Homeward Bound

Our PCI Team in Huehuetenango

Goodbyes suck. They suck when you leave your family and they also suck when you leave your Guatemalan family as well.

We met with our PCI team at a small cafe and had a nice breakfast and said our goodbyes with Bal Maria, Paulina, Yasmin, Mishel, Dali, Wendy, Henry, Juan Carlos, and Danilo. Throughout the last 2 weeks we have been working side by side with each other in our clinics, capacitaciones, and during our long drives to remote communities. They have been patient with us during our bad Spanish and times of speaking English. They will be continuing the work as we head back to the US. We will miss them and look forward to working together in the future.

La Familia Lopez Guevara

Next we said goodbye to Arnoldo, Abesaida, and Paty (now 5 days shy of her due date). Staying with the Familia Lopez Guevara means becoming family. You share the trials of the day with each other, the challenges ahead, and all get stuffed to the ears by Abesaida. All of our thoughts and best wishes are directed toward Paty having a safe labor and healthy baby son.
We boarded a bus owned by the Los Halcones (The Falcons) company and took the 6 hour bus ride back to Guatemala city to the Hotel Ciudad Vieja. It feels like a luxury resort after the hotels in Santa Eulalia and Todos Santos and we are ready to put our feet up a little. 

Josh and David

At dinner we met with two graduates of Rafael Landivar Medical School who have stayed with us in Portland, Natalia (plus her mom) and Bonnie. Bonnie has fully graduated and is doing HIV research while she prepares to take the USMLE and apply for internal medicine residency in the US. Natalia is completing her thesis, also planning on taking the USMLE. What a treat is was to spend time with two Guatemalans who have lives with us in Portland, as we prepare to head back home.

Meeting in Guatemala City with Natalia and Bonnie

As we head home via Houston, we took some time to thank Suzy for her efforts in leading us through the last two weeks, navigating the challenges of working in Guatemala, making personal connections, delivering real care, and trying to make things a little better.

San José las Flores, Thursday 18 de Octubre

You will not find San José las Flores on any tourist map. Or any printed map for that matter. OK, you can find it on Google maps if you know where to look, but it doesn't know how to get there by any road. It is a small aldea (village) along a winding dirt road that takes about 2 1/2 hours from Huehue. The road is often surrounded by tall hills as you wind along through the foggy altiplano. There is a Puesto de Salud (health post) with almost nothing inside, that is usually not staffed by nurses and almost never by physicians.

Over the last 2 weeks the places we have gone (Casa Materna, Santa Eulalia, San Juan Ixcoy) were determined by communication between the PCI (Project Concern International) leader in Huehue and the various communities she is in touch with. At some point, there was a decision to have us make a trip there.






We left Huehue at 5am with our drivers and headed up the windy road to the mirador, then headed east along the dirt road where our average speed was about 8 mph. Once we arrived, we had a small breakfast in a restaurant with a wood fire then headed to the Puesto de Salud.

As with previous clinics we had done, we brought our ultrasound, our medicine supply from Providence, our basic instruments (otoscope, stethoscope, flashlight), and set to work. The Guatemalan system is usually that people are given a number, then form a line and are seen in numeric order. The problem with this system is that usually the person with the number is with other family who have medical questions as well. Fortunately, the people in San José speak Spanish making less of a language barrier.

Josh diagnosed dementia in an 80yo man whose son brought him and had never heard of dementia before. Melissa had a many pediatric visits. Mariah and Rosapicante (yes, she does have a name) split their time between ultrasounds and consults. They were doing so well with ultrasounds that Chris left them and did mostly adult consults. One woman came in as a victim of domestic violence.



At the end of the day, we left many of our supplies with the puesto. One of the nursing aides was touched to the point of crying that we had brought much needed supplies. San José las Flores is a lovely remote town with very poor access to health care. The need and the appreciation of the people we met were both powerful and stirring. 





We drove back along the road to Huehue and arrived around 7 to have our last dinner with Abesaida, Arnoldo, and Paty. We had bought our bus tickets already and did our final packing for the trip home.

