Centro de Salud

The free clinic in town is located in the center plaza square. It is government-run and financed by the Department of Health. It provides a majority of the town’s medical care, especially for the very poor who cannot afford the private hospital. The clinic is staffed by two local “nurses” and a general physician. (A generalist has finished medical school, but is not required to complete an internship or residency). The building is made up of three rooms: a waiting area with 3 benches, a large room sectioned off with curtains for “private visits” and a small windowless room for labor and delivery.

from the outside

from the outside

the pharmacy next door - family members buy the meds and bring them to the doctor

the pharmacy next door – family members buy the meds and bring them to the doctor

I was walking through town, on my way to an afternoon run when I was called for an emergency in the Centro de Salud. A woman had just given birth and noted to have a cervical laceration that the generalist could not repair. I ran into the building and was greeted by a waiting room full of women, I suspect, waiting for the delivery. One of the nurses ushered me towards the back. The birthing room was dark and small, barely accommodating four people. In the center, an exam table with stirrups from the 1960s stood under the only spotlight. There was one sink in the corner, running water from the lake, and a bar of soap. The patient was appropriately exhausted after delivery a 9+lb infant. The father was pacing around in the back corner, alternating his gaze from the chubby baby in the basket and his wife. The two nurses were buzzing around the physician and patient, following orders and assessing the patient’s moans and cries.

I was shocked at the situation and immediately noted the public health violations. The nurses were not wearing gloves. The physician was wearing gloves (they cannot afford sterile gloves) but was touching everything in the room. The lap tapes were strewn about the tables and floor, and the instruments were cleaned with soap and water between uses.

By the time I finished repairing the cervical laceration, the patient had had a 1L blood loss. I packed the vagina and recommended that they send the patient to the public hospital in Solola (2 hours away) to be monitored and for a possible blood transfusion. The family was reluctant, because of cost, but they were far more fearful of the alternative.

— vicki

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Too Many Cooks

Various public health organizations and independent volunteers have come through Santiago Atitlán over the years, and they have been fairly successful in promoting maternal and child health. In addition, the Guatemalan government has taken on the WHO millennium goals (albeit 10 years later) by organizing public health education initiatives and financing local health departments and public hospitals. The end result is that women in rural towns, like Santiago Atitlán, seek annual Pap smears and regular prenatal care and vaccinate their children – and it is affordable. Unfortunately, the public health providers have yet to emphasize the importance of continuity of care.

It was puzzling. I was seeing pregnant patients for their first prenatal visit in the Consulta Externa and they were far along into their second trimester, only to hear that they had been following a comadrona. I was performing ultrasounds thinking that it was their first anatomy evaluation in their third trimester only to find out twenty minutes later that they had just had an ultrasound the week prior. I was evaluating women in the ER who were just seen at the Centro de Salud for the same complaint. It took me a week to recognize the pattern: women believed that appropriate prenatal care involved seeing as many physicians, nurses, comadronas as possible. It was thoroughly confusing; and in my US-state-of-mind, a waste of resources

In Santiago Atitlán alone, there is a private non-profit hospital (El Hospitalito), a free government run clinic (Centro de Salud), a private local NGO (Rxiin Tnamet) and solo-practicing comadronas. Each neighboring town has its own Centro de Salud and access to the large public free hospital 2-3 hours away. None of these organizations communicate and there is no central health record system. (Actually, women are suppose to carry a manila card that was provided to them at their first centro de salud visit that is suppose to contain all the pertinent labs and visits but no provider actually fills them out… it would be too obviously useful). Many women bounce to and from each available resource and are told inconsistent information about their pregnancy, which in turn is regurgitated in pieces. It is like a schizophrenic game of telephone.

