Team OB/GYN

Hey everyone! I really wanted to use this post to focus on a time that I spent with two wonderful Ob/Gyns from the US. Hospitalito Atitlan works with many volunteer physicians and residents from the US and other countries and a couple weeks ago, Dr. Michelson from Texas and Dr. Lebo from California dedicated a week of their time to working at the hospital. In general, Hospitalito Atitlan asks for volunteer physicians to devote at least two weeks, but because the need for obstetrical care is so high in the region, they make an exception for gynecologists. During their time here, the gynecologists were on call 24/7 in case of emergency c-sections or other gynecologic emergencies and then also see patients for consults during the day.

With Dr. Lebo and Dr. Michelson

Me with Dr. Lebo and Dr. Michelson

It was very interesting to see them work in a low resource setting. After the first couple days, they quickly adjusted the way they handled visits to accomodate needs. For example, when ordering labs, they tried to order ones that were only absolutely necessary and that would help make a diagnosis and less labs to rule out diagnosis. They tried to clump laboratories together where they could to save costs on patients having to return multiple times for different laboratories. Also, while in the US you would have seperate technicians for ultrasounds, the gynecologists became the ultrasound experts of the hospital and performed many during their week there, and were called on for ultrasound questions by the other physicians as well.

It was also interesting watching them in the operating room. I only observed one procedure, but I learned there are extra challenges that you need to consider when working in a developing country such as working with slightly different instruments, language barriers, trying to make due with limited surgical supplies, and little backup in case of emergencies.

Dr. Lebo and Dr. Michelson working together on a case:

Dr. Lebo and Dr. Michelson performing a tubal ligation

Dr. Lebo and Dr. Michelson

One of the really neat things that the hospital does every month is go out to smaller communities for “club de embarazadas” or pregnancy clubs. They reach two different communities every month, Cerro de Oro and Chacaya, and members of the pregnancy club get free prenatal visits and referrals to the hospital for ultrasounds (which are free if referred from the pregnancy club). In addition to prenatal visits, they receive a lecture in the beginning of the visit on a topic related to pregnancy or womens health. They spoke about pre-eclampsia and pre-natal care during the sessions that I participated in.

I went out with a different gynecologist to the two different sites throughout the week. In a half day we saw approximately 20 patients in each site and I really strengthened my prenatal visit skills. Unfortunately, there is no laboratory at the clinic, which means we weren’t able to do prenatal labs. We referred each patient to get prenatal labs at either Hospitalito or the public hospital (2 hours away). Unfortunately, in this case, much of the responsibilty in this case was put on the patient and those that could afford the trip went, while there were others that were very far along in their pregnancy and still had not gone to get their prenatal labs, mostly for financial reasons. We are very lucky in the US that as physicians, we don’t worry about costs. We do everything we can for the patient and then they either get a bill weeks later or insurance gets the bill and we never even see the costs. Unfortunately, here this is not the case. While most services at the public hospitals are completely free, elective services and those at private hospitals have a cost. The cost seems like pennies compared to the US (for example, its about $150 for a delivery at a private hospital), for a population that makes an average of $3-5 a day, it’s extremely significant. Even for free services, patients at times aren’t able to receive them because of the cost of the bus ride to the closest public hospital. With this in mind, it puts you in a completely different mind frame when treating the patient and doing only what is ABSOLUTELY necessary for their care to not raise their costs.

Below are photos from our visit to rural towns, Cerro de Oro and Chacaya:

Cerro de Oro, one of the smaller villages we visisted

View on the way to Cerro de Oro

At Cerro de Oro, being welcomed by the health post

At cerro de Oro with the daughter of one of the mothers in the pregnancy club

The clinic at Cerro de Oro. Patients waiting to be seen by the gynecologist

The pregnancy club awaiting their presentation

Pregnancy club women participating in the activity

At the health post at Cerro de Oro

With Cirulina, the translator at Cerro de Oro. She helped translate from Tzutujil to Spanish

At the beach at Cerro de Oro with Dr. Michelson

At the beach of Cerro de Oro with Dr. Michelson

The health post at Chacaya

Educating the pregnancy club patients on prenatal care

Me and Dr. Lebo resting in between patients with a snack of tamales

The clinic room that was used in the Chacaya clinic

Finally, Dr. Lebo’s daughter is part of an organization that makes dresses out of pillow cases to donate internationally. She brought down many dresses to donate to the children that came to the pregnancy club and throughout the town. Below are photos of the dresses that we gave out that week to children.