El Cumpleañero (Birthday Boy)

"Estas son las mañanitas, que cantaba Josue David" So begins the song "Las Mañanitias", which is sung at dawn for people on their birthday in Mexico and Central America. As it turns out, today was the birthday of both Josh and his baby that was delivered today during another capacitación. Father and child both celebrating a birthday and having a postpartum hemorrhage, all in one.

Today was another day of capacitaciones,a skills fair for midwives and nursing assistants. The government Ministry of Health requires each comadrona to attend 11 such training sessions in a given year in order to renew their registration card. Most of these are taught by nurses and staff from the various health clinics, but today's was taught by a group of six Americans and two Guatemalans from Casa Materna.

We left from Arnoldo and Abesaida's house around 8 and arrived a half-hour later in Chiantla which is a smaller town on the outskirts of Huehue. We were met by about 25 comadronas from Chiantla and neighboring towns. Almost all spoke Spanish (which was a major improvement in communication), although there were a few that spoke primarily Mam. Our jobs were quite similar from two days prior: Melissa teaching shoulder dystocia, Rosalicia and Mariah teaching postpartum hemorrhage, Chris doing neonatal resuscitation, Josh teaching emergency breech delivery, Suzy talking about the birth kits, Paulina (from Casa Materna) talking about nutrition, and Yasmin (also from Casa Materna) teaching emergency signs in pregnancy.

After the talk we had a chance to chat as a group, and the comadronas were very appreciative of the manual skills and knowledge they were able to practice during the session. They also made a point of singing a very special "Happy Birthday" to Josh.

After lunch we repeated most of the same stations with nursing assistants from the local Puestos de Salud and CAPs. Most did not have a ton of obstetrical experience, but were also quite appreciative of the training. 

One very encouraging development in recent days is that it seems like our efforts to make misoprostol available to comadronas in distant communities is beginning to pay off. As mentioned previously, the law prevents this medication from being dispensed by non physicians. In towns that are as many as 6 hours from the hospital by car, and have only a Puesto de Salud (which haven't been permitted to stock Misoprostol), it appears the departmental health officials are moving towards making misoprostol available to the Puestos who can give it to the patient en route to the hospital. This is not a done deal, but it is enormously important in the effort to decrease maternal deaths.

CAP in Santa Eulalia

CAP waiting room

Today was a clinic day at the CAP (Centro de Atención Personal) in Santa Eulalia. In Guatemala, there are three levels of non-private medical care. The lowest level is the Puesto de Salud (health post), which you would find in smaller towns, and is staffed by nurses and only offer basic services. The next level is the CAP; some are staffed by physicians and can do deliveries, others are staffed by nurses only. The National Hospital in Huehue is the only hospital with full surgical, medical, pediatric, and OB/GYN services.

Suzy brought last year’s group to the CAP in Santa Eulalia and we returned this year. We arrived to find a waiting room fairly full and set to work. Josh and Melissa did consultas for moms and kids. Melissa had two 10 month old children whose weight was about average for a two month old. She also had a woman whose blood pressure was 240 and whom she sent by ambulance to the hospital in Huehue. She also footed the Q 200 ($27) bill for the ride.

Mariah and Rosalicia each did a half day of consultas and a half day of ultrasounds with Chris using the portable ultrasound that Sonosite lent to us. Rosalicia did an ultrasound for twins who were both head down. The mom said (via our Q’anjobal interpreter) that she was planning to deliver at home, but we advised her delivering at the CAP would be a safer option. Josh and Chris did a successful version (manually applying pressure to a baby in utero to get it to flip into a head first position. All in all a good clinic day.

Soloma

We headed back to Huehue along the four hour ride dodging the many potholes, through the fog, up and over the altiplano, stopping in Soloma for lunch. Throughout the ride, we reflected on our presence here and whether we are truly helping or not in a chaotic setting. When we arrived back at Abesaida’s house, we found that Paty (Abesaida’s daughter who is 38 weeks pregnant) had severely elevated blood pressure and needed more urgent evaluation, so we sent her (after dinner of course) to the private clinic/hospital where her obstetrician works.

