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