One of the local children in the homemade drenes brought by Dr. Lebo

Dr. Lebo dressing one of the children in dresses she brought from home made from pillow cases

Working with these women was truly a phenomenal experience. They made me feel so comfortable and really let me participate to learn different things. Thanks for the opportunity and hopefully I see you guys soon!

Till Next time 🙂

Surgery Jornada in Hospitalito Atitlan

Things are going well here in Santiago, Atitlan and I am getting used to living here and working at the hospital. I wanted to focus this blog on one of the best experiences that I have had at Santiago so far. During my 2nd week here I had the incredible opportunity to work with a surgical team from various hospitals around Minnesota. Each year, a team led by Dr. Kevin Bjork come to Hospitalito Atitlan to offer up their volunteer services for the week. The team included approximately 40 people including 2 general surgeons, an ob/gyn, a urologist, anesthesiologists, nurses, physicians assistant, translators, technicians, EMTs, undergraduate students, and more. While I spent most of the week with the surgical teams, the rest of the team performed a number of other services ranging from installing solar panels (which will save the hospital approximately $20,000 a year), to sewing curtains and planting a medicinal plant garden.

New solar panels installed

The medicinal garden built that week

The week started out on a Sunday. The community had advertised about the coming Jornada (in english this translates roughly to event) and patients came from Santiago and villages all over the lake. The lines were out the door. The team saw and evaluated approximately 120 patients on Sunday and scheduled approximately 60 surgeries for the next 5 days. These numbers are incredible given the circumstances. There are 4 surgeons that were evaluating the patients, making it an average of 30 patients per surgeon to do a history, physical examination, and evaluation for surgery. Many of these patients had little to no previously health information available. Making things even more difficult, many patients did not even speak spanish but the local Mayan dialect, Tzutzujil. While some members of the team had spanish knowledge, a lot of translating was needed and with only one translator that was able to translate from tzutzujil to english, in many cases double translating was needed from tzutzujil to spanish to English. My main role this day was helping with the translations The day was exciting, and the surgical team was ready for their full roster of surgeries.

Waiting room on day 1

What I witnessed the following week was nothing short of amazing. When working in a developing country, you are definitely expected to run into some snags and unexpected events, but the way the team dealt with these issues made me proud to be helping them. Below are some of the highlights of this week.

1. The first night there was a question by overnight guatemalan team about one of the patients, and while they were able to get someone in from the surgical team, there were issues with translating. After that night, they made sure that there was someone that would stay all night at the hospital form the surgical team, along with a translator. Physicians Assistant, Chris Kane, stayed overnight almost nightly without hesitation, with translator and nursing student, Katie.

2. I had never witnessed a team that had such a high level of care for their patients. Taking time away from their careers, away from their families, working for free this week, they put the needs of the patients before theirs. Members of the team were getting dehydrated from staying in the operating rooms for hours, surgery after surgery, giving up valuable sleep, sleeping in the hospital, and taking the time to explain all the details to every patient.

Chris, Physician Assistant, rehydrating after many consecutive long shifts

In the locker room, resting in between patients

3. This is was the first time the Jornada had brought a Urologist, Dr. Brad Qualey, making his patient load extremely large. Dr. Brad is one of a kind, with the kind of personality that melts your heart. He did an incredible job but as to be expected ran into some issues. Many of the procedures performed were TURPS (trans-urethral resection of the prostate) for which he used a newer technology called a green light laser, which is ideal for this setting because it decreases recovery time and post-op bleeding. However, on more than one occasion, the machine over-heating. The technician worked overtime to keep it running and working throughout the week. In order to have good visualization during the procedure, there needs to be a pressurized flow of saline solution through the equipment. While in the US, it would be pressurized automatically here there was no such equipment, which meant that someone needed to use all their strength to hand squeeze saline through the equipment (this involved rotating people every 10 minutes or so during the procedure). Pictures below of the Urologist, Dr. Brad Qualey and working with him.

Me and Jenna with Dr. Qualey

Dr. Brad Qualey

Getting ready for a TURP procedure with fancy protective eyewear

Dr. Qualey, performing a TURP

Green light laser machine used for TURPS, that was generously donated to Hospitality

Me and Jenna,

4. The hospital is not equipped with a blood bank. This did not pose a huge problem as many of the procederes performed had minimal blood lose, but there were a couple open procedures that necessitated that they work quick with no mistakes.

5.For the first time ever, I saw a surgeon cry, faced with the difficult decision to remove a large thigh mass and worried that the procedure might not be safe given there was no imaging to show whether the mass had invaded into any important vasculature (they ultimately decided to remove the mass completely and safely :))

6. While many of the patients had happy endings, as we all know it medicine, bad news is inevitable as well. I remember having to translate to a patient that their bladder mass looked unmistakeably like an advancing cancer that had little chance of cure, or translating to another patient that had waited 2 and half years to get a procedure done that the proper equipment was not available to safely perform the procedure and he would have to wait till next year. The surgeons did all they could with what they had, but as situations go, even in the US, not everything turns out the way you want it to.