For me, the frustration goes back to this idea of wasting resources because ultimately, the cost of this inefficient system falls on the patient and families themselves. Women come to El Hospitalito and spend a month’s (or more) salary to pay for a safe delivery with a physician. The cost of the delivery is not bundled – they pay for every instrument opened, piece of gauze used, bag of IV fluids, ultrasounds, blood tests run, and hours spent on their admission. The cost of every repeated test falls on the patient, who is not educated enough to know the difference. And there stands the organizations, proud of their atruistic contributions but at times too introverted to see the flaws of disconnected medical care.

— vicki

C-Sections

The cesarean section rate at The Hospitalito is surprisingly high at around 50%. I was initially shocked when I heard this statistic given how efficient Guatemalan women are at having vaginal deliveries (it’s true! They genetically have gynecoid pelvises that often accommodate 8+lb infants) and the unavailability of emergent anesthesia. The statistics are explained by the fact that women generally come (or are brought by their comadronas) for obstetrical complications and because anesthesia isn’t readily available that they have a lower threshold to perform c-sections.

My first c-section experience seemed indicative of developing country obstetrics, a startling contrast to my training experience in the US. Back home, we learn to make evidence-based mental algorithms for each situation and apply them to each individual with the aid of clinical judgement, labs and imaging, and sometimes, instinct. Here, I only have clinical judgement and instinct – all based on just 2.5 years.

Terrifying.

That was what I was feeling when I got called by the Centro de Salud for a transfer of a 16 year old G0 at 41.5wks with decreased fetal movement and suspected IUGR as she was measuring much smaller than her dates would suggest. (I was sure at this point that I was a black cloud of death given my experience thus far). The young girl arrived with her comadrona, husband (no older than 18 and likely a shotgun wedding) and her mother. I put the fetal monitoring on and was relieved to hear a heartbeat but I see intermittent variable decels. I performed a biophysical profile – 4/8 – no breathing and an AFI of 3.4cm. EFW was approximately a month behind. It would have been an easy decision in the US: admit to L&D, induction of labor for IUGR, oligohydramnios and postdates with Cervidil.

I spent an hour discussing the diagnosis and the need for delivery. The comadrona was on board and played a vital role in convincing the patient and family to stay. The mode of delivery was another battle, and it took me some time to figure out which side of it I was on. The obvious choice in the US was not the obvious choice here.

On one hand, a c-section would be the safer option. They don’t have Cervidil, only Cytotec. The risk of fetal intolerance or tachysystole would have been acceptable if a stat c-section was possible – it was not. Anesthesia was at least 30 minutes away and performed by the hospital medical director, a generalist taught to place a spinal but with limited general anesthesia experience. In addition, considering the variable decels without labor, oligohydramnios and a BPP 4/8, there was a slim chance the fetus would tolerate a long >24hr primiparous induction.

On the other hand, a vaginal delivery is generally safer and is associated with less long-term risk for the patient. She was only 16 years old, and in Guatemala, likely to have 4 or 5 more children. VBACs are not rare but need to be performed in a hospital with an available OR and blood bank, which incurs a greater cost for her and her family. And of course, c-sections are not without inherent risks, especially at place without general anesthesia and blood products… and me as the primary surgeon…solo.

A cheat sheet of instruments hanging outside the OR in the scrub area.

A cheat sheet of instruments hanging outside the OR in the scrub area.

In the end, we proceeded with the c-section. I held my breath as the spinal went in, steadied my hands and talked myself (and my assistant, the generalist on call, who it turns out had never done a c-section) through the section (with Dr. Khoury’s Lebanese voice going “hurry up, she has a spinal and you are not an intern”) and let out a huge sigh of relief at the last subcuticular stitch. I survived my first solo c-section (with a Rani Ramaswamy tiny Pfannenstiel incision, no less)!

When I first got here, I was adamant that I would provide the same care to these patients as I do in the US and thought that if I made different decisions based on outside factors that I was compromising this promise. I very quickly realized that here, medical decisions are heavily influenced by cultural, social and economical factors, and sometimes, the best patient care is not free of compromise.

