If I had ten million dollars

On Wednesday, we had a chance to meet with a fellow named Salvador Baltizón, a physician working for Project Concern International who is currently tasked with writing a grant. USAID has apparently offered $10-25m in aid to focus on improving health in Huehuetenango and Quiché departments. He essentially posed the question, “what would we do if we had millions of dollars to spend to try and improve the health and well being of the people in western Guatemala”.

The question is not a simple as it seems. Huehuetenango alone is a region with nine different languages (including Spanish), two hospitals (Huehue and Barillas 6 hours away), 2 CAIMIs (health centers that can do cesareans when staffing is present), several CAPs (like Santa Eulalia and Jacaltenango - mini health centers that can do vaginal deliveries) and dozens of Puestos de Salud (Health Outposts that can do very basic medical care). There is about one physician per 10,000 people and poverty can be overwhelming. The makeshift road network connecting cities and remote villages is sketchy at best. 

Popti speaking comadronas in Jacaltenango

We did not see only barriers to improving health. Cell phone service is not bad (even in remote villages), and internet with wireless access is becoming more available. There is a hospital in the Quiché department with a similarly modeled “Casa Materna” that actually inside the hospital and patients can deliver without needing to leave the Casa. There are often visiting medical teams offering periodic opportunities for medical and surgical treatment. 

Our vision, along with Casa Materna, has always been to make pregnancy and birth safer, and to empower midwives and women with choosing when and where and how to have their births when possible. To that end, we allowed ourselves a little dreaming. A dream of having contraception readily available (which it mostly is). A dream of local midwives with a standardized training in managing birth emergencies and readily equipped to initiate treatment when needed. A dream of readily available electronic communication for remote communities in order to be able to consult as needed. And for women with higher risk pregnancies, a dream of delivering inside of Casa Materna, with a midwife speaking her own language with the support and respect of the hospital medical team when intervention is needed.

Carly, the "muñeca pero en viva" (real life doll)

Dr. Baltizón brought us to think, almost like a child at Christmas time, what if we had enough resources to take a step forward in the vision of Casa Materna that every woman should have the opportunity of a safe pregnancy and birth within her cultural norms.

Chojzunil, a small remote town outside of Santa Eulalia

Nos Vemos

One of my favorite Spanish expressions, “nos vemos” literally means “we will see each other (again)” as opposed to “adios” which does not express a hope of a future meeting. On Friday morning, we met with the most of the PCI staff in Huehuetenango to have a breakfast and to say goodbye. One of the customs when you have a “reunión (meeting) is to have speeches with affectionate language, and this day was no exception. Bal Maria (PCI director in Huehue) spoke about her appreciation for the work we do in partnering with them. Our sense is that our partnership with PCI and Casa Materna continues to build and strengthen.

The staff of PCI prepared and served the meal which was excellent. We said goodbye to Bal Maria, our drivers (Danilo, Juan Carlos, Josue, Henry, & Roni), our nurse partners José & Yasmín, Dra. Susan, Dali, Vilma, and staff too numerous to count. And of course there was lots of photos, hugs, tears, and thanks. 

Breakfast at PCI Headquarters

We boarded the Los Halcones (Falcons) bus for the seven hour trip back to the capital where we arrived at our hotel and met up with Abesaida (our normal host in Huehue who was undergoing treatment in the capital.) We also met Arnoldo, Paty, Abesaida’s brother William and his wife, Paty’s friend Miku, and Natalia, a graduate from Landívar University, currently working as a hospitalist.

Jemie, Chris, Kristen, Karin, Miku, Arnoldo, Pablito, Carly, Suzy, Abesaida, Brenda, Paty, Conchis, and William

We spent a quiet night at Hotel Ciudad Vieja and had a second round of hugs and tears. We expressed our hopes for the future with the simple expression “nos vemos”.

Pablito celebrating his second birthday

My Dinner with Manuel

Thursday was a day of “Féria de Salud” (Health Fair) at Casa Materna. We divided up strategically: Chris working with Dra. Susan, Brenda working with Carly on ultrasounds, and Jemie & Kristen doing consults. Jemie had a patient with a congenital vascular growth in her thumb. We are currently trying to connect her with a team of traveling surgeons who can treat her in Huehuetenango.

8yo girl with a vascular malformation of the thumb

Brenda with one of Manuel's new kittens

That night we visited Manuel Saenz, a genteel Guatemalan man who is a wonderful host and entertainer. Not only did he share his newborn cats and give us a tour of his new home, but also showed us a slideshow of his recent trip to Asia, including Taiwan, Vietnam, Cambodia, and Thailand.

