Last week in Billings

It's been an unexpectedly fun rotation here in Billings. First of all, the rotation itself was quite good, with great attendings and friendly clinic staff. I don't know if I've felt so welcomed on any of my other rotations. It's been 100% clinic time, with no inpatient, which was just fine with me. I can handle not being in a hospital for four weeks. So I didn't get to see any patients languishing in comas, oh well.

The real treat has been the opportunity to get out and explore Montana. I've put nearly 2000 miles on the Xterra in the past 3 weeks just driving around seeing the sights. I forgot how much I enjoy being on the road. The best trip was the drive through Bozeman and Yellowstone two weekends ago. Many of the roads in the park were still snowed in so there were few other people in the park. I saw only one RV all day. Lots of bison to see, and be chased by. Thank god for quick acceleration.

Unfortunately, my truck broke down the following day in a little town called Roundup. I ended up parked in a local guy's garage where we tried all afternoon to figure out what was wrong. I finally had to get it towed back to the dealership in Billings, where it only took 5 days and nearly $500 to fix. But the afternoon in Roundup was very memorable. The mechanic and his wife even had me stay for dinner while I waited for the tow-truck. Awesome people.
The whole area is very much cowboy country. The big event this last weekend was branding, when the ranch owners have a jolly ol' time jamming red hot brands onto baby cows' flesh. Oh what fun!
I think I got enough of the cowboy thing my first weekend here when I went to see the PBR. That's Professional Bull Riders for those of you who don't keep up with high-testosterone sports. I was expecting nothing more than a bit of bull-riding and a whole lot of beer-drinking. But no, PBR is a huge deal. The show began with the requisite prayer and then jumped straight into an elaborate opening ceremony complete with smoke and pyrotechnics. The bull-riders come from around the world and are, apparently, the best at their craft. Pretty damn exciting. I felt a bit out of place without wranglers, a cowboy hat and a belt buckle the size of the International Space Station but I still had a good time.
Well, three more days `til I hit the road, probably never to return to big sky country.

Last day in Guatemala

I’m back in Guatemala City enjoying my last day here. I have kind of mixed feelings about leaving. It’s always sad saying goodbye to people you’ve worked with and leaving a program just as you start getting the hang of it. But I really miss the comforts of home. If all goes well, I’ll be stuffing my face with a piece of Pagliacci pizza in less than 30 hours. And it’ll be nice to get into bed tomorrow night without having to check for unwanted guests (not the human kind).
I’ve learned a lot during my visit here. Not just medical Spanish but lessons about life and medical care in poverty-stricken Latin America. I had some preconceptions about coming here, the greatest of which was the idea that Mayans would be completely unreceptive to western medical care. I found the opposite to be true. Maybe it was because we served a select population that came to the clinic or because Mayan Medical Aid had already done much of the groundwork. But even those I talked to in town who I didn’t see in the clinic seemed open to and appreciative of our presence. I’ve felt a lot more resistance and resentment in clinics back home than I experienced here.
The hardest part about working here was learning to slow down. Nothing happens “on time” and even patient interviews are a lengthier process. The men, especially, expect a good deal of chit-chat before getting to the problem that brought them into the clinic. The husband of my home-visit was a good example. On the rare occasion that he would ask me for something he would precede it with about a minute of compliments and expressions of gratitude. It was pretty uncomfortable but I learned to just sit and say “gracias” at the right moments.
When I had the time, my favorite question to ask was, “what do you think caused this?” Most of the time the responses fit into our western view of medical cause-and-effect but I had a fair share of patients that attributed their ills to earlier sustos or curses. Many of the patients I saw had already tried traditional healers and remedies. If I had more time here I’d love to catalog all the local plants with medicinal uses and start a garden in Santa Cruz to keep the traditions alive.
The truth is, I’m not sure how soon I’ll be returning to this corner of the planet. I’ve been to Latin America quite a few times during the last two decades and am ready to see other parts of the world. I think I’ve kept coming back because I feel comfortable in a country where I can speak the language. But it may just be time to reach out and expand my horizons a bit more. For now, goodbye Guatemala, hello…wherever.

For the last two weeks we’ve had a full complement of students at the clinic. It’s made things a bit more interesting than the first two weeks. We’re actually getting lectures two days a week although I didn’t make it on Wednesday due to some gut bug. Fortunately, I started feeling better that afternoon and was able to make it to the clinic on Thursday. On Tuesday the San Pablo clinic was as busy as ever but there was some sort of funeral in Totonicapan on Thursday, which made for a slow clinic day. The last patient of the day was a young boy who had a pebble stuck under the skin of his left elbow for two years. We don’t have too many opportunities to do procedures so extracting it was a welcome break from the routine.
On Thursday I made a break for Antigua instead of heading back to Santa Cruz. I spent the night at Hotel San Miguel worrying about bed bugs then caught a shuttle at 6 am for Volcan Pacaya. The short climb to the side of this very active volcano was one of the best hikes I’ve ever had. It’s hard to describe what it’s like standing between two slow-moving rivers of lava. Awe-inspiring is the only word I can think of.

The revered wooden gentleman above is none other than the deity Maximón. It took two boats, a steep climb and an 80 cent payment to an enterprising six-year-old guide to have the privilege of paying my respects; or at least gawking like the shameless tourist that I am. It was a fascinating ritual during which one man was praying while Maximón was given rum and cigarettes. The man to Maximón’s left did nothing but collect the now-holy cigarette ashes. I spent some time taking it all in before paying my dues and leaving. By the way, it costs surprisingly little to have Maximón place a curse on someone, but I won’t go into that now.
This week was my second visit to the clinic at Tzununá. We basically just hauled all our equipment into the municipal building and set up shop in whichever rooms were available. Very simple, very effective and definitely not JCAHO accredited. It’s kinda nice to provide healthcare without all the bureaucracy we’re used to in the US. And whatever bureaucracy there is here, I’m pretty sheltered from it as a student. I’m definitely going to miss that aspect of this rotation. But, the truth is, I’m ready to be back in cold, dreary Washington. Just a couple weeks to go.

