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.

First few days in Guatemala

What a wonderful world we live in. A person can be in a totally different world in just a few hours.
My first couple of days here weren´t too exciting. I didn´t head out to the beach like I had originally planned but stayed in Guatemala City instead. On my first day here I participated in my favorite recreational pastime, sitting on my ass doing nothing. It was while I in the Central Plaza, engaged in this strenuous activity, that I met a gentleman named Hector. He´s a rural schoolteacher who was in the city to get some dental work done and file a dispute over his pay. Neither of us had much to do during the morning so he offered me a walking tour of the city. We ended up wandering around for hours practicing Spanish/English and admiring rows upon rows of dead animals in the market that tourists are warned not to go into. After a great lunch we parted ways and I ended up spending some time at the typical tourist sites. My second day was spent doing much of the same, with the added excitement of having my pocket picked on the city bus. They didn´t get much money but stole a sizeable chunk of my pride. In 20 years of traveling to somewhat sketchy places I´d never been robbed. Cest la vie. By the third morning my lungs were starting to feel like they´d been put through a meat grinder due to the pollution so I hopped the bus to Antigua.
I had forgotten just how beautiful this town was. There are a lot more tourists than I remember seeing 13 years ago but it´s still an incredible place to visit. Much of the city was destroyed by a large earthquake 200 years ago and several since, leaving some great ruins to visit. A luxury resort was built on one of those sites so people can enjoy crumbling walls for only $140 per night. Unfortunately my stomach started feeling a bit bad last night so I downed Immodium and Cipro and headed to the farmacia to stock up on gut goodies. An American woman stopped me at the counter and insisted that I try Xanax for my ills. She said she was a paramedic and gave it to her patients. Then she pulled out a blister pack of Xanax and offered it to me. She added that she also had a supply of morphine if I so desired and that it was all okay since she was a paramedic. Rule number 17 of international travel, the tourists are often far more interesting than the locals.
Well, it´s about time to head to the market, this time with my money in a safer pocket.

Last RUOP Journal

Journal 8 – July 8, 2006

It’s good to be back. Although leaving the clinic was pretty tough. I really felt like I belonged there, at least in the clinic, not necessarily the town. They even had a going away potluck and bought me a gift.

The kind of medicine practiced there is exactly what I’d like to do. The bonds formed between the physician and his patients make it a highly rewarding experience. The doctors and staff don’t seem to mind putting in the extra time and effort that it takes. There seems to be a higher level of commitment to their patients, probably because they’re related to, or at least friends with, most of them. I didn’t see this level of care at Group Health.

So am I getting ready to pack everything up and move to Cathlamet? Not quite. I was getting pretty tired of the area. It doesn’t have much to offer in the way of activities and there’s little diversity to speak of. Toward the end I started to spend more time with the ex-hippies out in Skamokawa. But the people of Cathlamet are wonderful. Maybe a bit conservative but refreshingly unpretentious.

So the big question is, can I find a place where this kind of medicine is practiced but still enjoy some of the life that a place like Seattle has to offer? Well, I still have three years to figure that out.

Last words of wisdom: If you’re ever in Cathlamet stop by Janet’s and get the Dungeness Crab and White Cheddar Omelet. That’s about all I have.

Journal 7

Journal 7 – July 5, 2006

I’m starting to get to know some of these people pretty well, or at least parts of them. Like MW’s knee which I’ve pumped full of Synvisc twice now or SG’s gouty toe. Funny, I don’t always remember names but I can remember problems. I bumped into a patient in the lounge one evening and again in the grocery store the next day. We had good, long conversations but I just couldn’t pull his name up from my memory. All I could remember was that he survived bladder cancer and has a stoma. Just running out of space I guess. I don’t know how I’m going to squeeze another year of classes in there.

We had a great 4^th of July here. Thankfully, nobody got hurt. The pager didn’t go off once. It gave us plenty of time to stuff ourselves full of burgers and ice cream and then blow a bunch of stuff up. Dr. Wright is a completely different person around a bag full of fireworks. The only bad part about last night was getting up at 5 this morning to go do rounds.

Kayaking in Skamokawa

The town of Skamokawa














Steamboat Slough





















more Steamboat Slough

















Skamokawa Creek outlet to the Columbia River

Journal 6

Journal 6 – June 30, 2006

It seems like they saved up the unusual cases just for my visit. I was expecting 4 weeks of otitis media and diabetes care. Now I can add transverse myelitis to the list. One of our patients is in the hospital right now paralyzed from the neck down with no apparent cause. The plan was to do an LP on Thursday to find out what happened but, the time I left on Friday, it still hadn’t been done. We thought the neurologist planned on doing it at noon on Thursday but found late that afternoon that he hadn’t even visited the patient (that he early said was the most serious neurology case in the hospital). When someone was finally able to get in contact with them he stated that the neurology department doesn’t do LPs and it would have to be done in radiology under fluoroscopy. Radiology said they couldn’t do it because they were going home. As if things weren’t bad enough for this lady. Being bounced around within the bureaucracy had to be frustrating.

Little obstacles like this seem to be quite common in Peace Health. I’m beginning to wonder if it’s the same in all large healthcare organizations. Is this my future?

Last note for the day: ambulances and people who get motion sickness don’t mix!

Journal 5

Journal 5 – June 27, 2006

This has been a pretty sad weekend here in Cathlamet. One of the volunteer EMTs drowned trying to pull someone’s jet-ski up from the bottom of the river. He was diving alone and just didn’t come back up. They still haven’t found his body. This kind of thing hits a community this small pretty hard. Not too many people were talking about it but the mood in the clinic has been noticeably gloomier the last two days. Just two months ago another EMT was crushed between two vehicles and passed away. I met his parents in the clinic this morning and was able to talk with them about it briefly, although I really didn’t know what to say. Nothing here has made me feel more like an outsider than listening to this couple talking about a tragedy that’s affected everyone else so deeply.