Interior of Manuel's home

Manuel sharing photos from his asian trip

COMADRONAS EN SANTA EULALIA

Hi! It's Brenda writing to you again.

 I would have to say, personally, this was the most gratifying day so far. Mostly because we (even those of us coming here for the first time to Santa Eulalia). have become friends with these most amazingly compassionate, caring, friendly and welcoming team of  nurse professionals, comadronas (lay midwives), and one physician.

We had the privilege of working with them the past 3 days (including that very fun soccer game on the last night!)What an absolutely incredible community, supporting these women who live in very remote areas (many whose family members walk/run hours to reach the CAP to ask for an ambulance and "enfermera profesional" - their equivalent of a very experienced and talented Nurse Practitioner to come out to  a home down a steep mountainside where there is a birth complication) in order to save someone's life.

Today we spent the morning at a very nice space at their small convention center in Santa Eulalia teaching a "Capacitacion" or training for the local comadronas.  We started the session with another dramatization of a birth followed by a postpartum hemorrhage (where I had the opportunity to star as the birthing then bleeding patient). Once again the comadrona saved the day when the Doctor Tonto could not figure out what to do for the bleeding.

Then, we began working mostly in small groups for stations to teach again about nutrition, danger signs of pregnancy, postpartum hemorrhage, breech delivery, shoulder dystocia, etc. We all felt comfortable in our teaching roles after having done this with the Jacaltenango community last week. We were all impressed with the 40+ group of comadronas (including 2 men comadrones!) who seemed very attentive and engaged -- practicing hands on skills, asking questions and sharing stories.  Many had years of experience (20-55years) while others were apprentices with 0-2 years.
We had a few interpreters to help us translate from Spanish to Q'anob'al, and some of the comadronas who were bilingual also helped.

In the end, we were generously thanked by many individuals' testimony of how they feel we have helped them and we were presented with a lovely handmade wall hanging personalized about our visit.


What a way to feel welcomed and appreciated !  I honestly can't wait to come again in the future.

--Brenda

Chojzunil

Over the last trips we have made an effort to reach out to smaller communities outside of larger towns. These smaller towns always have less resources and less access to health care than bigger communities. Today we traveled to Chojzunil (Cho - su - neal). It is 2 1/2 hour drive along a 20 mile road that at minimum requires four-wheel drive and a high clearance. The road winds east from Santa Eulalia through the Cuchumatanes mountains. Chojzunil has no pharmacy, no hotel, no internet access.

Chojzunil sits in the center of the photo atop a narrow ridge extending east.

The goals of today were to do "consultas" (medical visits) and ultrasounds. Most of the patients spoke only Q'anjob'al, although there were a few Spanish speaking patients as well. Sometimes a consulta is a nicely lobbed softball, fairly easy to diagnose and figure out a plan. Other times it feels as though there is no feasible solution. Carly had a young boy who has been having generalized seizures and developmental regression (losing physical and mental abilities he previously had). They had previously been prescribed an antiseizure medication but could not afford it. Getting to the capital for a pediatric neurology consult was beyond their means. We ended up creating a plan with the only anti-seizure medication we had, Phenobarbital.

friendly kids in town

Chris had two patients with a new diagnosis of diabetes. The first was a woman who is 58 and had gone from 105 pounds to 98 (not obese). Her glucose was 440, and we made plans to start insulin, only to realize later that insulin is difficult and expensive to purchase. The second patient had a blood glucose of 580, and probably had Diabetic Ketoacidosis (hyperventilation, tachycardia). We made arrangements to give her IV fluids, and transport her to Huehuetenango (5+ hours). the following day. Even so the patient and her family were very reluctant to go to the capital because of limited money, and a language/cultural barrier.

Ana is happy about getting reading glasses.

Brenda, Jemie, and Susan (doctor at Casa Materna) did ultrasounds while Kristen did consults and Suzy manned the pharmacy/lab with José Andrés. At about 11, Suzy, Kristen, Jemie, and Carlie met with a group of about 15 midwives for some pregnancy emergency training.

Carly and Jemie discussing postpartum hemorrhage with a comadrona

At the end of the day, we met up with several of the nurses from the CAP and played a game of fútbol. As if running wasn't enough by itself, Santa Eulalia sits at about 7500 feet and made it difficult to catch one's breath while playing. Nonetheless Jemie won the golden boot, while Carly played excellent defense while Chris and Kristen survived.

