Last Entry

I never thought it would end like this. Although I entered medical school with compassion and emotion seeping out of my pores, the last year (plus a few months) has caused me to feel callused and hardened. The things that others gasp at or can’t bear to listen to have become part of my daily life. I take care of children who are dying and yet, not a single tear escapes my ducts. I often think about this transformation that I have made, wondering whether it is good– and just part of a necessesary protective mechanism– or bad– suggesting that I no longer feel true emotions and ergo no longer qualify as a human. I have wondered if maybe my tear ducts have become blocked by sand that the sandman has packed in ever-so-tightly while I slumber in the tiny, cold call rooms of the hospital. Long story short– it takes a lot to make me cry.

I knew this trip would be transformational. I knew it would be difficult. I embarked on a journey that I never would have gone on just 3 years ago when I was a shy medical student, overridden by fear andn afraid of exhibiting my ignorance. But I had chosen to go to medical school because of my experiences in the third world country of Tanzania. I had felt a strong desire to return and help the hundreds of people who lined up, waiting for a doctor’s touch– needing basic medical services, but devastatingly underserved. In addition, since I started medical school, I had detested myself for taking French in high school and not capitalizing on the opportunities that I had to learn Spanish in college– or even after college– when life was simple and I did have the time. I hated not being able to connect with hundreds of patients that I saw within my very own country. Although many people discouraged me from going, saying that Spanish was a critical and necessary skill for anyone partaking in this experience to have, I had to go to Guatemala, for it was the perfect culmination of all of the things that I aspired to do, know, and be in order to be in my medical career.

I knew that it would be a struggle, that the days on which I would feel completely ignorant would outnumber those on which I felt like I had made some semblance of a difference. I told myself this over and over again as I prepared for the trip, locking into my head the reminder that the experience would be transient and no matter what happened during it, I would come out stronger. I imagined all the things that could go wrong– lost luggage, robbery, or even worse– seeing sick, dying children, losing a patient, feeling helpless. I told myself that no matter what happened, it would be worth it.

When you prepare yourself for horrors, any lack thereof is a delightful surprise. Needless to say, there were definitely hard days. Some of my days, I went to sleep with a hodgepodge of English, Spanish, and Spanglish words flying around in my head, begging craving the security of a country in whicch everyone spoke English and communication was easy. There were days on which I cursed my inability to share my positive or funny thoughts with others, or to console them when I witnessed hardship. There is only so much compassion and humor that can be conveyed through body language. But more importantly, I was surprised by the true, pure beauty that characterized my Guatemala experience. More frequently, I was highly aware of the lush, vibrant rain forest that surrounded me, the bold, happy colors that people wore, the compassionate actions that I saw people taking to help others in their community, the genuine smiles with which I was greeted. And the very best thing continued to be the adorable children walking to school on the sides of the road in thier uniforms as we drove to clinic each day, the toddlers waddling around outside their houses, the moments that I witnessed between beautiful mothers and their pudgy-cheeked neonates whom they pressed so tightly and securely against their chests so that they could be consoled by the rhythm of their beating hearts. These were the things that kept me going.

And despite the challenges, my recently-identified inability to cry persisted. No matter how hard each day was or how skinny the children I saw in clinic were, not a single tear was shed. I carried on with my calloused skin untouched– possibly harder. Even though I was filled with a strong love for this new patient population and desire to come up with a plan that would truly help them in hte ways they wanted and needed to be helped, I failed to show true, tangible signs of the associated emotions.

Admittedly, I even counted the days while in Guatemala. At the beginning, I counted the number of days I had been there, and toward the end, counted down to my departure. I shared this factoid with my family, saying “it’s just what you do when you’re in Guatemala,” but at the same time wondering what this action said about my character. Even though I loved it here and treasured my experience, I yearned to be with my friends. Although I was building solid and lasting friendships here, I yeared to see familiar faces. I imagined that my last day at clinic would be fabulous and that at the end, I would rejoice in the feeling of being– my favorite word– DONE.