7. It was exciting to scrub into surgeries again since my 3rd year surgery rotation. I saw and participated in a range of different procederes including hernia repairs with Dr. Kevin Bjork and Dr. Dawn Stapleton, prostatectomies with Dr. Brad Qualey, and tubal ligations with Dr. John McGuiness.

Me, helping suture

Me, helping suture

Overall, it was an exhausting, but thrilling experience. I saw a side of surgeons that I rarely saw during my surgery rotation. Even to this day, even though the team is back home to their regular careers and families, they call into the hospital for updates on patients that they treated.

On the final day that the team was in Santiago, they invited me and Jenna to take a boat ride across the lake and out to lunch. It was a perfect way to end the long week.

the view of the lake from the boat

The whole team, celebrating a long week

On the boat during the last day

Me with Barbara, nurse

This week was definitely one of the most memorable weeks that I’ve had here. One of the most wonderful feelings was watching patients, that had waiting so long to get procedures that were once out of reach, treated. A big THANK YOU to Dr. Kevin Bjork’s team for all that you do for the people of Santiago every year. Hopefully next year I can be available to come and see the work you do once again

More pictures of my experience below!!:

one patient that is looking at a mass the surgical team removed from his chest – so precious!!
Photocredit: Jenna berger

Me and Jenna with student, Reed

Me and Jenna with Dr. McGuiness

Operating room

me and Jenna in the operating room

Chris and student, Aaron

Jenna became one of the patients as she got a small cyst removed

me and Jenna, with members of the team

Me and jenna with fellow students

Me and one of the students, Tim

Operating room, ready for a patient

Chris, Physician Assitant with his daughter

Dr. Stapleton and Dr. Bjork discussing cases

Post-operative recovery room

Jacinto, local scrub tech, hand washing laproscopic equipment

thigh mass removed

Specimen of large gallstones removed after removing the gallbladder

finger amputation

Mass removed from a breast

Gallbladder after being removed

Till next time!

Month 1 in Primeros Pasos Clinic!

Current clinic team!

So I have officially completed my first month in the clinic!! Its been a pretty steep learning curve but I am finally getting the hang of how things work in the clinic and am able to be an effective member of the team. Before I go into my experience more,a little bit about the health care system here in Guatemala:

In comparison to what I have seen in Mexico, the healthcare system in Guatemala is much less developed. While they have a universal system, up to 40% of the population has no access to care. The system is divided into 3 sectors: Public, private non-profit and private for-profit. The public sector is run by Minesterio de Salud Publica y Asistencia Social (MSPAS) which provides health care services through facilities ranging from primary care service to tertiary hospitals. Services are free of charge at these facilities.

The Private non-profit sector is monitored but not under direct control of MSPAS. The Integrated Health Care System (SIAS) contracts with private providers to provide healthcare in remote rural areas that have no access to health facilities. Each private provider is services approximately 10,000 residents. Next there is IGSS (Guatemalan Social Security Institute) which covers government employees that pay into the system. Finally, the private for-profit sector, which is largely unavailable to the general population because of its high costs.

The clinic that I am working at in completely funded by donations, but does receive informational pamphlets and contraceptives from the Ministry of Health. We have one physician and 6 local medical students. I am currently one of two foreign medical student working at the clinic. The medical students here have much more responsibility that those in the US. They run clinic rooms on their own, prescribe medications, and deliver educational plans. I have heard from other students that have visited the public run institutions and many of them have only one medical student as the “doctor”. It’s phenomenal the amount of responsibility placed on students. During my first week I was completely overwhelmed. In the US, I had never written a prescription or seen patients without the oversight of a physician. By the 4th week I was starting to feel more confident in my abilities to see patients on my own with a fellow Guatemalan medical student, but also felt secure that there was a doctor in the room next door in case I had any questions.

The 5th week of my time here was probably the steepest learning curve for me. The clinic got a whole new group of Guatemalan medical students and the doctor wanted me to help train them in how the clinic worked. Even though I had spent the last four months at the clinic, I was still struggling in writing proper notes in spanish and other basic things. However, I was surprised at how much I had learned that month and was able to teach other other medical students. I am excited to keep learning!!

