Jacaltenango and around

The Road to Pajal

Day 10. Monday. 

Due to rumors of protests closing the route to Jacaltenango from Huehue, we had to leave at 5am in order to miss the hubbub and get to our destination.  We slept in the PCI vehicles most of the way, only to wake up to some of the most beautiful scenery in the country. Cloud-covered mountains, winding roads, people walking along the roads starting their days by carrying firewood in bundles supported by a forehead strap, herding animals, washing laundry at the outdoor sinks (or pilas as they are known here). 

We arrived in the smaller town of San Antonio Huista first where we had breakfast. There was a locally grown coffee item on the menu, which was delicious, and actually had some strength to it. Guatemalans usually drink their coffee very weak, so it was a nice change.  After breakfast, we took a trip in our PCI pickups to the small village of Pajal, about an hour up a pitted, narrow, sometimes very sharply inclined road to ever increasing rural amazingness. The crops growing on steepest  hills, the houses of the people blending into the landscape, the view of Mexico and the feeling of being on top of the world all added to the experience, along with the adrenaline of the possibility of rolling off the road in our nifty little pickups at any point. 

"Club de Embarazos"

Finalmente encontro los huevos!

Upon arrival, we were greeted by the “club de embarazadas”, or pregnancy group. Though the plan initially was for all of us to meet with the pregnant women, there is such a deficit of medical care in this country that when word gets out that a doctor is in town, one person tells two more, who each tell two more and the result is crowds of people waiting outside the centro de salud. So quick change of plan, Suzy had prepared a talk on prenatal and newborn nutrition which she gave to the women in a nearby structure, Peter started with ultrasounds, and Tom and Alexis were left to deal with the throngs of people waiting for a consult.  Gosh, did we ever miss Brenda, and Doctora Ana! It was an overwhelming number of people just looking to see a doctor. On top of the general lack of medical care, the current political situation is such that many of the “puestos de salud” (small clinic outposts generally staffed by nurses) have recently (and very abruptly) been closed, leaving many villages without an option for medical consult. This village, like many others, is at least half a days journey to the nearest CAP or hospital and the trip is expensive. Knowing the situation it was hard to set limits with the people but it seemed the line never got shorter no matter how many people we saw. After Suzy’s talk, she and Vilma, the other PCI nurse accompanying us, started seeing patients as well to try to increase our volume. With our small team we managed to see close to 70 before having to close the doors so we could make it back down the mountain before dark.  We were all so thankful not to have EPIC charts waiting for us at the end of the day! 

House-call in Pajal

In addition to the consults that we saw at the “puesto de salud”, one woman had come asking for a doctor to see her daughter. The daughter had recently had a home delivery and was not well.  Tom and Suzy set out on a house call to see her, particularly concerned (and curious) when someone said that they had ‘felt an animal running around her insides. The woman was laying in her bed in her small one room house. A quick exam showed she was had abdominal tenderness and a fever and most likely had endometritis. She had apparently been given antibiotic when she first became febrile but had taken one dose and then was advised by her midwife not to continue the medicine. Postpartum infection along with postpartum hemorrhage is one of the main causes of maternal mortality in this area and without her antibiotics this woman was in danger. We recommended resuming her antibiotics or starting another one if someone could obtain it for her, and going to the hospital as soon as possible if no rapid improvement. Unfortunately, as it has been with most of our consults this trip, there is no easy follow-up and we are let wondering what her outcome was after our departure. 

After a full day’s work, we were shepherded into a local woman’s house where we were served a late lunch at 4:30pm of beans, rice, eggs and veggies on Styrofoam plates. We tried to pay the woman for her services but were told that the community had come together to pay for our lunch. It is so humbling knowing that many in this community often did not have enough for their own families had thought to provide a lunch for us. After lunch we we got to drive back DOWN that amazing road, past San Antonio Huista to the town of Jacaltenango to Hotel Florida for sleep. The hotel was nothing like Florida, but the owner was friendly and welcoming and we were very thankful for showers with hot water!

Day 11. Tuesday. 