But as my last day wound down, and I came to realize that there were no more patients, this was it, I felt different. I hugged my new friends and said goodbye to them, and despite my broken Spanish goodbyes, sensed sincerity in the way that they were received. I sensed sadness in those I hugged. The last person I said goodbye to was Marco. As I stood across from him, looking into his now-familiar eyes, I told him how much I respected all that he is doing here in Guatemala. I apologized for my horrible Spanish skills and thanked him for his patience and leadership. I acknowledged his strong, determioned efforts and told him how much I admired his leadership skills. I had noticed that he sincerely respected and cared for all of his staff, as well as his patients. He was a genuine man whose soft, gentle demeanor had a calming presence and seemed to appease all who he cared for. I made sure to tell him what I had noticed, as although we all want our own confidence and internal motivation to be our sole driving force, I know that external validation ccan be an even-more-profound and important motivator. And it was weird, because as I told him these things and thought about all that would happen at the clinic over the next weeks, months, years, my eyes became wetter than normal. “What is this?” I wondered.

And as I walked toward the busito, ready to leave the clinic for good, I said bye to Marco again, and surprised myself with my urge to run and hug him just one more time (I have always been a little awkward about hugs). And as I said my final goodbye, I looked at Marco, and he shared some of the kindest, most heartfelt words I have heard in a long time. And as I said goodbye, my eyes became wet again– “what is this?!”. And so I climbed onto the busito, slinked into my long pleather seat so that the driver couldn’t see me, and something must have happened to all of the sand that the sandman had packed into my tear ducts, because as we drove away, my oh my, this girl sure did cry.

Nine Year Old Boy

When I say nine year old boy, what do you think of? As a pediatrician, I envision the majority of the nine year old boys I have seen and known– running through their houses or buildings, shooting pretend guns at each other. At nine, boys latch on to their friends and allow them ot shape their personalities; they seem to stay as far from adults as possible, already starting to declare their independence and “manhood.”

As I sat at the front desk of the clinic, I watched as this nine year old boy arrived with his mom. He was dressed in a white collared shirt that said BANASA– likely a student at the primary school just yards away from the clinic. His small khaki pants fit his thin figure well. He and his mom immediately walked to the lab and returned holding a small container that we use to collect samples of specimens to analyze in the lab. “He must have diarrhea,” I pieced together. I watched as he and his mom sat sweetly and quietly, and waited to be seen.

Many patients filled in the space between their arrival and the next time I heard about him. A paper from the lab was handed to me, with a description of the stool sample that we had just collected– blood +++, micro: huevos de trichuris, ascaris, y entaemoeba histolytica. The boy had two different parasites plus an amoeba. I showed the paper to Marco, and together, we looked up and discussed the appropriate treament for these specific species. I scratched out a prescription and took it with me to the clinic room in which he waited.

I introduced myself to his mom, with my nomal, “I am learning Spanish, please speak slowly” disclaimer and asked them about his symptoms. Turns out this boy didn’t have diarrhea at all. Only horrible abdominal pain that made him writhe in pain and frankly bloody stool. In America, bloody stool is a red flag. In Guatemala, its significance is the same– it is a red flag here too, suggesting intestinal infection with serious, invasive species that are disrupting the wall fot the GI tract. People can easily bleed out slowly through GI bleeds, losing so much blood that they are unable to carry oxygen to their tissues. In addition, we knew this kid’s blood was caused by parasites— which are greedy animals that eat the already-scarce food that their host ingests, causing severe malnutrition. I emxamined the boy, who hopped up on to the exam table with the energy and vitality of a normal 9 year old boy. Instead of lying down slowly, he propelled himself back so quickly that his head bounced a couple of times upon hitting the table. Classic 9 year old boy– careless, invincible. But neither his pain nor his bloody stools were normal. The boy giggled as I “scratched out” his liver– an exam manuever that utilizes auscultation with a stethoscope and fine, light touches over the liver and down into the abdomen, using the sound waves that travel under the scratches and to the stethescope to determine the density of the underlying organs, utlimately helping the examiner to gave a general idea of the size of a child’s liver. His smile lit up the room. But when I examined the rest of his abdomen, he was stoic, but did admit that he felt quite a bit of pain when I palpated the middle and upper part. Pobre nino.

I talked with his mom about the importance of clean water, clean hands, and clean food, and found out that his two-year old sister had been treated for entamoeba just 6 months ago. She eagerly explained to me that her kids frequently eat without even washing thier hands, explaining how difficult it is to keep an eye on them at all times. I pieced her hand motions and words together, getting the general gist of what she was saying, but at the same time regretting that because of my rookie Spanish skills and the speed of her speech, I knew I was missing a lot of important details. I told her about the medications her son needed to take– just two medications that would get rid of his life-threating condition—and that he would need to return to clinic in 10 days for a repeat exam. She told me that she had understood what I said, but of course, I still had Marco come in to fill in the gaps and make sure that I had not missed any critical pieces of his history. We reviewed the plan one last time and sent them out the door.