Halfway

All the interesting events here seem to involve the animal kingdom. The dead bug count is now at four scorpions, two wasps, one centipede, two spiders that exceeded their size limit and two bugs that I couldn’t identify but looked scary enough to deserve a pre-emptive strike. Shock-and-awe was used effectively against a pack of dogs that decided to form a fight-club outside my window at two o’clock in the morning. And one unfortunate armadillo was turned into a tasty meal by the local tuk-tuk driver. No, I didn’t eat any.
Yesterday, in our new clinic at Tzununa, I saw a nine year-old boy with a case of the scabies that makes the Harborview ER look sanitary. He was nearly covered with itchy sores. We gave his whole family Ivermectin but it’ll be nearly impossible for them to clean all of their clothes and linens. We saw the normal amount of patients with parasitic infections and a handful of gut problems that were probably due to rotavirus. And, locally, a boy was bitten by a dog without vaccinations. For me this place sheds a whole new light on our relationship with the natural world.
I’ve been given an interesting case to follow, a woman in her 40s who had the misfortune of developing viral pericarditis several months ago. Since then she’s lost about 40 pounds and is quite malnourished. We’re trying to get her nutrition back on track but her weakness, cardiovascular state and a recent bout of diarrhea have complicated things. Part of the reason she’s in such bad shape is because a local curandero convinced her family to pay him a significant amount of cash to take care of her. For the most part I have no problem with traditional healers but he really took them for a ride, leaving her health in a pretty precarious state. But, with daily visits and encouragement, she’s been showing some improvement. We also have a bit of a mystery case on our hands, a young boy with bleeding gums/lips and petechiae. Likely von Wildebrand’s but we’ll know for sure when he visits a hematologist in Guatemala City next week.
Well, that’s enough med-speak to make everyone think I’ve been working hard. Yesterday I took a hike up to El Mirador, one of the little peaks overlooking Santa Cruz. It took about 2 ½ hours to get to the top but the view was worth every bit of the soreness I’m feeling this morning. I’ve also been meeting some interesting people here. There’s an odd mix of locals, ex-pats and travelers, all drawn here by the beauty of the lake and a different pace of life. Some come from strange, far-away lands like Italy, Australia and Alabama. One of the ex-pats rents out kayaks and has a 9’ Sunfish he said he’d let me take out when the wind is right, maybe today.

Just pics

Some more images from Lake Atitlan.

I couldn’t have asked for a more interesting week. I arrived in Panajachel on Saturday and in Santa Cruz on Sunday. The beauty of this place is awe-inspiring. Santa Cruz is a town of about 2000 that sits on a hill on the north side of the lake. The touristy businesses are located on Lake Atitlan but the center of town is about a twenty minute walk up the steepest set of stairs I’ve ever seen. The 5100 foot altitude makes the walk even tougher. I usually walk up the considerably less steep street that winds its way up to the village but still get passsed by 70 year old women carrying bundles of wood. But the tough climb is more than made up for by the incredible views of the lake and the two volcanoes on the other side.
I’m paying a bit more than I wanted for lodging at Casa Rosa but have a nice little apartment complete with furniture, hot water, a kitchen and scorpions. I’ve been told that there also black widow and brown recluse spiders to keep me company but none of them have introduced themselves as of yet. I don’t blame them after what happened to the scorpion. The hotel is surrounded by a small jungle and has some impressive views of the lake.
On Tuesday I went on my first boat trip to a local village named San Pablo to set up clinic for a day. Lots of kids, lots of parasites and even orbital cellulitis. I gave out more albendazole in one day than I saw in a year and a half in Seattle. Wednesday was supposed to be a lecture day but we were asked to help a man in the mountains who had fallen. After a 45 minute climb in the mid-day sun we found the guy and helped him back down to the clinic. Fortunately, he appeared to just have heat stress and recovered well. Totonicapan was our destination on Thursday. The clinic is a 2 hour boat/van ride from Santa Cruz and serves primarily adults. The most interesting patient was an elderly woman with congestive heart failure and diabetes. Not too different from what I saw daily at the VA but both diseases are pretty rare in this region. Both diabetes and cardiovascular disease are extremely uncommon in Santa Cruz due to the shorter life-spans and the amount of exercise the locals get walking up and down the hill. Interestingly, at least three of my patients yesterday attributed their problems to "sustos", or frights, that they had received years earlier. Just one of the cultural differences that makes working here so unique. On the way back we met an ex-pat that lives in Santa Cruz and was doing some shopping. He offered us a ride back across the lake so we loaded our stuff onto his party boat and headed out. About ten minutes into the ride his boat broke down and we were left stranded with a strong wind pushing us farther out onto the lake well after sunset. One of our assistants was able to call a friend to come rescue us but it took about an hour longer than we had planned. The good part was the chance to enjoy the lake after dark. After 3 ½ years in Seattle I had almost forgotten what stars looked like.
My plan for the weekend is to stock up on some necessities in Pana and then hit the market in Chichicastenango. I’ll definitely do some hiking if there’s time. There’s also diving and hang-gliding here so I’ll be running out of money before I run out of things to do.