Last days in Guatemala (Los Ultimos Dias in Guatemala)

Last days in Guatemala (Los Ultimos Dias in Guatemala)
Bueno! Hello!

Nestor and Antonio going all out.

Gladys conducting Patient Counseling Dimanica

Well, our team has had an incredible experience these past two weeks in this beautiful country. Yesterday morning we concluded the week-long training session with 2 sessions before the participants took their final exam. One was a brilliant dinaminca Glady Ramirez of MTI presented covering "Patient Counseling" or "Consejerîa".
 
Then our teamed focused on Faculty development and presented a very lively workshop on adult based learning, giving feedback especially to different types of learners. We used some of the same concepts that is presented during the ALSO Instructors course and restyled it to the AEIPI/IMCI course. Since all 9 of our participants will be teaching the same course over the course of the next few weeks before they learn the 2nd module, we wanted to help them develop their teaching skills. Culturally, we noted that it is particularly difficult for them to give negative or constructive feedback. So we emphasized the "Feedback Sandwich" technique and had them practice this in small groups. It was particularly enlightening that I encouraged them to use the same paradigm to evaluate our teaching as well. The session was a blast and of course filled with dînamincas, dancing, laughter and hugs.

Dr Chavez being with two challenging learners - the unprepared and the bored., as Laurie prepares to give feedback too.

Teaching the teachers.

Carrie Schonwald presented each participant with gifts and Providence St. Joseph as we gave affirmations, hugs and blessings and then we did our final dance! A group Salsa extravaganza!

This team of Guatemalan Doctors and Nurses will be teaching weekly the same material over the next 4 weeks to 40 doctors and nurses. We know they will be awesome!




Knowing our work was done for this week,  we hoped on a microbus and settled into the 7 hour ride to Antigua to meet the service team that had left that morning. We felt content and pretty happy, so the music was turned up and we sang Bob Marley and Bon Jovi songs together as the bus descended the mountains towards the main highway.

We arrived in Antigua later in the evening about 7:30 pm, had a lovely dinner and then of course, went Salsa Dancing. This time we did not get lost and the band was actually playing when we entered La Palmas Bar at 9:30 am.

Biance, Laurie and "Ki-Le" salsa'ing away.

Saturday am we all visited an extraordinary place in Antigua called Las Obras! It is a new and beautiful facility dedicated to the care of children and adults with developmental and physical disabilities. I was struck with how well the residents are loved and cared for. While many of us had very different and even contrasting experiences, the one that resonated for me was one of being inspired. One of the poorest countries in the Americas has built a place centered on love and respect for our most vulnerable brothers and sisters, certainly we in North America can learn and follow this example.

Two of the Buildings of the Campus

The rest of the day in Antigua, our group split up into small pairs and triplets and took in the beauty and clamor of this beautiful colonial old capital of Guatemala. We are meeting for dinner soon and then its lights out for an early morning departure back to the US.

We all are so appreciative to Providence Health, Project Concern and Medical Teams International for giving us all this opportunity these past two weeks. We thank our families and colleagues back home for all they have been doing so we could be here. We mostly want to express our gratitude to all the people of the communities of Huehuetenango, San Antonio de Huista, Santa Eulalia and of Uspantan and Chicaman in Quiche, Guatemala.

Until Next Time, Our hearts, minds and spirit is with you. Amor y Hasta Luego  a todos.

Robert Gobbo M.D. (El Loro Verde)

Day 4 in Quiche. Observation and Retroalimintation.

Dana Gersten, Laurie Davis, Lisa Arnold, Biance Fernandez, Carrie Schonwald and I had another very cool day here in Guatemala. Here are three of our perspectives.

Dana: I went to the Puesto de Salud en San Sabastian this morning with Gladys, Antonio and Miceala after a beautiful hour-long truck ride from Chicaman. They were wonderful and so were the patients we saw. However, I think am getting an intestinal "issue" and need to take care of that. Sorry! More tomorrow.

