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.