Read the sign. Or not.

Capacitaciones (Skills Training)

Josh having a postpartum hemorrhage

Monday we held a “Capacitación” in a hotel in Santa Eulalia. Our first session was with a group of comadronas (midwives) from as many as three hours away. Since 90% of babies in Huehuetenango Department are born with a comadrona, one of our ongoing goals has been to hold teaching sessions for obstetric emergencies and ultimately lower the maternal mortality in the department.

Melissa demonstrating shoulder dystocia

As we got started, one of the comadronas approached Chris and asked if we could start with a prayer. When he replied that Suzy was in charge, she looked again and said (in Spanish) “No, I think you are the one in charge.” This was the second training session in four years we have had with these comadronas, and it went WAY better as we had skilled interpreters in Q’anjob’al. Mariah, Josh, and Rosalicia taught postpartum hemorrhage and breech delivery. 



Suzy showed them everything in the delivery kits we had brought for them. Melissa and Chris taught shoulder dystocia and neonatal resuscitation. Although the comadronas knew much of what we were reviewing with them, there were definite knowledge gaps we found and encouraged them in methods to lower risk of injury to mom and baby. When we introduced ourselves, they assigned us our Q’anjob’al names and found it endlessly funny that Chris’ name translated to Ixtup (eesh-toop). Josh provided some comic relief with a postpartum hemorrhage skit.

The afternoon group of nurses

After lunch, we did nearly the same stations with nurses from the local CAP (Centro de Atención Personal) where they do deliveries. Needless to say, the lack of a language barrier (all of them spoke Spanish) and a medical education made the afternoon sessions go quite smoothly.

Suzy was given the pink hat

In the evening, we met up with other PCI employees for a game of indoor soccer. Josh and Chris were game (stupid) enough to play and in the end held their own, mostly because of size, despite playing at altitude and not being in the best shape.

Caminata (Hike)

On the trail with Rigoberto

Todos Santos is in the heart of the Cuchumatán mountains, and from Todos Santos run many trails for day hikes or multi-day hikes. We had made plans in advance to hike to one of the tallest points in Central America. Melissa contacted our guide Rigoberto by email and he met up with us Saturday night to plan out our Sunday caminata. The two main options we considered were a hike to “La Torre”, a 12,589 foot peak versus a 5 hour walk to a village by the name of San Juan Atitán. The main problem with the second option is that it would have involved at least 3 hours of bus/car transportation to return to Todos Santos.

Rigoberto met up with Josh, Melissa, Chris, and Mariah at 7am and we took a bus for about 30 minutes back toward Huehue (Todos Santos sits in a valley at around 8500 feet). We stopped at a small village called “La Ventosa” which is about 10,800 feet (for comparison, the peak of Mount Hood is 11,250 feet) and started upward, instantly feeling the altitude effects. Rigoberto and Josh (aka La Cabra, the goat) seemed to be immune to altitude.

Josh comparing height with Juanita

After about two hours we reached the summit, looking out over cloud covered lands below us, and enjoying the sunshine. La Torre is about 1,000 feet below the tallest peak in Central America, which is Tajumulco (13,845 feet), a volcano we could see from the where we were resting. After an hour or so at the top, we asked Rigoberto to bring us down an alternate route to a place called “La Maceta”. This turned out to be an amazing walk down a steep (3,000 foot descent) trail through canyons and along creek beds.

View of the "Chuj" (Sauna)

Suzy and Rosalicia spent the day in Todos Santos, having a little down time. Suzy of course has been our constant activities director and trip coordinator. They both went to a chub ("choo" = sauna) which is a small enclosed area (like the back of a pickup truck with a top installed) with a coal fire, and heated rocks that you can pour water on. They both had a good sweat and a good rest.

We all met back up at our hotel, said goodbye to Santiaga (the owner of the hotel/cooperative shop, and to Isabela and Juanita (see the photo with Josh) who were the hotel staff. From Todos Santos to Santa Eulalia is about 2-3 hours, made difficult by the potholes, but also the neblina (fog) that descends on the antiplano in the late afternoon. We sand and told stories in our two trucks as we made our way to Santa Eulalia with some staff from PCI including Paulina, a nurse, and Yasmin, a coordinator. We also discovered another spirit animal, Mariah La Tortuga (tortoise).

