the on-call students and pediatrician with a complicated birth that had just arrived in the Centro de Salud. The mother was a 25 year old, her second pregnancy, the first ending in a spontaneous abortion at week 25, who was currently 32 weeks pregnant. She has received no prenatal care, and had started labor yesterday. For many reasons – customs, finances, education – she elected to have her birth at home, with the help of a comodrona – a local woman who has been trained in childbirth; however, comodrona “training” varies dramatically. This particular comodrona was not medically trained, and went about assisting with labor. The mother seemed to be doing fine, until 30 minutes before, when the comodrona noted that a tiny foot protruding rather than the head. Knowing this was serious, the mother was transported – in the back of a pickup – to the Centro de Salud Barbara.

Arriving at the hospital, both feet were already delivered and the baby was blue and listless. The doctor who was there, after some manipulation, was able to deliver the shoulders and finally the head. There were no further complications of labor for the mother.

The baby, however, was in full arrest. Its one minute APGAR – Appearance, Pulse, Grimace, Activity, Respirations, (score from 0-10), were zero; the baby was blue, not moving, not breathing, with no pulse. We immediately gave oxygen and CPR, and, after 5 minutes, were able to restore breathing and pulse. The pediatrician was able to put an IV through the umbilical cord so that we could give drugs to the baby. After about 45 minutes of work, the baby was stable enough to transport to the city for additional care.

Although we don’t know what happened to the baby, it is very likely that he would have died. In a resource poor country like Guatemala, the limits of a viable baby is between 30-32 weeks, rather than 27 weeks in the US. Combined with the complicated birth, the lack of prenatal care, and the fetal arrest, this baby had little to no chance of surviving here. Again, this is a case where multiple factors worked against the mother and baby. With appropriate prenatal care – this problem would have been detected and could possible have been prevented. With proper education and training, the comodrona could have realized something was wrong much sooner in the delivery, and the mom could have been transported to a hospital that could have stopped labor using drugs, given steroids and performed a cesarean section. With more advanced medical resource, even a baby in such severe condition could have had a chance at live. All of these deficits, compounded in one case, make survival almost impossible for this type of delivery.

My Better Half

She is the person who supported my decision to go, when she really wanted me to stay.
She is the person who makes time to talk, even if there is none.
She is the person who listens to my rants, no matter how odd.
She is the person who always remembers the important events in my life, even if I don’t.
She is the person who never forgets to say “I love you”
She helps me to be strong, confident, to work hard every day, to see the sun behind the clouds,
It is for her I am here, and it is her I miss the most

DESTINATION: Miami
DURATION: 16 Hours

The first of our rendezvous – around the time of our anniversary, we planned a quick getaway to Miami. However, due to a massive Guatemalan flight delay, what was originally going to be 2 days became 16 hours together in Miami. However, we made the best of it. We stayed in a beautiful hotel in Coconut Grove, complete with flat screen, overpriced in room bar, and whirlpool. The next morning, we had a gourmet brunch at the Rusty Pelican, then made our way over to the beach. All in all, a great 16 hours.

DESTINATION: Costa Rica
DURATION: A little longer

Costa Rica, the better planned of our vacations, gave us a little more time to rest and relax in what turned out to be the middle of the rainy season for the country. Weather aside, another great trip – some highlights include: Canopy tour, chicharones (fried pork skin), visit to the beach, animal refugee, cerviche (semi raw dish – fish / shrimp are “cooked” with lime juice), hot springs, beautiful sunsets, being able to sleep in, without the natural “rooster / dog” alarm at 5:00AM – I benefited from this last part the most.

Besides the obvious luxury of visiting places where I don’t need to carry a bottle of bleach to disinfect food, it has been special to be able to spend time with Judy. She has sacrificed more than I realize to help me have a successful experience in Guatemala. I am glad that these trips give us something to look forward to, and helps to make our time apart go by even just a little bit faster.

Feet First

It’s 8:00PM at the Centro de Salud in San Juan and a few students, including myself, are beginning a 12 hour call– my second here in Guatemala. We sit in the common room, making dinner, chatting about the day’s events – me mostly trying to understand Spanish - when one of the nurses briskly walks in and tells us a woman with strong labor pains has just been brought in by a pick-up truck – a common mode of transportation here in Guatemala.