— vicki

Full Moon

Mayan moon goddess

Mayan moon goddess

In Mayan culture, the moon is represented by a female deity who is thought to have power over terrestrial events. The waxing moon symbolizes a young woman, youthful and fertile, whereas the waning moon symbolizes an old woman, experienced and ruling over childbirth. The full moon is a transition, in the lunar calendar and in a woman’s life, from child to adult through childbearing.

In Western culture, the full moon is associated with bad luck and cyclical insanity, hence “lunacy”. Multiple studies have attempted to associate the lunar cycle with psychiatric breakdowns, crime, illness/death, and animal attacks. There have even been studies attempting to confirm the existence of werewolves. (Really).

I am a true believer of the supernatural, even as it contrasts the evidence-based reality of science. As the moon waxed to its full bright potential last night, it coincided with both birth and bad luck.

I spent the morning performing ultrasounds – I provide free ultrasounds on Saturdays for women from the poorer neighboring towns as part of the hospitalito’s outreach program. These women wait months for a volunteer OB/GYN to perform an anatomy evaluation, which serves as the only form of genetic screening, aside from a nuchal translucency (rarely is there an OB available during that short time frame). Most of the time, the findings are normal and women walk out feeling reassured, as abortion is illegal in this strongly Catholic and Evangelical country and the financial burden of caring for a disabled child is unbearable.

My first diagnosis – anencephaly. I had only ever seen one case of this, diagnosed early in the first trimester and treated with a D&C. The fetus was approximately 26 weeks in gestation and had a heart beat. I counseled the patient regarding the diagnosis, emphasizing the fact that it was incompatible with life. She nodded and stated that God will keep it alive. I repeated myself, pointed to where the cranium should be and told her the fetus would not survive once born. Again, she nodded and stated that God will keep it alive. The conversation went on like this for 30 minutes, with multiple Spanish and Tzu’utujil interpreters and her comadrona. In the end, the patient decided that she will continue to carry the pregnancy to term (terminations are illegal, even for fetuses incompatible with life here anyway) and await spontaneous labor, which in most of these cases, doesn’t happen.

My second diagnosis – IUFD at 33 weeks. She was 42 years old, 9th pregnancy. She had not felt her baby move in three days. She apparently had gone to her local Centro de Salud the day before who told her everything was fine because they found a fetal heart rate on Doppler. She, like everyone else, had not had an ultrasound then or in her pregnancy because there was no OB to perform it. She came to the emergency room prepared, with her husband, mother and comadrona by her side and a small plastic bag filled with baby clothes (one outfit for a girl and one for a boy) and a tiny coffin. The ultrasound confirmed what her experienced body already knew. She opted for an induction of labor and delivered stoically 12 hours later. The female infant had the characteristic markers of Down’s Syndrome, which provided small but significant relief to the family. Without hesitation the comadrona soothed her patient with Tzu’utujil chanting, wrapped the infant in a traditional Mayan scarf, and locked the coffin under the waning moonlight.

— vicki

43.3 weeks

Approximately 80% of deliveries in Guatemala occur at home and the births are attended by comadronas (midwives). Comadronas are not formally trained; instead, they learn through unofficial apprenticeships lasting anywhere from 3 to 6 months. They are preferred over physicians for various reasons: they are more affordable and available, are often part of the community, and are set apart from Western medicine (many women are understandable so, skeptical of foreign aid). However, comadronas and modern medicine are not mutually exclusive; in fact, most women receive routine prenatal care through health clinics, including prenatal labs, ultrasounds and vaccinations. High risk pregnancies are referred to Obstetricos for management, and some comadronas are aware that the hospital is available for emergencies.