Post-football match

Yo amo a Santa Eulalia

Suzy here; I've been neglecting my blogging duties as I have been coordinating plans for the team, travel, supplies, meds, money, food, etc. I could resist no longer, because we are back to one of our favorite places, up in the beautiful and chilly mountains of the altiplano close to 10,000 feet in Santa Eulalia. I can't help but remember Melissa Paulissen, our pioneering resident when we began this residency trip 6 years ago. She was soooo happy up here and suggested that we keep coming back! The decision to return for this, now our 5th time, was easy to make.

Medicos de Canada visiting Santa Eulalia. José Andrés is second from right

We returned to the CAP today, this time to teach ultrasound again, as in Jacaltenango. They had also received an ultrasound machine from the Ministerio de Salud without any training. We were greeted by a sign advertising the Canadian doctor brigade, which we found amusing. Why not pretend to be from Canada and that we have a different president for a few days? Our nurse friend from the CAP, Jose Andrés, had set it up for us to have about a dozen pregnant women to get ultrasounds, and with 3 machines (2 that we brought and the 1 in the CAP), our team was able to train six or so care providers on the basics throughout the day without being overwhelmed or rushed. The personnel were interested, well organized and very quick to learn; also very appreciative which made it super gratifying! 

One of the nurses explains (in Q'anjob'al) her ultrasound while her spouse and comadrona watch.

Jemie imparting some ultrasound skills to Dr. Susan from Casa Materna

We also got treated to an awesome lunch by the municipality, and even received a visit from the Princesa Jolom Konob, (the Q'anjob'al word for Santa Eulalia) and of Xinabajul (the Mam word for Huehuetenango).

Chris meets the reigning Princesa Maya

Delivery room at the CAP in Santa Eulalia

My personal highlight for the day was delivering a soccer ball and pump that Kristen brought to the director of the school. All the children were in a field nearby today, because it is the "Día del Niño" and they got to play instead of go to school. When I went to meet the director I was swarmed by a sea of children, who all gathered around me and leaned their heads towards me; I was instructed that they were waiting for a blessing and I should touch their heads. I would touch them and they would then run away laughing. It was like a scene from Jesus Christ Superstar!  It made my heart sing.

Director of the nearby school (right)

Kids thanking us for the soccer ball

La Santa Susana, ha ha

Comadrona training in Jacaltenango

This is Kristen Jamsa blogging tonight from Casa del Mundo, a lovely spot on Lake Atitlan, where we are spending the weekend.  The past few days have been incredibly rich and varied.  Yesterday we started off with a full morning of training in Jacaltenango with a group of 29 local midwives, known here as comadronas.  As the lone midwife on our team, I was thrilled to be working with my sister comadronas in Guatemala, a group of hard working, under resourced and often unappreciated women.  Most of the comadronas in Guatemala speak only their regional Mayan language and have little or no formal education, yet they provide care for the majority of birthing mothers in rural Guatemala. They are hungry for knowledge,  adequate resources to provide for women in their communities, and respect for their profession. 

 We had 7 "training stations" set up in one large, cement floored space, each with a different educational topic-  warning signs in pregnancy and labor, nutrition, hemorrhage, shoulder dystocia, newborn resuscitation, breech delivery, and a "birth kit" station which I manned.  We provided a very simple bag containing some essential equipment needed for a birth to each midwife that attended.  My job was to explain the contents of the bags to the comadronas with the help of an interpreter.  The flashlights and digital thermometers were the big hits of my station.   Use of a digital thermometer seemed to be a new skill for all of the women, and they were fascinated by the beeping sound it made.  It was humbling to witness the outpouring of appreciation these women expressed at such a small offering on our part.   Their needs are so great and our ability to meet them so inadequate. 

comadona ice breaker

Yasmin explaining danger signs

Kristen birth kit station

After our morning with the comadronas, we loaded into the PCI trucks which have made our travels here so easy and comfortable and headed back into Huehue and then onto Lake Atitlan, about a 6 hour drive in total.  We spent a fun evening in Panahachel,  a morning at a nature reserve near the lake, and took a short boat ride across the lake to Jaibalito and Casa del Mundo, arguably one of the loveliest spots in Guatemala.   We continue to eat delicious foods, meet wonderfully kind and generous people, and marvel that such richness and abundant beauty can coexist with so much poverty.   

Sunset on Lago Atilán

San Andrés Huista

Poco a poco (in English: step by step) was the general theme for me today. On this trip we have had the opportunity to be trained on the use of ultrasounds by Chris and Brenda (two experienced family practitioners). For those who haven't used an ultrasound before, it can be quite difficult to figure out the gentle movements and nuances to the machine. Jemie and I, along with local practitioners, have been lucky to get one-on-one training over these last several days. It takes a lot of patience and guidance to get through each ultrasound as we discover discrete structures to bring into focus and measure. Ever so slowly, each of us have been gaining comfort with their instruction. This is of great benefit to us in our future practice, and for the local physicians to provide improved care to their patients.

