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.

On Call All Saints Day

According to history - Halloween began as All-Hallows-Eve, the night before All Saints Day. November 1st was reserved to celebrate the Saints of the church, followed by All Souls Day on November 2nd which celebrated all departed souls.

As such, previously unknown to me, the day with the powerful spiritual Mojo is actually not Halloween, but rather the day after, when all the spirits are said to rejoin the living world. If I had known this fact previously, I would have switched my on call day. The spirits were out, and they were urging people to go to the hospital. Here was the day:

NOVEMBER 1st
6:30AM - We receive call from the overnight team - 2 deliveries, but otherwise quiet during the night of Halloween.

6:30AM-7:30AM - Tranquil - able to check email, have a bit of breakfast. We check on the post-partum patients, go over notes from last night. Being a holiday, we are looking forward to an easy day - Whoops!

7:30AM - a few follow up patients, a 6 year old boy who has pain when swallowing, but, oddly, no fever. His physical exam revealed enlarged tonsils with pus, large lymph nodes, and still no fever - after more questioning, we found out that he was given only 1 injection of Penicillin 4 days prior by a private doctor - we decided it was best to continue treatment for strep throat.

Next a 12month old who 3 days ago, fell while walking and ended up with swelling around the right eye. The parents decided to spend the 150 Quetzals - 18$ to get an X-Ray of the head / face. Here, one must pay for imaging - if they didn't have the money, they would either forgo imaging or be forced to travel 1 hour to the public hospital in the city. As it turned out, the X-Rays did not show a fracture, and the 12 month old looked great - Pretty easy so far.

8:00AM - Our first challenge - a woman in labor - 5 centimeters dilated. We palpated the stomach, did an internal exam to determine stage of labor, if the babies head was correctly positioned down. These maneuvers are not always easy - but, without access to an Ultrasound, you do the best you can.

8:30AM-10:00AM - Other patients are steadily coming in - not overwhelming, but not the easy day I had envisioned

10:30AM - Somehow, in only 2.5 hours, our pregnant ladies cervix dilated to the full 10 cm - she was ready to have her baby.

11:00AM - A 6lb baby boy enters the world - with hand over his face while coming out, as if saying "NO, put me back in". Luckily I performed my primary responsibility well - I did not drop the baby.

11:30AM - We finish with mom and baby - they are wheeled to our post partum ward. However, we look over at our waiting bench - and it is full

11:30AM - 3:00PM - A flurry of patients, emergencies. A boy with the largest leg infection I have ever seen (he received a cut from a bike pedal 20 days prior, was not given the correct antibiotic by a local doctor), another man whose hand was so swollen by infection he could not use it. A woman wit severe dehydration who needed IV fluid, a boy with developmental delays who had fallen, another woman in Labor whose baby was actually positioned the wrong way - transverse in her belly. All this along with other, more typical cases of cold, flu, prenatal care.

3:30PM - A lul - this could be it - Just need to check on the 4 people in our post partum ward, then we can sit

5:00PM - Lunch

5:15PM - Almost simultaneously, two more women in labor - for one it is her 7th baby (she is 32) and the other - her 11th baby (she is 38). They are both dilated to 5 cm - meaning that they could both give birth at the same time.

6:00PM-11:00PM - more patients - a finger fracture, more kids with colds. Our dehydrated lady finally looks better after 2 liters of IV fluid (after about 10 tries to find a usable vein). But, our labor ladies are now 7 and 8 centimeters.

12:30AM- I fall asleep on one of the observation beds - close enough so I can hear when they wheel our ladies to the delivery room

1:30AM - Our lady gives birth to her 11th child

2:00AM - Our other lady is not progressing through labor - she is still dilated to only 8cm. We check on our 4 post partum ladies again - every 6 hours. They are not happy for the 2AM wake up call.

3:30AM - I once again pass out on the observation beds.

5:00AM - Our lady continues to not be ready to give birth, still under 10 cm. Now we are thinking of sending her to the city hospital.

5:30AM - we need to check on our 4 post partum ladies one more time, before transferring to the next team

6:30AM - THE NEXT DAY - We hand off - and I promptly go to be for 4 hours before afternoon class.

What a day.

Going out in Guatemala

It is not all work in Guatemala. About 1 hour away, we have the more up-scale haven of Antigua. In the 1700's Antigua was the capital of Guatemala, however, after a series of earthquakes that destroyed the city, the capital was moved to present day Guatemala City. Today, while Guatemala City is poor, industrialized, and occasionally dangerous, Antigua has become the tourist capital of the State, clean streets, lots of restaurants, bars, and hotels, and, of course, plenty of folks who speak English.