I stood in the back of the exam room and watched them gather their things. The mom clutched her purse and the boy jumped off of the exam table to leave the clinic and return to school. He was almost out the door when he turned around and approached me. He didn’t say anything at all, but at that moment, the nine year old boy wrapped his arms around my legs and midline and squeezed me tightly. He didn’t need to say anything– that said it all.

Many of the patients I have seen have sad stories, laced with poverty, malnutrition, and a paucity of healthcare. However, just as many, if not more of the stories are characterized by situations in which my skills as a resident, and our resources as a clinic are truly able to help. If this boy had not gotten medical attention, he would have continued to loose blood and his parasites would have grown larger, stealing his food from him with every single meal. But his sweet hug was yet another reminder that in the midst of many large problems, it is definitely possible ot make a difference– one nine year old boy at a time.

Busito takes on the rio grande

Every day, I wake up at 6am in order to be ready for a 1.5 hour drive in what Rosa calls my “busito” (translation– little bus). My driver, Eddie, is a kind man with a lazy eye who has befriended all of the employees at our clinic. Every day, he greets me with with a greeting “Buenos dias, Doctora! Adelante!” Eddie drives fast, and the busita is old. As a result, I have found that I will inevitably arrive at the clinic a little more green than my baseline. However, this can all be avoided by lying on the seat of the bus, not looking out the window, and preferably, distracting myself by listening attentively to audible. However, as can be expected, there have been a few other bumps in the road to clinic.

On our first day of clinic, when we were a crew of four– Drs. Gaensbauer (both James and Becky), Andrea, and myself– we had a different driver. That morning, he picked us up in a small, rickety town car. As we drove over the long, old stone road that leads to the Finca, we could feel the car falling apart beneath our feet. With each bump, we heard the low frame of the car scrape against the hard earth. We joked to each other that the car didn’t have much more time left in its life. To our pleasure, that afternoon, the same driver picked us up, but he was in a new car– a van similar to the ones that parents navigated around town in in the U.S. in the early 1980s. “Es como carro Americana.” the driver boasted as we piled in– “sort of…” we replied. The first thing that I noticed was that the gas gauge was broken. Upon starting the car, it lit up, but did not move. It would seem as though the car was out of gas; however, the driver reassured Andrea, who sat in the front, that the people from whom he had purchased the car– today– told him that it was broken, but he did have gas. We started the spanking-new van and were on our way. The ride was much smoother than our ride in the little car had been. Maybe a bit louder, but in general, we were much more comfortable. We settled into the seats and prepared ourselves for the long ride home. About 15 minutes into the drive– when we had gotten relatively far from the banana plantation, but were still far from the city of Coatepeque, the car sounded to be working a little harder than it had at the beginning of the ride. As we rounded a corner by a field of cows, the engine stopped and the van abruptly stopped moving forward. Shit. To our surprise, the driver quickly stuck his arm out the window to wave at a passing motorcyclist. The man stopped and in a swift motion, the driver jumped on the cycle, telling us he was going to get gas and would be back. And then he was gone.

We waited patiently for him, wondering where he had gone and when he would return. We were four Americans in a van stopped in the middle of the road. We were pretty much clueless. So we did what we had to do– made the best of the situation, relaxed in the car, and took some photos of our new cow friends who eagerly approached the fence by which we were stopped:

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Many cars and pedestrians walked by, staring. We just grinned back. About 20 minutes later, we heard a motorcycle coming down the road. It was our driver, with a tank of gas in his hand. He poured it into the tank, and after turning the key about 10 times, pumping the gas, the car started, and we were back on our way. As we drove along further and further, James commented that he wondered how long that small bottle of gas would last us. About 2 minutes later, the car abruptly stopped again. We were still quite far from Coatepeque. Once again, the driver waved down a motorcyclist passing by. Unfortunately, our driver did not have any cash. He asked James– the only man in our group and our hero– whether he had any cash. James handed over 30 quetzales (equivalent to like $3.50). This time, instead of jumping on a cycle with a passerby, our driver elected to give the money to the cyclist and asked him to return with gas. So he handed James’s money to a man none of us knew and as the man drove off with our money in hand, we all wondered if he would return.

