Last Day in Chicaman and Hello to Semana Santa in Antigua Providence St. Joseph's Spring 2018

Providence St. Joseph's Spring 2018 Thursday and then Semana Santa in Antigua..

Head Nurses Porfirio and Amanada with data completed

On Thursday of this week, the Medical Team completed its final assessments at the hospital in Uspantan. 

There were plenty of ill children that met criteria for an assessment pre and post consultation. 

Mary observed the process in the waiting area and exam rooms, while the chief of nursing, Porfirio and I interviewed mothers with their infants before the left the hospital urgent care area. 

Traditional Midwives in meeting on Hospital Grounds

After completing our data collections, we were treated at the hospital to a visit with a group of traditional indigenous midwives.

The group of nearly 30 was having their monthly meeting on the hospital grounds. 

They have been an integral part of serving their community and providing a cultural bridge for the women sent to the hospital to labor or deliver with more complicated pregnancies and births. 

Medicinal Herb Garden

Nearly 90% of the deliveries still happen in the villages with many of these “comadronas” or midwives. They each are registered with the ministry of health, have regular trainings and even a quality review similar to the midwives we met 5 years ago in Todos Santos. What was more remarkable is that 2 “comadronas” are on site and employed by this hospital in Uspantan to help care for their people using traditional herbal remedies and treatments. Within the hospital courtyard sits a small structure with a few beds and even a sweat lodge that is used by these women. Pictured is one of the more experienced midwives with the head nurse, Porfirio. In addition, a traditional medicinal herb garden with plants used for all sorts of symptoms and conditions was well tended adjacent. It was heartwarming to witness the way the medical and nursing staff value the traditional caregivers contribution to the care at this small yet very bust hospital.

CAP (Centro Attencion Permanente) and Health Post teams.

Hospital Facility Assessment Team

At the conclusion we met separately for a feedback session with the hospital and clinic teams. We noticed that both groups of professionals were quite positive about completing the assessment and look forward to reviewing the data. 

Mary helping with data entry (maybe)

After identifying gaps, a process similar to what we are familiar with in continuous quality improvement (Plan-Do-Study-Act) will be initiated. Both Mary and I know that this is a first step, but were both impressed with the teams commitment to moving forward, even without significant government support. I encouraged all to keep at it, and that this type of work requires considering what can be done and a longer term cycle of planning and assessment. We hope we will continue to be able to provide whatever support we can provide.

After the conclusion of the feedback sessions, we and the Providence St. Joseph’s service team were treated to a goodbye dinner complete with a marimba band, dancing, traditional Guatemalan meal of Peppian and presentations by the MTI staff. It was a heartwarming and beautiful evening. The MTI staff of Walter, Gladys R and Gladis, Horacio, Ramon and Romeo are all amazing people, who are wonderful examples to us all of their love, commitment and service. 

We are all so grateful for their leadership and friendship. 

Horacio is proudly now a Timbers "Guerrero"

On early Friday morning, the teams packed it all up and left Chicaman for the 8 hour bus ride to Antigua with one of the world’s best “Pilote’s” Horacio. After many hair pin turns, ruts, steep climbs and descents, we were treated to a stop at Chichicastenango.

This is a community in the department of Quiche which boasts an rich Mayan spiritual tradition that is interwoven within Catholicism and not only welcomed but revered. Pictured in the flood of the church with is many stone tables replete with candles and offerings. A procession of Shaman entered the main square to visit the northern church structure, complete with drums, placards and statures signifying the beginning of Santa Semana or Holy Week.

The minibus arrived in Antigua in the early afternoon. The teams enjoyed not only the charm of this beautiful colonial city, but also the start of processions and excitement of this time of year.

The teams left early Sunday morning after sightseeing, a visit to Las Obras and a final reflection time with team leaders Gladys Rivera and Mark…… 

They left at 6 am Sunday morning but I am fortunate that I will be able to spend the week here with my partner, Kim, traveling in this amazing country and seeing some of its most beautiful and amazing places.

I hope to be back within the year, as Providence and MTI plan their next chapter in their story of working together to provide support to the communities in Chicaman and Uspantan, Guatemala.

Thank you for reading.

Bob Gobbo MD

Residency Director.

Providence Hood River Family Medicine Rural Residency Program

Mary's Blog

Mary's Blog: In Our Stories Live Love, Connection and Resiliency.

My amazing medical team partner Mary Zozoaya Monohan was working today with the health facilities assessment team at the CAP (essentially a small rural emergency department, obstetrical unit and clinic) in Chicaman while I was involved in the training the team at the Hospital in Uspantan. Here is her blog entry for today! Thanks Mary.