Laurie: Our clinic day finally arrived and I got to go to the ‘CAP’ or the main clinic for Chicaman.  The clinic paint was peeling, and the medical equipment reduced to the bare essentials.  Even washing hands between patients became a significant obstacle because the clinic’s one sink was located in the only clinic bathroom.  Oh, and of course there was no soap for this sink.  But despite all these physical obstacles the care provided was par excellence.  Each patient we saw, from the mother of nine children who presented with breastfeeding problems to the 15 year old pregnant patient with unknown dates were treated with empathy, professionalism, kindness and love.  I don’t think I have ever had a day with so many kisses and hugs from both the clinic staff and our classmates.  Tomorrow our grand adventure comes to a close and with tears in our eyes and Quetzals burning a hole in our pockets we will hit the road to Antiqua to check out the local hot spots and bring this grand adventure to an end.   

Lisa and Bob: We arrived this morning at the hospital in Uspantan to observe prenatal visits and births attended by 4 of our participants. We were to document if the elements of risk assessment and classification paradigm we introduced during the workshops were put into practice clinically and provide feedback to our colleagues. We were also taken on a tour of the facility by Dr. Cristobal! Pictured are some awesome posters that were on the hallway walls. Can't wake to make copies and post em around hood river! 

We gathered all together in the afternoon to provide feedback, or "Retroalimentacion" (which now is a word we say frequently in many different American accents in order to continue to chuckle) that was preceded by another dance session - this time Cumbia...which I don't really understand but is pretty hip-swinging.

We will be soon going to a dinner later tonight that Medical Teams International provided our two Providence Service teams. Tomorrow we will provide a faculty development session on small group teaching and providing feedback. Then it’s off to Antigua for some fun.

One more entry by the team to come. Thanks for reading and we know we could not be here without all of our colleagues, partners, family and friends caring for our practices, families and pets back home.

Hasta Luego.

Roberto Gobbo “El Loro”

Day 3 in Chicaman/Uspantan. Neonatal Resuscitation and the Golden Stethoscope Award.

Day 3 in Chicaman/Uspantan. Neonatal Resuscitation and the Golden Stethoscope Award.

Dana, Lisa and Bianca teaching the steps and cadence of 1-2-Breath

Notice the bag and mask!

 Today was another great day, filled with the resuscitation of many infant mannequins.  We started with a review of yesterday’s content, and then moved on to the subject of the day: helping babies breathe!  Dana asked all of the students to close their eyes, and for each of them to imagine that she (or he) was the attendant at a birth, and because she had the skills to resuscitate a newborn, the baby survived.

Dr. Abel & baby skin to skin

We talked about how they prepare for each birth in the places they work -: gathering equipment and identifying a space and a helper in case a resuscitation is necessary.  We practiced caring for babies during “The Golden Minute” – keeping them warm and making sure that they are breathing - if not, we start ventilation by the end of that first golden minute after birth.

After a mid-morning “light snack” of café con leche, platanos  maduros fritos AND tostados with chicken(!), the lovely Roberta returned for her final performance of the trip.  This time the poor women had a shoulder dystocia – resolved with the Gaskin Maneuver – AND her infant wasn’t breathing at birth, so Dana led a successful resuscitation with assistance from the group.  Then we taught the waltz. 

Now it was time to put it all together

No, really.  It turns out that the triple meter timing of the waltz can help us to time the “breaths” given to a newborn baby who isn’t breathing.  We count: 1-2-3, and give the baby a breath each time we count “1”, which results in about 40 breaths per minute – perfect!  Bob even downloaded the famous blue danube waltz, and together with our students we counted 1-2-3 as we swirled around our salon.  With the strains of the blue danube still in our heads, we practiced with the ambu bags, squeezing the bag on “1” and watching for the baby’s chest to rise.   

Neonatal Resuscitation La Liga Match - Barca vs. Real Madrid.

Everyone took turns working through different resuscitation scenarios – sometimes the baby started to breathe soon after birth, other times the baby required chest compressions and/or many long minutes of ventilation.

We employed a game of our own invention – el bebe caliente (the hot baby) – to select “volunteers” to bring to life the scenarios that our very creative Bob Gobbo had written for his actors/students.  One patient had a postpartum hemorrhage and a baby that needed extensive resuscitation – 2 simultaneous emergencies that required multiple additional assistants to join the initial delivery team. Another patient had a stillbirth, and gave us the opportunity to discuss how to best support the woman and her family when this happens. Yet another had her baby in a “tuk tuk”, and carried her limp baby into the hospital, with the umbilical cord still hanging from beneath her dress.  The students blew us away – not just with their resuscitation abilities, but with the enthusiasm they brought to their roles.