This time, there was more tension in the air. James worried about whether this would continue to happen after he left Guatemala the next day. He worried that the driver would leave us girls– or worse, just me after the two others left– stranded in the middle of the street, helpless. We watched him as he stood in front of the van, hands over head, has face tight, worried. Thankfully, the man returned with more gas and a young boy to fill our tank for us. The boy poured the gas in, hopped in the van next to me, and we waited for the driver to start the car. He turned the key– nothing. Again– nothing. He sputtered a few swear words, tightened up, and leaned back. We wondered if there was a different problem. But after at least 15 more rounds of turning the key and pumping the gas, we were on our way. When we got to Coatepeque, the driver informed us that we would be filling up the gas tank. But instead of stopping at the first gas station we saw, he continued on, driving through Coatepeque, past many, many more gas stations. We had no idea where he was going as he talked loudly to someone on the other end of his cell phone. Finally, he stopped in front of a house and we waited (for what, we didn’t know). The driver unstrapped the gold watch that he donned on his left wrist and informed us that we just needed to wait a few minutes– he was pawning his watch for gas money. “No way.” said James. “I will pay.” After much coersion, the driver agreed to take James money– again. But we still had to wait for the driver’s brother in law to arrive so that he could explain that he didn’t need to sell his watch anymore. Finally, after the brother arrived and the driver explained, we drove to a gas station and filled up. Then we drove to a grocery store and bought some gallo, the local beer here in Guatemala. It had been a long day. We deserved our own anti-fuel when we finally returned home.

James left the next morning and it was just the girls. However, James did not leave without mentioning what had happened to the people in charge. That day at clinic, we heard that James had emailed Marco and Marco informed us that the driver would be fired. That evening, we had plenty of gas and made it all the way home without issues. We sighed with relief as we drove up the stone road to the Finca. However, we had sighed too soon. A black truck filled with coffee plantation laborers blocked the entrance to the Finca. The front wheels of the truck sunk deeply into the gutter that lined the street. The tires spun, but nothing happened. Shortly after our driver got out to help, we got out, too. It was easier to just walk the rest of the way.

Just like that– the next day, the driver was gone. With Eddie, things have been better. Our van is very reliable and I trust his character and judgment greatly. In fact, after Eddie started working, there were no complications with the drive. Every day, I get to work (green, but…) on time. I thought the curse of the drive home from clinic was long lost. Until Friday…

On Friday afternoon, the weather was all over the place. There were moments of sunshine and moments of drizzling rain. As the afternoon moved along, the number of patients at clinic dwindled to nothing, and a dark blanket of clouds moved in to cover us. In fact, it became so dark that we needed to turn the clinic lights on in order to see, something that had never happened before. The minute hand on the clock slowly crept toward the twelve that would mark 5:00– the end of our work week. When the clock finally struck 5:00– we gathered up our things, and at that very moment– we were stuck in a downpour. I ran to the bus, soaked by the time I got there and sat in my seat, watching sheets of water wash over our bus. If I hadn’t known better, I’d have thought that we had driven into a waterfall. We slowly drove down the dirt road that led away from the clinic. I noticed that we were driving much slower than normal. Eddie was cautious, and likely did not want to cause our wheels to sink down into the mud and trap us in the storm.

We inched along the same Guatemalan road to Coatepeque that I have come to know very well, but it looked completely different. The front yards of each home had been converted into giant brown sheets of water. As we drove by the houses lower on the hill, I remembered Becky telling me about the homes with dirt floors that were contiguous with the earth outside. I wondered what was happening to those homes. In Colorado, when it rains, we dance. Here in Guatemala, as wonderful as it is for the tropical crops– especially right now, when Guatemala is at the end of a drought that have put its crops and livelihood in danger– there are many side-effects that hugely affect the people who live here. I thought about our patients with diarrhea as I saw the water swirling through gutters, picking trash and other waste up on its way, and continuing to flow downhill towards the homes we had passed. I wondered what this would mean for clinic on Monday. I wondered if everyone would be able to stay warm and dry. I praised the rain, and at the same time, I cursed it.

