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
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.
No comments:
Post a Comment