Todos Santos

View of the Altiplano

Saturday! We got up this morning and had a wonderful breakfast of eggs, beans, and tortillas from Abesaida before packing up our things and walking to the bus station. Next week we are scheduled to spend Monday and Tuesday in Santa Eulalia (ay-oo-la-lee-uh), a town which is along the same road as San Juan Ixcoy (up and over the altiplano). We had decided to spend the weekend in Todos Santos Cuchumatán, then travel from there to Santa Eulalia.

Todos Santos from Above

Anyone who has traveled in Central America that taking a bus from A to B is never as simple as Uber. You go to the “terminal” which is a largish area with many buses and drivers and vendors going all which ways, then you ask at least 5 people where is the bus to the place you are going, and cross fingers that it didn’t just leave or is more than a few hours wait. Today we got lucky and got on board the mini-bus to Todos Santos, an amazing community nestled in a valley coming from the Altiplano.

Men of Todos Santos surveying the town square

Todos Santos Cuchumatán (the Cuchumatánes is the mountain range of the altiplano) is a community with a very strong self identity and bond that not all cities in Guatemala share. All of the men wear a very specific outfit with red pants, striped coat, a straw hat, and sometimes black chaps. The women have an outfit that often includes the hat, along with the traditional huipil (wee-peel, which is the top), the corte (a length of fabric which forms the skirt), and the cinta (seen-ta) belt. Mam is the predominant language, although most people speak a mix of Spanish and Mam.

Cemetery in Todos Santos

The real goal of the weekend was to get out of the city and come to a town and do some hiking. We managed to take a very long hike above and around the city, traveling though old Mayan ruins and stopping at a cemetery. Everyone we met along the way wished us a good afternoon, often in a sing-songy “buenas taaaardes”. Finally, we had dinner at our small hotel and met with our guide Rigoberto for our intended hike tomorrow.

We also met a few women weaving traditional Mayan cloth who were super nice and let us take a picture.

ALSO Course, Friday 14 de Octubre

Christina having an eclamptic seizure

ALSO is a course, akin to CPR training that family physicians who practice obstetrics are advised to take every 2-3 years. The goal of the course is to learn a systematic approach when emergency situations happen, such as a mom having a hemorrhage after the baby is delivered, or a baby’s shoulder getting stuck. In these situations, every second counts and needs to be spent in resolving the emergency.

Friday we held our fourth annual mini-ALSO course at a hotel in Huehue (way-way). The people who attended the class were nurses, internos (6th year medical students), quintos (5th year medical students), and OB/GYN residents, along with their chief resident and two of their residency faculty, Dr. Cano and Figueroa.

We assured them in the beginning that we were indeed intelligent people despite speaking Spanish like kindergartners and launched into the course. Chris led off with 3rd trimester bleeding while Josh dressed in drag as the bleeding mom. Rosalicia then spoke about preeclampsia while Chris played the preeclamptic then eclamptic mother who had a large seizure, much to the entertainment of everyone.

Suzy demonstrating the breast pump

What came next was three very short lectures with hands-on workshops using the pelvic models we brought with us. Melissa started with shoulder dystocia (shoulder getting stuck in the birth canal), then Josh who spoke about delivering a baby who is unexpectedly breech, then Mariah, who focused on postpartum hemorrhage. Probably the most entertaining part was when Josh (speaking in Spanish) asked the group, “What do you do when a woman comes along with her butt hanging out?”. The intended question was to ask them about how they manage a baby who is coming out breech.

