I am developing a crush on Guatemala. It is a such a beautiful country, and the people are so admirable in many ways. Hard workers, happy, flexible, welcoming. They are all gorgeous too — must be in the Mayan genes.

In my own personal education and growth department, I’m really happy with how my Spanish has come back around. Definitely not fluent, but more functional than I was before, particularly when asking about specific “dolors” and such. And it is great to practice medicine in a very limited-resource setting. It is a reminder about how to get back to basics (history and physical is 90% of your work!), and also a reminder about when a diagnostic test or a specialist consultation is really going to make a major difference in your medical advice. When things are readily available, the over-arching mentality is that you may as well do everything if there is even a remote possibility that it might be useful. This is not even mentioning the pressure from the toxic medical-legal environment that exists in Western medical practice. That attitude is a lot of what has caused the medical economics crisis in U.S. healthcare, and we would do well to remind ourselves every once in a while whether a CBC and a metabolic panel every morning is REALLY going to change what we’re doing for the patient. We could definitely stop getting chest x-rays for every patient at the door of the ER. There is the flip side of the coin as well, which I also ran into quite a bit –situations where a diagnostic test actually WOULD be useful, but since they are not available or patients cannot afford them, we end up airing on the side of overtreatment rather than undertreatment. Things I would have been comfortable watching for a few days in the U.S. I ended up treating here, simply because follow-up is so difficult if things end up getting worse. More than a few times I had no idea what I was treating, but the patient certainly seemed to have something legitimate needing some attention, and so a lot of educated guesswork came into play regarding which antibiotic, how much, and how long a course would be needed to treat that “something”.

Today we had a half-day of clinic, where the complaint of the day was pelvic pain. I don’t know whether people share symptoms while their waiting in line or what, but everyone seemed to have the same story. Bilateral ovarian pain, followed by epigastric pain, and then (if I let them keep going), headache. It’s interesting to see how complaints cluster in different populations – I hardly had any pelvic pain in Rio Dulce.

Yesterday was a bit of a “rest day”, for some more than others. In the morning we had teaching for the prometoras (lay health workers) and comedronas (lay midwives) in the four villages surrounding Monterico. I gave my little speech about diabetes and metformin again, which is becoming pretty slick now! It was nice to see all the interest from the women – and a few men – who came to the training.

In the evening, we cooked dinner for our Guatemalan hosts, which is a tradition passed on from other trips. We made a “fish stew” with tilapia, potatos, carrots, and a few other interesting things, including (not intentionally) a generous helping of MSG. Apparently someone thought it was salt. Oops!

Since I am leaving earlier than planned (and rather at the last minute — this only came together tonight), I did not get to do all of my official goodbyes or take last photographs or anything like that. So I suppose I’ll just have to come back. So there =).

I knew it was going to be a long day when I came out for breakfast a little before seven, and saw people already waiting in line. Okay … going to be that kind of day!

It was that kind of day – apparently word spreads fast that there is a clinic team in town. Not just docs, but some labs, a pharmacy, and teeth cleaning also! We also opened up a room for VIA today, which is a very simple way to screen a cervix for pre-cancerous lesions that need to be frozen off. Essentially, you paint the cervix with white vinegar (yes, the stuff you use in your kitchen), and this makes cells that are high in glycogen (aka those that are using a lot of quick energy to divide rapidly, because they are trying to be cancerous) show up as bright white spots. Then you nuke the problem spots with liquid nitrogen guns. Very simple and worthwhile. The problem is, it takes some time, and there are lots of cervixes (attached to women, of course) in the immediate area. In short, we saw 95 people today, and sent away a good number to come back on Thursday for VIA when we open again. Busy busy busy!!

I led another group diabetes visit, which I had done once in Rio Dulce. This one was a little more organized – I had them all get their blood pressures and blood sugars done BEFORE they came to see me – but still took quite a bit out of me. But I must say my little speech in spanish about good diet, good exercise, and taking your medicines is coming along quite nicely. I can even field questions, after having it repeated twice and requesting that the speaker slow down once. We gave metformin, a statin, and aspirin to every diabetic to last six months, and we have their names on a list so we can find them when we come back. I feel satisfied.