For many women, becoming a comadrona was a result of “a vision” and the influence of a higher power, rather than a desire or passion. For Nicolasa, becoming a midwife was not a choice. One night, at the age of 16, she had a dream that she was comadrona and attending to a delivery. The next morning, she told her mother, who in response told her she was given “a calling” and must pursue it. Nicolasa had no desire to follow this path and brushed off her mother’s urging. The dream recurred, week after week. Still, Nicolasa refused. After a month, “bad luck” started to happen to her family. First her uncle fell off the roof, next her grandfather passed away, and then her younger sister fell ill. It could have been a coincidence, but Nicolasa could not carry the burden of ill-fate any longer and reluctantly sought a comadrona for guidance.

7 years later, Nicolasa met me at my first delivery at El Hospitalito. She brought in a young woman who had been in labor for 12 hours. She was approximately 43 weeks pregnant (a situation not uncommon as most comadronas do not induce labor as many believe that spontaneous labor occurs only when the infant is “ready”). The patient and Nicolasa were planning on delivering at home, but at 8cm dilation, her membranes ruptured, revealing thick meconium. Nicolasa had her start pushing to expedite delivery, but there was no descent of the fetal head or further dilation after an hour. The exhausted pair and family came into the hospital frustrated and fearful that they would be met with a cesarean section. They weren’t. (A cesarean section is a rather risky procedure here – anesthesia is 30 minutes away, there is no blood bank or ventilator, and the nearest ICU is 2 hours away). After 3 hours and with reassurance and patience, the infant delivered through thick meconium and intermittent deep variable decels. The patient did well, while the infant required significant bronchial suctioning (a nerve-racking first time for me) and O2 for labored breathing and grunting. The infant looked like a little old man, with a slight greenish tint, but was otherwise normal. We monitored both mom and baby for a night and they left the next morning for home, where they will stay in confinement for the next month.

labor and delivery suite

labor and delivery suite

maternity garden

maternity garden

nursery

nursery

— vicki

Chacaya

image

El Hospitalito runs a Club de Mujeres Embarazadas that provides charity prenatal care for women in the underserved neighboring villages. A physician goes out to each town monthly and visits with every pregnant patient, while the pharmacy provides free prenatal vitamins and folate and the nurses provide nutritional counseling. The patients are either delivered by the town comadrona (midwife) or a physician at the hospital.

image

Today, I went to Chacayá, a small town approximately 30 minutes from Santiago Atitlán. In this town, everyone knows everyone, and Victor, the medico (health provider) has every patients’ health record locked in his filing cabinet memory. Here, there are no street names or house numbers. Most people describe their houses by the color or the distance from the nearest landmark (a tienda or escuela or distinctive tree). To keep track of where his patients live, Victor has a colorful map of the town, where “blocks” are sectioned off and designated a color. Each house within each section has a number from 1-25. Patients then lead him to their house, where he makes a mental note of its location and puts a color-coded thumbtack (blue for low weight children, red for pregnant, red+black for high risk pregnancy) on the map. The patient is then told to memorize their section color and house number. He informs me that “this allows us to find the women when they call and are sick or when they are in labor”.

Currently, there are 14 pregnant women ranging from 8 weeks to 39 weeks. One patient, a 16 year old G1P0 at 39.4wks came in complaining of diffuse body itching, worse on the palms and soles of her feet and at night and dark urine. Symptoms began 4 days ago. No rash. No epigastric or right upper quadrant pain or nausea/vomiting. No other medical history and otherwise uncomplicated pregnancy thus far. There is no lab, but I didn’t need bile acids and LFTs to tell me that she likely had cholestasis of pregnancy. There was a fetal heart rate and good fetal movement by her account. But, again, no ultrasound and no fetal monitoring capabilities. I counseled her with Victor as my Tzu’utujil interpreter, gently telling her that she had an increase risk of stillbirth with this diagnosis and telling her that I thought her labor needed to be induced. She matter-of-factly told me that she planned on delivering with a comadrona, who do not induce labor. I recommended delivery with me at the hospital but was met with resistance from her family. I bit my lip and held in my discontent, and quickly scribbled a prescription for Benadryl (the pharmacy cannot afford Ursodiol) and let her leave. If all goes well for her, she will never have to see me again.