Our two top bars in Antigua are MonoLoco (Crazy Monkey) and Rileys. MonoLoco was founded by 2 former Bostonians. As such, there is a wall devoted to the Red Sox, and always some type of football, baseball, basketball or hockey game showing. The burritos are a little smaller than a football, and the drink selection is pretty reasonably priced.

Rileys, I am pretty sure, is the only Irish bar in all of Guatemala. It is the place to go for a Guiness or other export - of course, you pay for the luxury, around 8-9$ US for a Guiness (as a comparison, you can buy a whole litro - liter -of the local Gallo brand for around 4$). Still a fun place to be, lots of different folks from around the world. And, of course, once you are tired of the pub scene, the local dance club is right across the street.

Los Puestos

The puestos are really where we get the bulk of our clinical work. Each student has their own puesto for 4 month, I have been working with students at different puestos. As you can see from the pictures, the puestos have very limited supplies / medications / resources. However, they serve as a first contact for the most impoverished people of Guatemala


A typical puesto clinic / office. Below, one of the puestos had a hands free stethoscope – pretty advanced technology, I'm thinking of taking it with me back to the states. Additionally, some pictures of the surrounding houses. Most are wood / siding, with dirt floor. Many families live with livestock, and have no access to clean water / sewage systems.

The people living in the rural areas are usually of Mayan descent (note the difference in appearance from the Guatemalan medical students and the local people). Thirty years of civil war, which ended just 10 years ago, has kept many of these populations living in extreme poverty, often living off of about 30-40 cents per day (approx 2-3 Quetzal)

Typical diet depends on level of poverty. The most impoverished will typically have 1-2 tortillas (corn) – the staple food of Guatemala, tea, and occasional frijol (black beans are the most popular here in Guatemala). With a bit more money, the diet adds rice, plantains, eggs, and occasional chicken. The most well off surrounding the puestos will add in fruit, vegetables.

Of course, there is a downside. Here, soda, chips and cookies only cost around 15 cents. And, with effective advertising and low levels of education, many of the Mayan people think that beautiful, healthy people drink soda and eat chips / sweets. As such many of the kids have rather poor diets / rotting teeth. It is pretty sad when you have to pull permanent teeth from a 15 year old kid.


That is what has been amazing about medicine in Guatemala - in such a poor country, you really see the effects of disease. My mom always warned me that soda would rot my teeth, but, coming here, you actually see the long term effect. Diseases like cancer, diabetes, congenital malformations are not detected until they have advanced far beyond what we normally see in the US. Of course, it can be sad as well, as, usually, there are few resources to help these individuals.

My First Two Weeks

During my first two weeks, I was with a group of students who were finishing their four months here at the Centro de Salud. It was quite a culture shock in the beginning, my last rotation was in the ED at Children’s where we were well supervised and had access to any test we wanted. Here, we are the primary doctors, performing procedures, making decisions, often with little to no laboratory / imaging data. The outgoing Guatemalan students, after almost 4 months, were very comfortable in their role, and, according, they let me manage almost any situation I wanted. Below, I am suturing a child head post trauma. Also, I was the “attending” on 4-5 births, an incredible experience, seeing as we have only stethascopes and Leopold Maneuvers. Also below is a picture of us out on the town. It is a funny change, the Guatemalan students are, medically, at the level of our 2nd year residents, but, for many, this is their first time living away from their parents.

First Blog from Guatemala - Centro de Salud Barbara

My first attempt at blogging from Guatemala, only 42 days into my trip. I -will try to include lots of pictures since they are more interesting than my ramblings anyway.

I arrived in Guatemala on September 18th and, later that day, started my 2 month clerkship at the Centro de Salud Barbara, located just outside San Juan Sacetepequez, one of the suburbs of Guatemala City.

The Centro de Salud is the headquarters for students from the Francisco Marroquin Medical School during their required 4 month Rural Medicine Rotation.

During their rotation, students serve as the attending doctors in the Centro de Salud, managing patients, stabilizing emergency trauma and attending deliveries. Doctors are available by phone for consult, but do not normally provide care at the Centro.

The Centro de Salud has 2-3 consultation officies, 4 observation beds, one delivery room, and a fairly large post-partum ward, consisting of 8 beds. In addition, there is a basic laboratory for various blood tests, as well as an ultrasound room and ophthalmology room, each of which is open once a week and stationed by local radiologists / ophthalmologists.

There is a dormitory attached to the back of the Centro de Salud, which has been my home away from home for the past 1.5 months. There is one common room with a combined kitchen, living area, connected to 8 bedrooms and, thankfully, 4 bathrooms. The dorm is home for the international medical students, as well as about half of the guatemalan medical students as well as a designated call room for students covering the Centro de Salud at night. Having spent the last 3 years of my life in a dorm, it is really not much of a change.