We ended the day with the much-anticipated selection of the recipient of the golden stethoscope award for best acting. The winner was determined by the volume of group applause, and the candidates were all so talented that we needed to select the top two to receive “tie-breaker applause”. In the end, the very deserving Veronika narrowly defeated her colleague Dr Mario Lopez, and accepted the coveted prize. (Picture not yet available)

Tomorrow, we head out into the field to evaluate our students on the job.  Lisa and Bob will be at the hospital in Uspantan, Laurie will be at the CAP in Chicaman, and Dana will take the long drive to the San Sebastian health post.  We can’t wait to see these brilliant nurses and doctors putting their talleres to work!

Hasta Manana.

Lisa “La Colibri” Arnold.

Day 2: Risk Assessment at Birth and Essential Newborn Care

Day 2: Risk Assessment at Birth and Essential Newborn Care

Laurie with the Stethocope D'Oro

  Our team today conducted our 2nd day in Chicaman/Uspantsan teaching and learning from our medical and nursing colleagues.. Besides a fantastic playlist of music the material focused on patient risk assessment using the AIEPI classification framework (red-yellow-green) for women presenting in labor and then shifted to care of the newborn immediately after delivery, the first 90 minutes and “warning or danger signs”. 

High Risk Pregnancy "Lisa" presenting in labor with a breech baby

Lisa and Dana led the intrapartum risk assessment piece with both a lively discussion and then role play with each of them role playing a high risk pregnancy with participant. 

Dana being evalauted by Dr Mario for Pre-Eclampsia

It was done in Dinamica style with the canasta caliente (hot basket) to music of Ricardo Arhona (Guatemala’s own singer songwriter extraordinaire) All of the participants did well in their care of these high risk women!

The rest of the day focused on care of the newborn care. Dana told aa somber story of an infant who could not be resuscitation due to lack of attention. We reviewed Guatemala mortality statistics and stressed that over 60% of under 5-year old mortality is due to newborns who die in the first 28 days of life. Child mortality reduction must focus on care of the newborn, especially in the first 48 hours of life

My Helpful Translating Partner Kyle of MTI

After each did a simulated birth: the training manual focused our teaching on the steps of essential newborn care – drying infant, placing skin to skin, delayed cord clamping and supporting initiation of breast feeding. It was wonderful to see how the participants already are valuing and universally adopting these practices which only in the past 5 years have been common and recommended practice in the US.

After another playful dinåminica featuring the music of Bruce Springsteen (Born in the USA of course) and the hot cabbage, we moved into the next 90 minutes of attention to the infant, the importance of the maintaining skin-to-skin contact and monitoring. This was done in small groups of two with one instructor and some very helpful translators in Kyle, Gia, Carrie and Bianca. 

Lisa and Dana did get yet another dance lesson, this time another salsa dance that included the wave to the tune of El Pescador by Los Lobos. Everyone with swinging hips and moving to “el ritmo”.

Dr. Cristobal as a "Mom"needing to provide additional skin-to-skin time for her baby's low temp

The last sessions of the day focused on warning signs of ill newborns and treatment strategies based on risk stratification. We finished with a group “sick infant lottery” to the Rolling Stones “Paint it Black”. 

All participants randomly selected a “case” from the basket if the music again stopped in their hand. Each was given the information of the infant’s condition and then discussed their diagnosis, risk assessment and treatment plan with us.

The Canasta Caliente and Efra Michaela with her newborn ill infant

We finished the afternoon on schedule and posed for this group photo on the roof of the hotel. We have gotten to know these very intelligent, committed, thoughtful and funny health care workers these past two days and admirer them greatly. Tomorrow we will focus on neonatal resuscitation and appreciate Providence lending us their infant model, bags and  masks to teach help teach these techniques.

We are very grateful for this wonderful opportunity PHI and MTI have provided us. Now its time to get some sleep.