As this is a fairly frequent occurrence, we gather our equipment and promptly make our way down to our observation room. An initial survey reveals a woman in her mid 20’s, breathing rapidly, sweating, in visible pain with each contraction. One of the students quickly gloves his hands and performs a tactile exam – used to determine the cervical dilation, effacement (or thinning), and the position of the baby. Simultaneously, another student searches for the fetal heart rate using one of our handheld Doppler devices.

I work with the nurses to obtain a bit of history. Second pregnancy – no prenatal care – her last period was approximately 8 months prior – she had been laboring in her home with the help of a local comodrona – midwife – for the past 5-6 hours, but the midwife felt there was something strange about the babies position and so they came in.

It is the student performing the tactile who first notices the problem. Normally, when performing a tactile, you encounter the cervix with a variable dilation, followed by the circular, formed, top of the babies head. However, rather than a head, he immediately felt an object just behind the opening of the vagina – small, moveable – he worked his fingers up and the object continued to grow - he realized instantly – it was the baby’s foot.

Normal delivery of a baby through the pelvis is a tricky manipulation of space. The babies head is naturally larger than the opening of a normal pelvis – if one was to just try to pull a baby through, it would cause severe damage to the baby, and, most likely, would not work. However, nature has adapted to this space discrepancy – first, a babies head is not circular – that is, it does not have the same diameter around all parts. In fact, depending on how you position the head, the overall diameter – width – decreases. Additionally, nature has not yet fused the bones of the skull together, allowing them to overlap and further minimize space – we know it as the soft spots on the babies head. However, in order to take advantage of these benefits, the baby, inside the uterus, must, during labor, turn and move in specific orientations to fit through the pelvis – otherwise it is like fitting a square peg through a circular hole. Nature has adapted for this difficult process – when the baby is head down in the uterus (cephalic), the shape of the pelvis and force of contractions naturally turn the baby in the correct manner. When this occurs, delivery of a baby is a rather uncomplicated process – the job of the physician then primarily focuses on catching the baby (of course I simplify – but it can be quite tricky to catch wet, slippery babies)

However, the physics and beauty of nature goes out the window during a breach presentation (when the baby presents feet down). First, the smallest part of the baby – everything below the shoulders – is delivered first, usually quickly. This leaves the largest parts of the baby, shoulders and head, stuck behind the pelvis. The normal head movements are more difficult, because the babies head is starting from the wrong position, and a human head can only move so many ways. Additionally, and most dangerous – the umbilical cord partially comes out with the lower torso of the baby – while this itself is not dangerous, there is a high risk of pinching the cord when the baby tries to squeeze its shoulders and head through – cutting off the oxygen supply to the baby.

As you can imagine, this is an emergency – in almost any hospital in the US, this mom would have immediately had a cesarean section, which bypasses the pelvis entirely and simply takes the baby directly from the uterus (I have firsthand knowledge of this, being one of those babies who wanted to enter the world feet first).

However, here in the Centro de Salud, we don’t have the resources or personnel for a cesarean. In fact, on call during the night, the closest attending doctor, a pediatrician, is approximately 30 minutes away by car. Additionally, the nearest hospital to have a cesarean is a 1.5 hour ambulance ride away – too much time.

We bring the woman into the delivery room, and the Guatemalan students act masterfully. Their training in medical school has focused more on practical technique, to meet the demands of the overburdened hospitals. This has not only given them more clinical skill, but has also instilled a sense of confidence, of focus. We all realize the gravity of the situation, but, while I am thinking of options, their minds are already made up – they know what must be done.

Using specific maneuvers, they insert their fingers past the pelvis to the babies head, one hand on the back of the head for support, pushing down, the other on the face, causing the babies head to flex to its chest, they then turn their hands 90 degrees up, pulling the feet toward the ceiling, delivering the face first. Of course, this procedure is difficult due to a lack of space, and takes what feels like an eternity to work. But, the students stay focused and the baby is ultimately delivered.

We cut the cord, bring the baby over for possible recusitation, although somewhat blue and not crying in the first few seconds, after we warm, dry and give a bit of oxygen, the baby pinks up and starts crying.