Jemie doing ultrasound on a patient in San Andrés Huista

Today we traveled to San Andrés Huista, a beautiful town that seemed to appear out of nowhere amongst the forested mountainside. Upon our arrival, we were greeted by many pregnant women dressed in colorful traditional clothing, with toddlers hanging from their backs, while others ran and played. Most of the women spoke only Popti (see our language map below) and little Spanish. We were very dependent on our Spanish-Popti interpreters, although we did manage to learn a couple of words (girl = Ix 'eesh', boy = Winak 'wee-nahk'. Poco a poco we saw each woman; they were in various stages of pregnancy and for the majority of them it was the first/only ultrasound they would likely receive prior to delivery. Through these efforts, we diagnosed a missed spontaneous abortion, placenta previa, and helped confirm/change appropriate dates for delivery.

Our full team at the Puesto de Salud, including Dr. Dorian

While working in the capacity of a physician, you have the unique opportunity to get a glance into someone's life that you may not otherwise have. One such experience was when we offered contraception to a young woman who already had 2 children, that came in concerned she was pregnant again. She responded with, "I'll have to ask my husband," and quickly left. We later learned from the local physician and nurses that San Andrés Huista is an insular and patriarchal society, in which the husbands can choose if/when a women can receive medical care. Contraception is not permitted. Apparently one woman from the community died about a year ago from a postpartum hemorrhage after delivering her 14th child as she wasn't able to access appropriate medical care in time.

Women at the Puesto de Salud wearing their local traje (traditional outfit)

Poco a poco we make changes in our lives and the world around us.

Visiting Rio Azúl

On the way back to Jacaltenango, we crossed the Rio Azúl (Blue River), so called due to the calcium content from dissolved limestone upstream. It was amazing.

Jacaltenango

Jacaltenango is a city of about 40,000 people to the west of Huehuetenango. It is about a three hour drive along a road that passes less than a mile from the border with Mexico. Six years ago when we made our first trip, we met Dorian Rojas, a physician who has worked in Jacaltenango for the last 8 years at the CAP (clinic/hospital with 6 obstetrical beds for vaginal deliveries). He has managed to continue working at the CAP despite a period of 5 months without pay, and his boss being fired for arrogance and abuse of power. Today he is the medical director and has four physicians working with him. They were given an ultrasound machine eight months ago without any instruction. Today's mission was to work with Dorian and his partners on basic obstetrical ultrasound skills.

Suzy, Kristen, Dorian, Brenda, Carly, Jemie, Chris

We managed to leave Huehue a little after 6am and travel to Jacaltenango. Chris & Brenda focused primarily on working with the CAP physicians while Suzy & Kristen did some training with a group of comadronas (lay midwives). Jemie and Carly visited a couple of laboring women and did more ultrasounds as well. The day was partially hampered by lack of electricity, although fortunately the ultrasound machine loaned to us by Sonosite can operate on batteries as well. Jazmin, is a nurse who is working with PCI and joined us for the trip as well.

Yasmin, Carly, and Jemie demonstrating Ultrasound poses

A word on Guatemalan place names. When the Spaniards invaded Guatemala from Mexico in the 1520's they brought with them a lot of mercenary Nahuatl (Aztec) speaking soldiers and assigned place names in the form of [Nahuatl descriptive word]+[Nahuatl suffix]. Thus the Mayan city of Xinabahul became Huehuetenango (place of the ancients). Jacaltenango translates roughly as place of huts.

ULTRASONIDOS

As Jemie and Carly explored the hospital, Kristen, Chris and I saw patients at Casa Materna (CM).
Chris used our loaner portable sonosite "backpack" ultrasound while I became familiar with the (actually quite nice) ultrasound machine at Casa Materna that was donated from Japan, to scan pregnant women who came many hours to HueHuetenango from more remote areas, some of which were having their first ultrasound (and first visit of their pregnancy). Others had an earlier ultrasound but were approaching their due date and wanted to know if everything was "ok" (and if it was a boy or girl!)  I had a glitch or two (like how to clear the last person's info in order to scan a new patient - default is always "reboot" - so we turned the machine off and on again, and presto!) - but all in all pretty smooth of a start. When the ultrasound business slowed, we saw a "consulta" (primary care patient) or two. Mostly some aches and pains and urinary infections.
Kristen was busy doing women's health (pap smears, pelvics, removing some tough to get to nexplanon inserts ), and seeing children.