Sueños Dulce – Sweet Dreams

Roberto “El Loro” Gobbo

Primer Dia de AEIPI en Chicaman/Uspantan - First day of the Infant and Maternal Course in Qiuche Guaemala

Primer Dia de AEIPI en Chicaman/Uspantan - First day of the Infant and Maternal Course in Qiuche Guatemala

Chicaman Sunrise

Monday was a day that our team had been studying and preparing for several months. Providence and its partner Medical Team’s International had been asked by the medical community to resume teaching a World Health Organization Course that had been previously been provided in Guatemala until about 8 years ago to due lack of government funding. This had been preceded by over 2 years of study since Providence Health International made its commitment to provide expertise and resources to Guatemala and specifically this region or department Quiche and the communities of Chicaman and Uspåntan. 

Workshop emphasizing AIEPI Strategy

The mortality statistics for Guatemala are that 15/1000 newborns die in the first year of life. The maternal mortality rate, although much improved over the past decade, is still quite high among rural indigenous women. The AEIPI (Spanish acronym for Atencion Integradas en la Enfermadades de Prevalentes in la Infancia - translated in English as IMCI –Infant and Maternal Care Integration) is a course for medical and nursing professionals that is taught in a series of 3-4 day modules. Each module has a specific focus and more facilitated than taught in keeping with principles of adult based and popular education. The first few days are the workshops and the next 1-2 are direct observation. Emphasis is placed on providing preventative care and acute care within frameworks designed to help health workers recognize the risk level after conducting a patient evaluation and then strategizing the risk as Red (high), Yellow (Intemediate) and Green (Low). Treatment and follow-up plans are then outlined for the provider in the format of colorful charts and templated registration forms.

At the Papelogråfelo

Glady Ramirez participating

If this sounds a bit complicated don’t feel troubled, it was a bit overwhelming to us initially, especially trying to do this in Spanish and coordinating the information in 3 different manuals in each language. Furthermore, the facilitator must to their best to draw out the participants in an active and participatory way, avoid Powerpoint and make the experience positive and fun. I can say that I could not have a better team to do this with. Lisa Arnold, Laurie Davis, Dana Gersten, Carrie Schonwald, our interpreter Bianca Fernandez and I were up to the task! Much of the course introduction is about the AIEPI strategy which is based on principle of social justice, addressing social determinants of health and placing high value on health care as a human right. It is very beautifully written yet can be a bit difficult to communicate effectively. 

However, in order to enliven and personalize the content and experience, we used several popular education techniques we have learned from our own community health workers in Hood River. The Hot Cabbage (Repollo Caliente), the Hot Basket (Canasta Caliente), Sociodramas (involved a returning very odd looking pregnant character) were blended into the day and a few more were added of our own creations Doctor’s Hot Seat (Asiento de Medico) and Salsa Dancing. Pre-test, Reading the syllabus and completing assignments in worksheets, group discussion, Flipcharts, reading and role play remained the mainstays of the course.

When our team arrived at the salon upstairs in a restaurant in Uspantan, we were greeted by Gladys Ramirez RN and Walter Lopez M.D. who are the key individuals from Medical Teams International and have taught this course many times before in Guatemala before 2010. After introductions to the course of the 8 participants of physicians and nurses, who will become trainers after completing the modules for other clinicians in Guatemala.

We had an amazing day. The participants were engaged, patient with our process, pronunciation and seemed to really get into the dînamicas (role plays, games and dancing). Many were quite experienced physicians and nursing with over 20 years of caring for the people of this area and gave their time to be with us, many had office hours later in the evening as well. Pictured are scenes for the day. Our team took some time at the end of our day for a brief reflection on gratitude for the day, and later that evening we were provided almost immediate feedback by Gladys on our teaching, facilitating and organization.

Dana painting the "Oscar"

We were told “Thumbs Up” even though we knew they were being super kind to us as well. A short stroll up to a church on hill near our hotel provided a nice back-drop for a group photo. The primary Providence Team completed their community service project in the community building latrines for individual families. We shared dinner with these hardworking nurses and employees of Providence/St. Joseph and then went back to work reviewing our curriculum for the next day which will be covering Labor risk assessment and essential newborn care.

Dana took on the job of painting a “donated” stethoscope gold to be awarded to the best play acting by a participant at the end of the week. We consider it our “Oscar”. Too tired to write more now but “hasta mañana”

Bob “El Loro Verde” Gobbo

Dias de Capitaciones en Santa Eulalia y Regressomas Al Capital

Morning in Santa Eulalia

Obstetrical Teaching and Workshops with the Midwives of Santa Eulalia and Nurses of the CAP

Lisa Arnold and Dana Gersten have been wonderful colleagues and teachers (not just of things medical but dancing and keeping  "el ritmo" going on this journey. 

