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First day in clinic
Although this was a big day, it will be a small post. It will be a small post because it was a big day. Let me explain. A big day is a day that is long, hard work, involving many activities and lots of people, conducted in several languages of which you have varying comfort levels. After a day such as this, although there is lots to write about, the blog post must be small, because you are exhausted.
But I will try to hit the highlights. So the whole team — myself, two other family doctors (one of them a faculty member at my program), two nurses, a logistical specialist, a photographer/gofer, a couple other helpful adults, and a brave 12-year-old — is in the Rio Dulce area of Guatemala, which is about 5 hours away down the most windy road on God’s green earth (thank you, God, for creating dramamine as you were creating said windy road). Our team also includes quite a cadre of Guatemalans, all from the CCCG church organization that we work with and through while we are here. There are about six of them here, the majority in their early twenties, with fairly good command of English (which is a blessing).
The Rio Dulce (“sweet river”) is actually a tributary that comes out of a larger lake called Lake Isobel. We are staying at a little camp/retreat site with cabins right on the shores of Lake Isobel, which is just as lovely and tranquil as a lake can be. This site where we are is apparently where Guatemalans come to have a little resort-style getaway.
Our day today started at 0730, when we took the truck out and jounced 45 minutes down a dirt path to one of our first villages, called Tablitas. Almsost all the villages here were created by necessity, to provide a home for the Mayans that were displaced from their land during the civil war in the 1980s. It is a charming place, and most of the people we passed smiled and waved in a friendly way. The houses are all made with cane/bamboo walls and thatched roofs, with laundry hanging in the front, an outhouse in the back (if you’re lucky), and children/dogs/chickens running through everything. There is a school with about two or three rooms for the primary-school children in the morning, and the midde-school children (if there are any) in the afternoon. There is the church building, with movable plastic chairs and wooden benches, which also serves as an all-purpose meeting hall. And that, for all intents and purposes, is the village.
These meetings are meant to accomplish a couple of purposes. One is that we (Jennifer’s team) want to find out any health problems/sanitation problems that the village is having, that maybe we can give some thought to. We can do this because we come back every six months, as opposed to doing a one-stop medical tourism visit and never setting foot in the place again. Two is that we — and the church group from CCCG — want to know how past projects that we have introduced to the village are coming along. These projects run the gamut from small things like gardens to large things like microfinance and composting toilets. While some of us run the meetings, another group goes down to the school to administer albendazole (for worms) and flouride treatment to the children.
The meetings were … interesting. Not extremely informative, to be honest. The first one was with the pastor, two of the lay health workers (comedronas, or lay midwives), and maybe 7-8 of the male leaders of the village. These included their own church leaders as well as the “Cocones”, which are part of the traditional Mayan government system. Only the pastor and one other man spoke both Spanish and Quechi, which is the Mayan language. All the rest spoke only Quechi. Jennifer and I speak Spanish (mas o menos) and English, and the CCCG cadre speak spanish and English (more or less). So it was pretty entertaining, language wise. Jennifer might say something in Spanish, which would then be immediately repeated by a CCCG person, in better Spanish. Then there would be a long silence when the men would stare at each other and exchange long, incomprehensible glances. Then a man might answer in the native language, and then there would be another long silence, which one of us would finally break with a “que dijo?” (“What did he say?”). Then the pastor would give a translation (who knows how accurate), a CCCG helper would translate back into English, and then Jennifer or I would translate further based on what we understood from the pastor’s spanish and what came out from the CCCG helper in English, which might or might not be the same thing. Over the course of an hour with many people talking, I don’t know if we understood each other at all! Well, not that bad. Maybe a little bit.
In any case, the men were not very talkative and did not seem extremely receptive to our questions about what were the major problems in the village. But a few of them finally said that food was a problem (rainy season had been bad, corn wasn’t growing), the men did not bring back enough money to buy food, and yes a few people had vegetable gardens but they needed seeds and no one had money for seeds. We talked for a minute about maybe creating a collection system for the rainwater during the rainy season, which seems like a workable solution for the future.
I’m going to skip the rest of the village meeting and talk a bit about the clinic, since it is already muy tarde y yo tengo mucho sueno! My faculty member who is down here with me has been running this sort of operation for about 3-4 years now, and it is pretty spiffy by now for what we are working with. We run out of one of the larger villages (Agua Caliente) in a building with one large room and two smaller rooms. We use sheets strung from the ceiling to partition the large room into stations — one for triage, one for laboratory, one for pharmacy, and one as a waiting room. Then the two smaller rooms are used as exam rooms, with a single table for exams, maybe a chair (not always!), and some supplies that we cart in including otoscope, tongue depressors, reflex hammer, cotton swabs, etc.
Patients come from Agua Caliente as well as the surrounding villages (we troll for them using a van to bring them in and take them back home). First they are checked in, with a very cool EMR system that was created especially for us, using a word document that has macros to fill in text fields with the elements of a basic medical history form and SOAP note. This document then gets saved to a thumb drive, which the patient carries with them to each station. Someone at the station plugs in the thumb drive, and voila! they have a medical record. Quite spiffy! We are actually very wired.
We saw about 50 patients today, almost all of them in family units consisting of a mother (where are the fathers???) and 3-5 children of varying heights. The most interesting (and sad) of them all was the very first patient, a little 2-year-old boy who’s mother said he hadn’t started walking yet. We put him down on the floor, asked mom to go across the room so he would try and follow her, and sure enough, he “scooted” on his bottom using only his feet and his hands! Did not crawl, didn’t even try to stand. He moved all his extremities well and had normal reflexes, and otherwise a normal exam, but had a somewhat floppy tone for a two year old. Probably some sort of neuromuscular disease — God knows what — and probably not much to do about it here. In the States you would get a lot of specialized physical/occupation therapy, wheelchairs or walkers, handicap aids, etc etc. Here in Guatemala…not so much. We put in a referral to a nearby town a couple hours away with specialists, but my guess is that even when the diagnosis is figured out, there will not be a lot to do about it. That is a major theme about practicing medicine here, and it makes me feel like I’m doing medicine from about 50 years ago. There are not many diagnostic tests available outside of the history and physical exam, so diagnosis is usually in question. Even if one had a sure diagnosis, there are a limited number of options for what to do about it. So is it even worth it to have a diagnosis if we are going to do nothing different? Logic would say no, especially since it is no mean expense to the family to travel both ways to see a specialist. So we treat what we have a remedy for and are fairly sure about, give other treatments and advice to palliate symptoms, and more or less ignore the rest. Good medicine? Who knows. It is the reality of medicine here.

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