Otherwise, things have been pretty much par for the course. The 18 yo with the heart problem is now in OSHU but his bed in the ICU has been taken by another one of our patients that has severe aortic valve stenosis. Dr. Wright was quizzing me on his EKG interpretation and I had to admit I’d only gotten 1/3 of the way through the EKG book he gave me to read. Although I did manage to salvage some dignity by catching an unusual T wave. Why can’t they pimp me on something I DO know? Ask me anything about intravesicular bacteria. Well, maybe not anything. Micro was such a long time ago.

Tourist for a Day

I thought I deserved a day at the coast so I cruised out to Long Beach and Cape Disappointment. I can't believe I'm getting paid to be here.













North Head Lighthouse




















Dead Man's Cove

Cathlamet Internet

Cathlamet's best internet access, the marina parking lot. You just have to be sure to get a shady spot.

Journal 4

Journal 4 – June 23, 2006

The last couple of days have been pretty mellow. Yesterday was a long one but there was nothing overly stressful. The afternoon turned out to be a mostly mental health afternoon. A lot of the local residents seem to turn to Dr. Wright for counseling even though mental health services are available. I like the fact that he doesn’t just dish out meds without really talking with the patient.

So I asked Dr. Wright about abortion yesterday on the way back from Longview. He, as well as the other practitioners in the clinic, is firmly against abortion. Women who want an abortion have to drive 1 ½ hours to Portland to get one. There’s a Planned Parenthood in Longview but they don’t offer the procedures. Although I respect the doctor’s right to not perform abortions it still troubles me that women have to go so far out of their way to get a legal procedure. I’m sure there are places where it’s even more difficult.

I was strolling through town today doing some street research for my III and people recognized me and said hi. That’s such a weird feeling. I can see why people like living in a place where everyone knows each other but, on the other hand, there’s a lot to be said for anonymity.

Cathlamet town pics

Journal 3

Journal 3 – June 21, 2006

Things have been hopping at the clinic. I can’t count the number of ambulances we’ve seen come through in the past 2 ½ days. Well, that’s not true, there’s only one ambulance, it just came a lot. The patients are brought to the clinic first for evaluation/stabilization before being taken to the hospital in Longview. Most were things like chest pain or stomach pain but one yesterday was a mystery.

An 18 yo was brought in because of severe orthostatic hypotension. His BP was almost undetectable when he sat up. He had been outdoors camping over the weekend and we assumed he was just dehydrated. So we started two IVs and pumped fluids into him but, after two bags, he was still hypotensive. As a matter of fact, he was cyanotic when he sat up. His ECG and labs were pretty normal so we sent him on to the hospital for an echo and heard nothing more about it before I left for the evening.

This morning during rounds we checked the computer before seeing him and got some pretty distressing news. He had an ejection fraction of <10% style=""> The cardiologist said he had never seen a case this bad in someone this young.

So giving him so much fluid (5 liters by the time he got to the hospital) was exactly the wrong thing to do. They spent all night in ICU diuresing him. The ARNP who saw him at the clinic was pretty distressed that she did the wrong thing but I don’t think she did.

So we started the day having to explain the problem to the kid and his mom. I can’t believe how tactfully the doctor presented such a dire case. Anybody know where I can buy some of this kind of tact?

Journal 2

Journal 2 – June 17, 2006

Part of my job here is to go with the doctors to do hospital rounds in Longview (about ½ hour away) each morning. The three practitioners rotate but I get to go every day, which makes for some pretty long days, although they recently rearranged their schedules so they don’t leave until about 6:30. Since St. John’s Hospital doesn’t use hospitalists the clinic docs direct their patients’ care throughout their hospitalization. I think I prefer this over the hospitalist system although I’m sure I haven’t had enough experience to be able to judge either. One drawback is that the doctors have to make the hour-long round-trip at least once a day and may have to change the clinic schedule at the last minute.

This week our schedule got a bit wacky due to a delivery on Thursday. We went to the hospital to admit the young woman on Wednesday night and stayed in the on-call rooms expecting to deliver early in the morning. But by nine she was only at 4cm so we headed back to Cathlamet to see a few patients. The call to get back to the hospital came about two hours later. I’d never seen a delivery before so it was a pretty amazing experience. I didn’t really do much except help stitch her up afterward but it was still memorable and I got to see my first Babinski sign. After finishing up there we headed back to the office and performed a vasectomy (not on the father). Quite a contrast in procedures for one day.

Interestingly, on the same day as the delivery the county made the final decision to stop doing Ob. at the end of this year. Last year they payed $60,000 in Ob. malpractice for the two physicians and only brought in $20,000 of reimbursement. Now women in Wahkiakum County will have to go elsewhere for care if they want to have children. It’s a shame but I guess it’s a sign of the times.

III Journal 1

Journal 1 – June 13, 2006

I came here with a sort of romantic idea about the rural clinic being continuity of care heaven. So far it’s been even better. During my first two days we saw maybe two patients the doctor didn’t know personally. Some had been coming to the same clinic for decades. So Dr. Goldstein wasn’t making all this up.

Dr. Wright and I had lunch at a local café and he noticed that everyone there was a patient of the clinic. He seemed to know everyone we met by name. As I was mulling this over this evening I realized that, although this makes for more effective care in the clinic, it also puts a lot more pressure on the doctor to perform well and to be professional even when “off the clock”. A doctor in Seattle could walk around their neighborhood for hours and not run into a single person they recognized. Even so, I still think I’d choose the intimacy I see here over anonymity. I could always drive to another town if I wanted to stir up trouble.