Today was filled with many of the things I most treasure in small moments in time. Being attentive to someone in need, problem solving when things don’t go as expected, family chipping in to help out and community with shared experiences.

I spent the day at the health center and will share stories from the day.

First, was a mother who came to the clinic with her young son and a niece. She had woken and found her undergarments were soiled with blood. She was 8 weeks pregnant. Despite the fear she must of felt she stayed calm and answered the multiple questions the obstetrician asked. It was determined she would need to travel to the hospital in Uspantan (about 30 minutes away in ambulance).  She was to be accompanied by someone. Her son and niece could not go with her but they were too young to go home alone. Her husband was working and her parents were not near. She called her mother-in-law, and although I could not hear the responses, the patients voice began to quiver, as every suggestion was not being met with a resounding yes. Family members were working and not available. Eventually, a distant relative was identified but it would take another 30 minutes before they arrived (1 person to accompany the children home and the other to accompany her to the hospital in another town). The fear was palpable, and she alone awaited transportation to the next level of care.

Secondly, was a grandmother, who was accompanying her pregnant daughter and grandson to the clinic. She was not coming for care but ended up needing to be seen. On their way, a dog had attacked them, she reported he was going for my grandson’s face, so she blocked the dog and had bites on both hands. They were penetrating and cleansed without any anesthetic and she simply grinned and grimaced and allowed the cleaning to occur. She was given antibiotics, some Tylenol and instructions for the wound care.

The third was a mother and grandmother we had observed sitting, waiting for test results. This 77 year old grandmother was having right upper quadrant abdominal pain. The tests were used to exclude appendicitis (looking for an elevated white blood cell count) but were incomplete in evaluating the liver disease some of the other tests alluded to. The health center had run out of the test strip and she had to go to the hospital to get the rest of the labs done. She was in extreme pain it was not till some of the labs came back that she was able to receive pain medicine. An injectable form of a pain medicine was given to her and oral medication as well, ‘to help with her suffering,’ the provider said.

As I review these stories, I think these seem like manageable issues. What isn’t included is the pot holes, and curves in the roads that this woman with abdominal pain would endure which would be difficult even with smooth roads. Having to travel to a place that is unknown, leaving your children and having to consider the possibility your pregnancy may not go on. Will the dogs that attacked the family on the way to the clinic be waiting on the return?

The strength, perseverance, humility I witnessed, reminded me that at our core we are united in our experience and human needs, community and connection is foundational and how important attentiveness, being fully present, is.

Mary Zozoaya Monohan FNP-BC/Nurse Coach - BC

Dia del Inspeciones! No somos JCAHO! Somos Uno!

Dia del Inspeciones!

The MTI teams of physicians, nurses, social workers and Mary and I began our day early. The 7 “modulos” evaluating the care at 2 Health Posts, 1 CAP (Centro de Atencion Permanente) and 1 Rural Hospital were set in place.

Modules 1 and 2 evaluated the care of 6 ill children at each site and included a post interview of the mother about the child’s condition and medication instructions.

Module CP evaluated the prenatal care provided, module 3 and 4 focused on the health care facility, supplies, medications, infrastructure, waste disposal and materials management. EmOnc modules 5 and 7 was select interview with maternity care providers.

Dr Antonio "consulta" child with a fever

Mary spent today and yesterday at the CAP and learned last evening that many of the forms were filled out incorrectly of the ill pediatric visits and a new batch of patients needed to be evaluated today. The MTI Coordinator nurse Gladys Ramirez and I went to the District Hospital in Uspantan and completed but all of one module today and will be back tomorrow to complete them.

The director of nursing and I went to each department documenting medication stocks, equipment, functional emergency generators and policies.  He shared with me that he was pleased to be part of a process he had not been able to do for his facility in the past 10 years.

Mary’s team at the CAP completed everything and had a great feedback session this evening. I did not know that Mary has extraordinary powers! It was a slow morning and I understand that  Mary did a little dance and prayer for more children and 5 more showed up one hour lately! Amazing!

Irma (photo above) and Faustino (left)
completing exit interviews at the CAP

In addition our “bruja de lluvia del ninos” (children rain witch) , I have been impressed how committed the group was in doing their best to complete the instruments accurately and were all excited to start this process of continual quality improvement.

Back at the MTI office in Chicaman this evening, the data is being inputted!

The results will be part of the plan for this community to identify what areas need attention but also to see the improvements since the instrument was last used in 2015.

Not sure if there were an new complaints placed back in the "Buzon de Quejas" about the process but we will check it tomorrow! :)

Dr Roberto

Formas, Flexibility and Fun:

Carlos, Mary, Gladys, Drs Bob and Walter.