Every day has a few diagnoses that seem to appear in clusters, and today it was pelvic pain (helloooo, pelvic exams!) and eye complaints. We washed out three eyes and did God knows how many pelvic exams. We also saw a case of chicken pox, which unfortunately arrived in the middle of a very busy clinic. I expect that some children will now go home sicker than when they arrived….but since there is no varicella vaccine here they may as well get it and have it over with. Interestingly, it is the first case of full-blown chicken pox that I have seen, since everyone is now getting vaccinated in the states. It definitely looks like a miserable experience.

After our clinic, which finished around 6pm (two hours later than normal), I am happy to say that several of us discovered a handy corner bar and enjoyed a round of $3 Margaritas. I am feeling substantially happier. I never like to feel frustrated because patients need care, and I’m afraid I felt like that for the last two hours of clinic today.

So I was up early this morning, since the sun comes up early (around 6 am) and we have no curtains in our little dormitory. So when the sun comes up, everyone gets up! We breakfasted in fine style, with omelets and a warm rice cereal (and excellent coffee — yay!), and then set up upstairs for our first clinic day. It started off slow but I guess word gets around, because by the end of the day we had seen 64 people. Not bad!

The people here all speak Spanish, which is a change from Rio Dulce, where the majority spoke some to no Spanish and mostly spoke Q’eqchi (kek’ChEE). When we were clearly not communicating, I never knew whether it was my limited Spanish, or theirs!

It was a pretty classic day in a primary care clinic — lots of headaches, lots of belly pain, coughs and colds, and a few interesting rashes to remind us that we’re in Guatemala where the bugs reign supreme. One little boy at the end of the clinic came in with a high fever for the last several days, and we packed him off for lab tests for malaria and dengue fever. Now we really remember where we are! He is coming back tomorrow with results, so I will try to update all of my dedicated readers on what the mystery diagnosis is. It’s almost like watching House.

When we lived in Dallas, it was tough to get people to visit us. Dallas is a perfectly decent place to live, but as for tourism potential, the script runs something like this:

Me: “C’mon, you can visit the JFK assassination museum!”

Friend: “Um, that sounds kind of morbid.”

Me: “Well, it’s actually a really good museum with a historically balanced point of view that refrains from overly sensationalist approaches and, well,–”

Friend: “…”

Whereas with Seattle, you can sell your friends on the Pike Place Market, the original Starbucks, or pretty much any one of fifteen other touristy selling points. But the most important factor, and the thing that makes this such an amazing place to live:

It’s freakin’ gorgeous.

We gripe and moan about the rainy weather. In part it’s totally true: winter here is depressing, dark and gray. But in part it’s an act to dissuade others from realizing what a paradise this place can be. They say the Vikings gave Iceland its name to ward off overly enthusiastic immigrants, and I can identify. If the rest of the country knew just how WORTH IT the sunny days make Seattle, they’d be flocking here en masse. And there are sunny days, believe it or not. Yesterday and today were two of them. So yesterday I took advantage of a sermon-prep break to go for a walk around Queen Anne Hill. (Non-Seattle friends take note: this is part of the city. It’s ten minutes from my apartment. Capitol Hill, where I live, is just as gorgeous: but you know, when you’re surrounded by this much beauty, you crave a little variety once in a while.)

Then there was today, when I preached at both morning services, then had a four-hour break before supplying at another nearby church whose pastor recently left. Four hours? A stunningly beautiful late-winter day? Time to light out for the mountains! Just a quick thirty-minute drive to exit 32, and I was hiking up the trail to Rattlesnake Ledge. Most of Seattle was there with me (did I mention that this scarily outdoorsy city is the headquarters for REI?). But who cares if it’s crowded? More company for the walk up.

Atlanta, New York, Dallas, you all have your charms. I’ve lived in you all and love you each in your own way. But you don’t have mountains. This Tahoe-bred boy needs some of those to call a town home for real. Seattle, it’s only been two years … but this relationship is feeling pretty serious.

We are staying at the retreat center of CCCG, which was all hand-built by the congregants themselves within the last 7 years or so. It is a beautiful facility, with dorm-style bunk beds (one room for ladies, one for the gents) a kitchen, and an open-air third floor that can be used for classes, meetings, or in our case, a clinic! We will start on that project tomorrow, and I will be back to faithfully blog about it.

Nighty-night, friends!

For those of you who are wondering, our little friend the asthma patient from last night did just fine. He had no trouble overnight, and at just before 5 am this morning we sent him and his mom and sister back to the village with another team that was headed up there. We put together a little care package for them which included more prednisolone ,a nebulizer machine, and an albuterol inhaler. We will send a steroid inhaler up in a week or so. Mission accomplished, at least for one kid!