One of the major things that I have noticed in the clinic is the lack of a really strong method of data collection. Each patient that is seen has a folder, and the folders are kept in large file cabinets. The sheets that the histories are written on are very simple and include history, physical, diagnosis, and treatment. If files are misplaced, a new folder is made without any reference to previous notes. I have had a significant amount of patients that I thought were “new patients” but that just had their folder misplaced which makes it harder for quality longitudinal care. In addition, lake of a sufficient system of data collection makes doing any sort of research almost impossible. A few years back the clinic had a volunteer that had set up a network so that the clinic was wired for an electronic system, but there was one problem: They were not able to afford computers! I have made it one of my goals during my time here, along with another foreign medical student from UVA to try to get refurbished computers from the US to this health clinic. That is definitely the first step to improving data collection, and a result being able to get sufficient data for research projects that can improve patient outcomes in the clinic.

Finally, during my time at the clinic I was able to spend one day with the education program, but more on that in another entry. Also, super interesting, one week we had a group form the US from Engineers Without Borders come visit the clinic in hopes of one day setting up a water sanitation system! Hope this was interesting! Pictures below of more of my time in the clinic! Till next time!!

Local volunteer painting a new sign outside the clinic

Celebrating birthdays for the month of September

Engineers without borders

Engineers without borders

Every Friday, a local medical student brings liquid nitrogen to freeze warts. Shown here is Guatemalan Medical Student Ceci freezing warts

patient with warts

patient with warts

patient with warts

Primeros Pasos Clinic

 

Puerto Escondido and Hospital General

So this marks the end of my first week here in Puerto Escondido. It’s been very exciting and I’m learning a lot to say the least. The first weekend we got situated in our homestay. I’m staying with a fellow med student, Mimi, and our host mom, Senora Addy Moncada. Her daughter is currently staying here as well, and also her grand-daughter, Suri, who is absolutely adorable! Here she is below with me and Mimi.

The house is gorgeous and Senora’s cooking is incredible! She is an avid member of the community, singing in the church choir and spends time cross-stiching various household items.

Our schedule this week included spending the mornings in our assigned clinic or the hospital and the afternoons are spanish classes. I’m in the advanced spanish class which is quite a challenge. The Hospital is called Hospital General de Puerto Escondido, and its quite small. You can see it below!

It has 30 beds and is extremely understaffed. The hospital has a couple internists, 2 gynocologists, 1 pediatrician, and 1 surgeon. The pediatrician is only there in the mornings/afternoons. Work in the hospital here is extremely difficult and it becomes hard to recruit physicians. There are no residents or many physicians in your field to consult with, meaning that all the paperwork falls on you. Also, everything in the hospital is reusable! This includes all the scrubs gowns, towels, brushes, everything.

I’ve seen some pretty incredible stuff here so far. The first 3 days I spent working with the pediatrician, Carla, and a 1st year student, Gabe. Here we are below, as well as the pediatric ward and neonatal room.

The pediatrician is extremily efficient. She sees patients in the inpatient ward, sees every baby born whether its a physiological birth or c-section, and also sees patients in outpatient clinic. We saw many general patients including a child that was post-op from appendicitis, a young girl with a breast fibroadenoma, a boy with hepatitis A, and a young baby with croup. We were also present at every c-section to inspect the newborns.

The last two days I spent on the Gynecology service. The service is very different than that in the US. The women are all in one room, they aren’t surrounded by family and arent hooked up to continous monitoring systems. Instead, the nurse checks the women and babies every 30 minutes or so with a doppler. There is one room used for c-sections and another for deliveries. Below is me with one of the gynecologist and the labor and delivery room

If the delivery room is being occupied and there is more than one delivery, the other delivery happens in the room with all the other women. We worked with both gynecologists, and I was able to scrub in on C-sections. During one of the c-sections, it became extremely obvious how understaffed the hospital was. Outside the OR room, another 17 yr old women had just been rolled in from a local clinic that was 27 weeks and in active labor. She had no prenatal care visits and came in with a foot already hanging out. It turns out she had twins, and no one in her family even knew she was pregnant! Both babies were delivered and the pediatrician rushed off to the neonatal room. However, like I mentioned before there was only one pediatrician, who had to make the decision to focus her efforts on the twin in the healthiest condition. Also, the hospital had only one pediatric ventilator, so it was explained to the family that if their condition worsened they would need to chose giving the ventilator to one twin and letting the other die. Difficult decisions and situations happen here on a daily basis given the lack of resources.

Next week, I will be in one of the smaller clinics, which are called Centro de Salud’s. It will be a great way to see a more general view of healthcare at the most basic level. In addition, I will talk a little bit more about the health system here and Puerto Escondido in general in another post as well. Overall, my time here so far has been incredible! Till next time!