Suzy and Kristen had an opportunity to meet with some local midwives ("comadronas") in HueHue to discuss how they are working with women in the community - and Suzy (of course!) recognized one of 2 midwives she knew from 18yrs ago who she helped to get an education scholarship for (to attend an out of country conference)

The afternoon was filled with teaching ultrasound, by scanning the women who stay in Casa Materna, waiting to deliver in the following weeks.  I taught the local CM doctor, and one very cute and pregnant CM nurse Yasmin (who will be traveling with us this week to remote villages-- we would be all happy to attend her birth if it happened en route but we promised it would NOT) using the machine at Casa Materna.

Chris taught Jemie and Carly (using 2 different portable machines side by side in the same room--= such double tasking talent!)

...and tomorrow it is off to Jacaltanango! to work at the CAP with Dr Dorian.
Stay tuned!!

Sala de partos

Carly and Jemie (second year residents) were given the opportunity to observe four a few hours in the maternity unit at the National  Hospital in Huehuetenango next to Casa Materna.

We were greeted by Isaac, an OB resident, and given a short tour while waiting for deliveries. The floor is divided into three rooms: labor, delivery, and recovery for postpartum women. Additionally, there are operating rooms and a separate recovery room for Cesarean deliveries. Typically they have upward of 20+ vaginal and 10+ Cesarean deliveries in one day.

The labor room is a large open room with seven beds, full of many nurses and nursing students milling about. We learned about the admission and labor flow sheet that is used to document H&P data and to track progress of labor. The resident explained that many women present in labor without having had any prenatal care, so most of the routine labs are done on admission. Continuous fetal monitoring was not feasible as supplies were limited. We observed one resident using his stethoscope to check fetal heart tones. Women who are laboring towards vaginal deliveries do not get epidurals because there is not adequate anesthesia support, so only women going for c-section will get anesthesia. We watched several women progress to complete dilation before being wheeled into the delivery area.

In the delivery room, there were three stirrup beds. Women are placed in the stirrups and told to push.  We saw one woman who had a female family member with her, but no spouses were present. It appears to be expected that things progress very quickly at this point, and providers use fundal pressure maneuvers to push baby (including two men pushing with all their strength) down and primiparas frequently receive episiotomies. The three women we saw delivered within 3-15 minutes after arriving in the delivery area. After delivery, women are told to perform breast massage to stimulate oxytocin release, and intramuscular oxytocin is available as needed.

After delivery, women are transitioned quickly to the recovery room where they are observed for an additional 2 hours prior to returning to the maternity floor.

There is a heavy emphasis on medical education, as the students take a lead role in labor management, delivery, and episiotomy repairs with resident supervision; we did not see any faculty doctors. Medical school is six years long in Guatemala, and the students we observed were in their sixth year, so could be considered equivalent to first or second year residents in the US. 

Arrival

Estela

Things you can count on arriving by plane in Guatemala City:

- being hit by the humidity

- praying that the customs agents don't stop and search your bags

- Estela is waiting there to bring you to her hometel

Walking the streets of Anigua

Estela is a blessing for picking us up so reliably after a long day of travel. She runs a boarding house in central Antigua that has been a place where we can spend a transition day before heading to Huehuetenango and going to work. Travelers to Antigua will know it is one of the most beautiful cities in Central America with architecture dating back to the 1500s.

One ton float

Today we were treated to an enormous procesión (parade) through the center of town, celebrating 800 years of the Mercedarian order of priests. Iglesia de la Merced is a church founded by the Mercedarians in the 1700's that survives to this day. A few people we asked about the parade told us the church had been there 800 years, it did not add up that the Mayans living there would build a christian church. The centerpiece of the parade was a huge hand-carried float carried by more than 80 people and probably weighing more than 1500 pounds. Here is a link to an article in La Prensa about the parade.

Meeting with Pascal

Later in the day, we met with Pascal who is the head administrator of PCI in Guatemala, running hundreds of programs from Casa Materna to distributing food to tens of thousands of Guatemalan kids daily. We also met up with Amalia, who is an online Spanish teacher and also runs some donation projects with rural schools.

Ceiba tree, national tree of Guatemala

At the end of the day we got to explore Antigua on foot and made it to a place called Santo Domingo, an old convent previously left in ruins and now restored to a beautiful hotel and conference center. You can see the enourmous Ceiba tree growing in the central plaza.