Tikal is one of the most important sites of Mayan ruins in Central America.  (I’m now switching into tour guide mode, so if you don’t care about history but just want picturesque descriptions of trees with spider monkeys, feel free to skip ahead now).  It was inhabited as early as 800 BC, although most of the structures we saw were from about 400 AD until about 900 AD, when the city was abandoned for mysterious reasons.  Our local guide told us that it was very lucky that the jungle had grown up and around the city to hide the structures, because it was protected from the Spanish conquistadors when they rode through destroying everything.  Now the Spanish government is helping with the excavation project, so apparently they’re trying to play nice now.  But many many of the 400 or so structures in the city are still covered by huge mounds of dirt and trees.  The excavation process is very slow — first all the trees on a particular mound of interest have to be cut down, and then you have to wait a period of at least two years before you start trying to remove the roots, so that they will have loosened up around the structures underneath.  I do not have enough patience to be an archeologist, that’s for sure!

The whole park is definitely still very jungle-y.  We started out walking for about 10 minutes under huge shady trees.  We stopped for a minute to admire the National Tree of Guatemala, which has huge roots that (apparently) line up with the cardinal directions.  I did not have a compass with me to verify this, but it sounds neat!  The branches of the tree is covered with “air-plants”, or reddish Bromeliads, so it looks like the branches are growing a shaggy overcoat of red fur.

The first stone pyramid we saw was unimpressive compared to some of the later ones, but I didn’t know that yet so it was still exciting.  In front of it were a line of large vertical stone plinths, which our guide explained line up with the rising sun on important days of the year — the two solstices, the two equinoxes, and a couple of other dates of importance that I don’t remember.  Our guide told us that Mayan descendents still come into the park on those particular dates to pray and offer sacrifices in front of the stones — hopefully not human ones anymore.

Then we went trekking, Jurassic-Park style, through the jungle to see a series of increasingly more impressive pyramids and temples.  We climbed some of the taller ones, which gave a fabulous view of a carpet of unspoiled forest with enormous stone monuments rising above.  One of my favorite places was right at the end of the tour, in the “central plaza” of the Tikal structures.  The most important temples, Temple I and Temple II, are at opposite ends of this plaza.  A very revered ruler is buried underneath Temple I, and it is thought that he was probably had some Mexican blood because the skeleton found underneath was almost 6 feet tall, which would have been mutantly large for a native Mayan.  On the other sides of the plaza were a burial monument where many rulers were buried, and the remains of a large palace that at one time had 300 stone beds for the royalty.  Stone beds, huh – you’d think they could have done a little better by their higher classes than just stone!  The neat thing is that the ruins are excavated and still left open, so you can clamber up and poke around into stone chambers, behind walls and plinths – you feel like you are discovering things rather than being shuffled along a beaten tour path.

Another perk of the tour was the wildlife – many many species of birds (mostly heard, not seen), both spider and howler monkeys (saw spider monkeys, heard the howlers), little gray foxes, and some wild turkeys!

We were dumped out at the requisite tourist mall at the edge of the park, and all agreed it was well worth the experience.  It is amazing that the structures are still in such good condition – I suppose being buried under a couple tons of dirt helped preserve things.  They are truly impressive feats of architecture and mathematics, and I’m curious to do a little more reading about what is known regarding pre-Columbian Mayan civilization now.

And yes, on the way back, we stopped at a Pizza Hut.  Mediocre pizza never tasted so good =).  A trip well worth the effort!

Oh, and I led a group Diabetes visit in Spanish! Que bueno! I was quite proud of myself. I talked about diet and exercise (Does gatorade have sugar? Yes. Coca-cola? Unfortunately, yes), and about adjusting metformin. One of the women from the village is a midwife (Comedrona), and we taught her how to take blood glucoses with a glucometer. The idea is that all the diabetics in the village will get their sugars checked by her once a week, and she will help adjust their metformin based on those sugars. In reality, who the heck knows what will happen. It will be a surprise when we come back in September. It is a little scary to leave 6 months worth of medicine (hypoglycemics among them) with people, and not be entirely sure what they will decide to do with them. But I suppose the best we can do is explain what to do with them. One man already had a blood sugar of 512, and so his chances of dying from diabetes are probably greater than his chances of having an adverse effect from improper dosing of Metformin. That’s one way to look at it, anyway.

Tonight I am in Tikal (!), and tomorrow we will go explore the famous ruins. Exciting!!