Day 1: Today started with a demonstration (manifestacion en Espanol)   While the Providence St Joseph's MTI Service Team road off to a small village to begin constructing a water storage and filtration system an hour away from Chicamam, Mar, Dr Walter Lopez, Gladys Ramirez and I walked just a few blocks to the MTI office for our planned day of orienting the nurses, staff and physicians of the planned health facilities assessments this week. Earlier that morning the main roads into Chicaman form the south were blocked by a series of demonstrations protesting unsafe road conditions. Needless to say, Walter and Gladys quickly and calmly delayed the start and reorganized the training by instituting a Plan B, C and even D (as they say is always necessary in this beautiful country)

Dr Walter Lopez explaining the "PDSA" vision

So after a brief morning diversion hike, we re-started and met nurses Fausto, Andres, Rebecca, Clarita, Irma, and Lubien and dug right into the presentations by Walter and Gladys explaining the rational for the assessment, the results of the survey 3 years ago and the importance of continual process improvement. Mary and I did are best to enliven the process with our role playing, dinamicas and my mispronunciation of many Spanish palabras. Can you tell which one of us is role playing a pregnant lady in labor and another with an 8 month infant with a cough needing an examination.

The attention span of our colleagues was impressive as we reviewed in depth these 8 instruments that have been developed by US AID and the WHO. Tomorrow Mary will serve as an advisor of the assessment of the Health Care facility (known as the "CAP") in Chicaman, while Gladys and I meet with some of our old friends from last year at the hospital in Uspantan and repeat the training with them.

The service team also had an amazing day, but worked a heck of a lot harder than us, well at least physically, mixing cement, connected gutters and pipes and forming molds for the cistern and water system they are building at a village nearby known as San Antonio. This evening we were privileged to hear their stories of their work and the amazing community they visited.

Hasta Manana! Dr. Roberto

Making it back to Guatemala with Providence St. Joseph's!

Making it back to Guatemala with Providence St. Joseph's!

Our excellent "pilote" Horocio en techo del Autobus

A Providence St. Joseph's service team left early Saturday morning from the states to Guatemala. Mary Zozaya Monohon (Nurse Practictioner from Olympia, Washington) and I are the only two members of the medical team this time. We will miss the third member of our team Morgan Shier MD and our 2nd year resident at Providence Hood River Family Medicine Residency who was unable to travel. Our good healing thoughts are with you Morgan, get better so you can come the next time. We will be joining a team of 16 Providence St Joseph's and Swedish professionals to the same community.

Both teams will be traveling to Uspantan and Chicaman, Guatemala.  Mary and I will work with local doctors and nurses in a quality improvement project for their hospital and three health posts of clinics. The focus of our work will be to reassess different quality measures and processes for care to women and children in these facilities. We have been trained in using the assessment tools that were developed by USAID and will repeating an assessment done in 2015. Since that time, there have been many trainings and modules to address care provided to their community. The larger service team with be involved in developing a water purification system for a small village community.

After our arrival in Guatemala City we were whisked from the airport treated to a welcome dinner at the Hotel Ciudad Vieja with MTI staff Romeo and Horacio. We left early Sunday morning for the 7.5 hour bus ride to Chicaman. The main highway was quite a bit smoother than I remember but the nixt 5 hours though Chichicastenango, Santa Cruz del Quiche and finally Chicaman had more than a few hairpin turns on some gravel and dirt roads. However, our expert pilote, Horacio took the ups, downs and turns safely and expertly.

Selfie Infiniti of part of the Team

Upon settling into the Hotel Dona Julietta in Chicaman we stretched our legs a bit and took a walk to the little chapel on the hill before attending a dinner presentation by the MTI staff members Carlos, Romeo and Gladys. I was struck with the commitment, organization and progress MTI has made in the over 60 communities and thousands of families in this region. By improving sanitation, water supply and development of community leaders and resources, many diseases have already dropped and healthy practices dramatically improved.



During a question and answer session, one was posed by a member of our Providence St Joseph's team to the group was whether it would be better for Providence to simply give the money instead of bringing our group to Guatemala directly to MTI to serve the communities. The answer that echoed amongst the MTI staff stressed the importance that our presence means to this community, and as trust has been built over the years, the value of their work and intentions is augmented by our own work and commitment. Our visit communicates that the peoples of this community are important to us. That was wonderful to hear, but the truth is equally valid that our own value is impacted. Perhaps more importantly, our voices and experiences need to be part of the conversation in the United States. Our work and service is only beginning.

Hasta manana!
Robert Gobbo "El Loro" in Guatemala.