Small Group Teaching

 After another breakfast and good coffee in San Antonio we drove across town to the “salon” where we were to meet a group of 40 local midwives. We were scheduled to start at 8am but upon our arrival at 8:30 there were two women waiting for us; we are all on Guatemala time now. At close to 10am we had 28 women and a group big enough to start with. It was impressive to hear the experience that was in the room! Some of the younger comadronas had been practicing for only 4 years, but ages and experience ranged up to a few in their 70s with 50 years of experience! We split into 4 groups and had small group discussions on the topics of Prenatal nutrition, “sinales de pelegro” (danger signs), Postpartum hemorrhage and neonatal resuscitation. Most of the woman were very engaged and also shared their own experiences with us. One  woman told the story of the birth of her own twins which she delivered at home; the first normally and the second breech delivered by “covering my hand in oil, then reaching up inside, finding the mouth with my finger and pulling to deliver the head”.  It sounds unbelievable but these woman have seen and done unbelievable things!


 

The comadronas practice breech deliveries

After the small groups we gathered back together, all the women sitting in children’s school desks, most with their feet swinging inches above the floor. For our final activity we had also brought pelvic models along with us to teach some maneuvers for difficult births. Although the midwives are taught that if the baby is breech she must deliver at the hospital, it seemed that the majority of the midwives had attended at least one breech birth so we decided that it would be useful to teach breech delivery. One woman started to tell the group about a breech delivery she had had, and proceeded to describe, step by step, everything we were about to teach. With such a clear description of a successful breech delivery we only had to demonstrate with the models before giving the women some hands on practice. 

Day 12. Wednesday.  

Guatemalan Public Health: CAP on strike

The next day we got to go to the local health center or CAP, Centro de Atencion Permanente. The CAP in Jacaltenango is run by a young doctor named Dorian Rojas who had met last year’s team at the handling obstetric emergencies talk given by Drs. Gobbo, Anderson and Paulissen.  He was kind enough to invite us to visit the CAP, a great opportunity to see how the public health system works in Guatemala. What we ended up seeing was not a typical day at the CAP, but probably was a good view of the reality of public health here. When we arrived at the CAP there was again a huge line of people waiting to be seen. Typically there are several doctors and nurses at the CAP who see consults all day, along with emergency medicine and deliveries. However, the day of our visit the people were told thy would not be seen other than emergencies and pregnant women in labor. Most of the staff had gone on strike and traveled to Huehueenango to protest recent cuts in government support. For this CAP recent cuts meant that none of the staff had been paid in 3 months. Despite not getting paid most of them, including Dr Dorian, continue to work every day, doing what they can with very limited medicines and equipment for the overwhelming number of poor people who need health care. I have to give a shout out here to Tisha at SE clinic and the Providence Warehouse for sending us down with extra medical supplies. Many of the items that wouldn’t be utilized at Casa Materna were brought here to the CAP. Dr. Dorian and the others who were here working today were so grateful for the gauze, the needles and syringes, the wound cleaner, gloves, the instruments for minor surgeries, etc.  They kept thanking us over and over. 

Dr Dorian on the ultrasound

Though we were not able to see general consults, we did have a morning full of ultrasound to do. They do not have an ultrasound at the CAP and patients have to pay out of pocket to a private doctor to get scans for prenatal care. Since we had brought the portable we were able to do 15 ultrasounds on women from 4weeks to 39 weeks pregnant. Alexis and Peter got more practice and Dr Dorian got to do some scans as well. Our hope in the future is to be able to continue to train local doctors to do prenatal ultrasounds at the CAPs in more remote communities. Overall it was a good day and it was fun to show the women their babies on the ultrasound and for some tell them the gender. We also had some more sobering cases; a 24 year old woman pregnant with her 6^th baby and two cases in a row of fetal demise. 

CAP Jacaltenango

After a long morning of ultrasound we left Dorian and headed back to Huehuetenango. This time we (mostly) stayed awake for the drive and got more impressive views of Gorge like passages, rivers, and of course beautiful local people an adorable children along the way. We arrived in Huehue exhausted, but invigorated from our journey.

NICKNAME QUIZ: the contest remains open.
Team: Susie, Tom, Brenda, Peter, Alexis
Nicknames: Mamut, Spuds, Tibarone, Mash, Santa ____