After the ALSO course, we managed to jump unawares into a political quagmire. In 2016, 72 women died in the Department of Huehuetenango in pregnancy. Likely there will be more this year. The largest reason was hemorrhage, followed by preeclampsia, followed by infection. 90% of babies are delivered outside the hospital by midwives in communities that are hours from the National Hospital in Huehuetenango. Lay midwives are prohibited by law in Guatemala from dispensing medication despite the World Health Organization advising that Misoprostol can be given by non-medical providers. Our idea prior to coming was to make Misoprostol (the only oral medication that can help stop acute bleeding after delivery) more available to rural health stations and we brought a couple hundred tablets. Turns out that that option is also has some serious bureaucratic barriers as well. After meeting with the head of maternal child health in Huehuetenango, we made an agreement with the doctor to leave the Misoprostol tablets with her and she would try to advance the proposal.

At the end of the day, we found the perfect way to spend night with Manuel Saenz, a friend of Suzy who is an artist and has a flat in downtown Huehue. Mariah bought a painting, and we all had the chance to share with someone who has a deep love for his country and a broader awareness of the world.

San Juan Ixcoy

Thursday was a challenging day in many respects. We were scheduled to do consultas and ultrasounds in San Juan Ixcoy (pronounced eesh-coy). First off, we all got up at 5 and met our drivers, Henry and Josue to make the 2 hour trip. Heading north from Huehuetenango you hit a very windy road with lots of switchbacks that takes you to the top of the altiplano (highlands), about 10,000 feet. We lost track of the potholes after the first thousand. After a brief stop for coffee, we got to San Juan Ixcoy around 9am.

We arrived at the "capacitación" which is the local clinic/mini hospital to find about 200 people waiting, and 50 or so hoping to have ultrasounds. There was a little disappointment when we said that 20-25 ultrasounds was probably all we could do but we got down to business fairly quickly and divided into teams. Melissa and Josh did consultas, while Chris, Rosalicia, and Mariah did a combination of consultas and ultrasounds. 

The patients themselves were lovely as usual. Most spoke Spanish, but some spoke Mam (pronounced "mom") and others Q'anjob'al (con-ho-ball). Of course our consultas were fairly limited without xray or labs (we could do urinalysis and pregnancy tests), but we had brought out own pharmacy thanks to the Providence pharmacy team and Debi Farr who supplied us with antibiotics and an assortment of other medicines. I suppose since we are doing shoutouts, we should say a huge THANK YOU to Sonosite for loaning us a very nice portable ultrasound machine that we brought with us.

We finished up around 4 but as our luck would have it, one of our pickups began to have some clutch problems on the road winding up and over the altiplano which slowed us down so we didn't get back until 7:30 or so to our host family. The night was spent preparing for a teaching session on Friday with medical students on obstetrical emergencies.

Feria de la Salud

In case you thought our trip to Guatemala was all fun and games, there is actually a reason we did not  post yesterday. For the past two days we worked at the Casa Materna in a Feria de la Salud (Health Fair). As you can see in the poster (of Melissa) we were seeing pregnant patients for prenatal consults, obstetrical ultrasounds, consults for pediatrics and general women's health. A "consulta" basically translates as a doctor visit to ask medical questions. Luckily our kind and competent colleague Dagmar "la Cubana" helped us with PAP tests, so la Flaminga Negra happily passed her PAP queen crown on to Dagmar.  Every one we meet wants to know "Donde esta El Loro, Dr. Gobbo?"  Pues Donde Beto??



Tuesday, we all worked in the Feria de Salud. On Wednesday, while Chris, Josh, and Melissa saw patients at Casa Materna, Rosalicia and Mariah were trailblazer residents, stepping Providence feet into the National Hospital. They were paired up with a nice resident, and got to see how birth is managed in a hospital with few resources, with as many as 16 vaginal births and 12 cesareans in a 4 hour period.







As is generally the case, the first day of the Feria was a cluster $#%$. In the morning as patients filled the front entry hall and spilled out the door. Gracias a Dios for the help of everyone at Casa Materna and the Rafael Landivar nursing students.







Last night we met with the Minister of Health of Huehuetenango, as well as Pascale and Bal Maria, the respective heads of PCI Guatemala and PCI Huehuetenango.  He approved placing misoprostol in remote rural health outposts, which is a step forward toward reducing the maternal death rate.  Tomorrow we head to San Juan Ixcoy for the first of our rural health clinics.