Looking back, I am still in awe of the students I worked with. Although we are technically the same level in medical school, their situation, their experiences have focused on practical clinical skills, while, in the states, we focus more on theory, understanding of underlying principles.

It is not to say that their education is superior – it is just that each of our educations have been optimized for our environments. In the US, students are always supervised and the clinical education focuses on exposure rather than mastery. The reason is simple, especially in Boston – there are an abundance of doctors to treat patients – therefore, standard of care dictates that doctors and residents should be the primary health providers. Additionally, our system is specialized, therefore, if I decide to go into dermatology, more than likely, I will never attend another birth – as the doctor – for the rest of my career. Therefore, our education focuses on building a foundation of principles, leaving the development of specific clinical skills until after you have decided on a tract in medicine.

Guatemala, however, is different. First, the hospitals are incredibly overburdened – there are just too many sick and not enough doctors. Therefore, the responsibility for patient care transfers down to the level of the intern / medical students. This deficiency is even more pronounced in the rural areas, where it can be many hours to the nearest hospital or clinic. Secondly, many of the graduating Guatemalan students will go on to be general medicine doctors – they will more than likely see all types of patients – pediatrics, obstetric, general adult medicine. Therefore, their education focuses on direct patient care early on, comparable to our residency programs. This not only shapes their clinical knowledge, but also their mentality – they are trained to be resourceful, to rely on themselves, to have confidence in their own skills.

Of course, these systems function well as long as the students in them stay in their respective countries. For me to come to Guatemala, I find that my clinical experience pales in comparison – I had never seen an emergency vaginal breech delivery, and for many good reasons – we have the resources for cesarean, we have adequate screening, access to ultrasound. Therefore, it has been quite the experience to practice medicine with this added responsibility, and without the equipment and procedures I am used to.

At the same time, some of the Guatemalan students have problems in the US system. Because they have been groomed to be decisive, they can come to diagnosis very quickly, and have trouble in a system that values a wide differential diagnosis and has almost unlimited medical resources at their disposal.

While it can be, at times, overwhelming to be here, practicing with these other students, it is also a great opportunity. To be able to practice in this setting, to add some of their clinical skills and, more importantly, some of their strong personality traits to my own character I believe will only serve to help me as I continue my career in medicine.

University of San Carlos

A little while back, I had the opportunity to explore Guatemala City. Usually known to tourists as the smoke filled, crime infested, less attractive city in Guatemala, the city does have some interesting and noteworthy sites, one of which is the countries only public university, San Carlos.

Before the civil war, San Carlos was the best university in Guatemala, attracting thousands of the most qualified students, regardless of their ability to pay. The professors were the top in their respected field, and the campus stood as a intellectual, left leaning institution.

However, with a series of military dictators came a rise in poverty, starvation and discrimination against indiginous people. The leaders of the university were some of the first to organize a revolt - the start of the 30 year civil war in Guatemala. Although they lacked funding and an organized military force, their intelligence and connections allowed them to mount a strong resistance to the government.



During the civil war, many of the leaders of the university were captured and killed. As such, the university lost both the support of the government and the people that made it great. At the same time, the brutal tactics of the resistance kept the country at war for 30 years - as is true in all cases, it seems that both sides are to blame for parts of a war that cost thousands of lives and has kept this country in poverty for many years.

Now, 10 years after the war ended, the university stands below many private university in quality of education and opportunities. Although recently it has started to rebound, it lacks the resources of the more well funded private universities.

However, the left leaning, anti government feelings of the university are still strong, and are demonstrated in the paintings that cover the outside of many of the buildings. Below are just a few examples:

Above is the image of a student who fought in the resistance and was killed. Roughly translated, the inscription reads "don't cry for those that died, imitate them"

A large mural covering one side of the building - from left to right - a hand with crying eye, photos of students killed, maiz - the princible crop, in the center below is the quetzal - the bird of guatemala, hand with flowers, on the right is a machete - which the people used to fight with.

The portrait is a famous woman in Guatemala. A student of San Carlos, she also won "Miss Guatemala" - she was branded an enemy to the government and killed. Below, translated "Women: in our fight, you lack a machine gun"

Portrait of Che and the woman above, two powerful figures for the resistance.