— vicki

El Primer Dia

It felt a lot like the first day of school… nervous energy, irrational fears, excitement, and a lot of hypotheticals. What if I suddenly forgot how to work-up amenorrhea? Or couldn’t auscultate a fetal heart rate with a stethoscope? Or perform fetal biometry? Or couldn’t find the cervix (like intern year)? On top of that, meeting an unfamiliar culture, hospital, and in Spanish. Luckily, I had Jenna, a one-year volunteer by my side to translate and a generous nursing staff fluent in both Spanis and Tz’utujil (the Mayan language).

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el hospitalito

When I arrived, they had a full OB/GYN clinic scheduled for me. The patients varied from annual exams (a testament to the success of the public health initiatives promoting Pap smears) to routine prenatal visits and sonograms. I learned a few lessons:

1. How to perform a Pap smear – training in an era of ThinPrep cytology with its fancy high risk HPV DNA probes (etc etc), I had never performed a traditional Pap smear. I now know why it has fallen out of favor because it’s hard not to fumble with the steps of prepping, collecting, and fixing all while trying hold a speculum in place.

2. How to perform a full physical exam on a fully dressed patient – it is an incredibly conservative culture here and many women do not feel comfortable removing their traje (traditional dress), even in front of a female physician. Auscultating the heart was easy… the pelvic exam, much more difficult (see lesson #1).

3. How to appreciate the cross-cultural beauty of seeing the first ultrasound – in the overwhelmingly busy day to day of residency, I often miss the opportunity to revel in the emotions of hearing the first heart beat and seeing the first ultrasound. A saw a (terrified) 16-year old for her first visit and her very professional husband and stoic mother (abuela) quietly guided her with reassuring nods and grunts through her whole visit. At the end, when I performed her ultrasound, she couldn’t help but glance at the screen and giggle, while her husband eagerly scanned the fuzzy white and black images with his eyes 5 inches from the screen, hoping to decipher a gender. All the while, the abuela-to-be smiled and pretended not to marvel at the novelty of ultrasound.

women

— vicki

Bienvenidos

I arrived in Santiago Atitlán yesterday after a sticky “chicken bus”-ride and was pleasantly greeted by clear skies, crisp mountain air, and a lazy, slightly overweight guard dog. I was introduced to this small town briefly in April, and my return is surprisingly familiar and for work rather than pleasure. With the support of The George Washington University OB/GYN, Holy Cross Hospital, and the Alpha Omega Alpha Honor Society, I am here to volunteer at El Hospitalito Atitlan as an “Obstetrico”.

El Hospitalito (as it is simply referred here) was built in 2005 with the goal of providing both primary and secondary medical care to the rural towns within a two hour (by road) radius. Over the years, it has expanded to include a full-service 24/7 emergency room with an ambulance, an operating room, x-ray and ultrasound, four delivery beds and sixteen inpatient beds. It does not yet have the capabilities for intensive care, as it does not yet have a blood bank, ventilators, or a 24-hour pharmacy. Higher level of care is available at a hospital in Solola, two hours by road and available to patients by transfer.

My job here is multifaceted. I will primarily work as house staff. I see patients from 8-5pm three days a week for both prenatal care and gynecologic issues, as well as perform ultrasounds. On off days, I will travel to neighboring villages and towns to provide prenatal care and preventative women’s health services. I take home call 24/7 and will be available for laboring patients and emergent GYN consults. My secondary project revolves around midwife education, in which I will focus on providing training sessions on peripartum emergencies, including postpartum hemorrhage, preeclampsia and obstructed labor.

I don’t know what the next weeks will hold for me, but I’m excited for this adventure and hope that you will enjoy following along!

my fierce guard dog

Canela (cinnamon), my fierce guard dog

— vicki