Lisa graciously volunteers to author this blog of Santa Eulalia and our meeting with Bal Maria. 

Iglesia S Eulalia

We woke in Santa Eulalia to blue skies and sunshine, and enjoyed the view of the hills from the roof of our hotel before heading to the salon to share our capitaciones.  When we arrived, the room was already filled with many of the comadronas (local midwives) we had come to meet.  They were dressed in traditional brightly colored cortes (skirts) and fajas (sash-like belts), 40-50 brave women who ‘hold the space’ for the laboring women in their care. Bob reprised his now-legendary role as “Roberta”, the pregnant patient who has an ataque (seizure) during her labor, and then we split into groups to deliver workshops on postpartum hemorrhage, shoulder dystocia, essential neonatal care, and complications of pregnancy.  

RN Freddy teaching about placenta remnants causing bleeding

Nurses practicing neonatal ventilation

The language of this region is Q’anjob’al, and many of the comadronas speak very little Spanish.  Thanks to Dana’s language sleuthing skills, we were able to begin our session with a tradition greeting of ‘txajin’ to which they replied to us ‘cai tu’, accompanied by smiles and nods.   

The wonderful nurses from the Santa Eulalia CAP translated our words from Spanish to Q’anjob’al during our workshops.  The comedrones began and ended the session with a prayer; we bowed our heads together – the comedrones, the nurses from the CAP, the staff from casa maternal, and the three of us who had been so warmly welcomed into this exchange of information. 

  We were all moved by the sense of community and common purpose shared by people of many different backgrounds and languages, all working together to support the women and families of this region. We shared a meal together before the comadronas left for their sometimes-long journeys home.  Every comedrone took the time to thank each of us with a heart-felt hug, a kiss on the cheek, or a hand taken in theirs and squeezed.  They are courageous and devoted women, for whom we feel such respect and admiration. Part 2 of the capitaci ones was for the nurses and medical students.

After just delivering Roberta's Baby, Dana helps lead the discussion as Lisa provides respiratory support

This time, poor “Roberta” had the misfortune of a shoulder dystocia while delivering her infant, who did not breathe at delivery and needed neonatal resuscitation, demonstrated by Lisa and Dana.  Fortunately, the resuscitation was successful, and we are happy to report that Roberta and her baby are both doing well. We then repeated our workshops, and sat down with the nurses and students for lunch, before making the windy trip back to Huehue.  

We shared a meal of delicious Abesiada – prepared chile rellenos with our host family, accompanied by much conversation and laughter.  The next morning, we met with Balmaria and the casa maternal team for breakfast, sharing our unforgettable experiences of the past few days and hearing about the far-reaching impact of PCI in improving the lives of women and families in these communities.

Bal Maria and Dali of PCI

On Friday we shared our final hugs for the trip with Abesaida and her family, feeling deeply moved  - yes, there may have been a few tears - by the welcome she had extended in opening her home and her family to us. 

We rode a very comfortable bus back to Guatemala City, and enjoyed a luxurious evening of dinner and salsa dancing.   

Ronald was NO Help!

We had a little trouble finding the perfect place to get our dance on, and had to stop once or twice to ask for directions. 

Salsa Dancing Lisa and Dan (I am solo) at Cadeleria in Zona 10

Ronald McDonald was not particularly helpful, but we did find two young law students who told us that the destination we had in mind was ‘feo’, extremely far from our current location, and who were kind enough to drive us to a better ‘dicso’, where we waited 2 hours for the live salsa band to start.  

It was worth the wait, however, and all three of us danced until we dropped, quite literally, into bed at around 2am.  

Tomorrow, we will venture out on part 2 of our Guatemalan adventure, joining the rest of the PCI team for the ride to Chicaman, where we will provide training sessions for nurses and doctors in the region.  If it fills our hearts the way this first week has, we may not fit on the plane!  Sending some of the love we have shared to each of you, thank you for reading!

Lisa Arnold - renamed by the Lopez-Guerrero familia and my co-workers Bob and Dana as  "La Colibrí Brilliante" (The brilliant hummingbird)