We continued driving down the muddy road, and drove through two watery areas. The other clinic workers who rode with us commented that the rushing water we were seeing was creating “new rivers.” This was quite the flood. Finally, flashback to our first days on the road. Our van came to a complete halt. We looked ahead and saw two pickup trucks and many people standing around. They were all staring at something, but we couldn’t quite see what. I stretched my neck above the seats of the van and saw it. Another new river– this one a rio grande. The river traversed the road at a perpendicular angle, making it look like we lived a continent away from those who were just 80 feet ahead on the very same street. There was a man standing in front of the water, telling people they could not cross. It was too deep.

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We stopped the car, and as we sat on the road, the pouring rain slowed to a drizzle. However, the water rushed on. The line of cars and trucks behind us continued to grow longer– it was late on a Friday afternoon. Everyone in the line was eager to get home to their families. But the river wouldn't let us. A line of high school-aged children marched out of an orange bus behind us and flooded into the street. Those who lived nearby flowed out of their houses to see what the commotion was about. We were now in a flood of people, too. As a group, we came to the executive decision that we would need to wait until the water level was lower for anyone to cross. However, we had no idea whether the rain would pick up again or how long it would take for the water level to decrease. So we just waited. I hung out of the window of the van, watching the people passing by. I saw girls walking close to boys– giggling at their every word. I saw boys chatting with each other. Moms held their children's hands as they toddled through the water. They didn't even think twice before forging through the water, getting their clothes wet. For the people I watched, this was not a tragedy– instead, there was actually a buzz of excitement in the air. Across the way, a man from a nearby church blared music over the loud speaker and announced what was happening, praising The Lord. The rain continued to be slow and it was decided that one of the high yellow busses that carried close to a hundred people may be able to pass. The bus behind us started its engine. People stood around, eagerly cheering it on as it approached the rio grande. We watched as the bus dove into the water…

It made it. We cheered as it emerged from the other side and continued down the road– the exhaust pipe sputtering out a mix of water and exhaust. We were getting somewhere now. All of the buses in the line proceeded to pass on through; however, the rest of us in line had much lower frames than the bus. If we attempted to forge the rivers, it was likely that our engines would flood with water. We continued to watch for almost an hour. Centimeter by centimeter, the water level decreased. We were getting somewhere.

I continued to watch the hustle and bustle around the rio grande– soaking in the experience. This could have been prevented by better ditches and perfectly-engineered roads. But here, such a luxury is not an option. The government’s money is already spread thinly enough. Here, this is just a part of life. My contemplative moment was interrupted by a loud– “thunk” and I looked over to my left just in time to see a school aged boy with a giant backpack climbing out of a deep, watery gutter. First a few people laughed– and not just giggles. They really laughed. And then, as if it was a movie, people started pointing at the boy, laughing as he pulled his soaking body and backpack out of the water. His clothes stuck to him and dripped with heavy, brown water. The entire crowd of people roared with laughter. The boy stoically walked on, and not a single person went to help him. As the laughter echoed in my head, I was overwhelmed with confusion about whether this was great– because everyone was now having a blast– or horrible– because it was all at the poor, wet boy’s expense. I watched the boy walk away– he did not appear to have any injuries, aside from his pride, so once again, I decided to just soak the experience in.

An hour and 45 minutes after we had stopped, the water level dropped low enough for us to drive through unscathed. We did not have to sleep in the road, and we would make it home in time for a late dinner. A complete unknown had turned into a street party, with hundreds of excited people forgetting that they would be late to get home and soaking in the moment. No one seemed mad. No one even honked. “Welcome to Guatemala.” My friend Carlos said to me. And I realized that what I had construed as car disasters in the past did not come close to the debacle of the rio grande. But as I sat there pondering the craziness of it all, I concluded that there truly was no other way I’d rather spend my Friday night.

A story on imminent fetal demise

Before our patient arrived at our clinic, we had already decided that as soon as we saw here, she was going to the hospital. We didn’t know her age or her gestational age, but Marco, our clinic director had come across her name while reviewing the board that is used to track the numbers and severity of patients that the clinical cares for. The day before, the clinic’s tecnicas had visited her in her home for a prenatal check up, and things had not gone well. The girl had reported that she had been feeling fetal movement on and off, but that this week, it had stopped. The tecnicas had searched for her fetal heart tones with a doppler probe, but no matter where they directed the sound waves of the probe, they heard silence. They had urged her to visit the clinic for a more sensitive ultrasound, but she was hesitant– her family was running short on money and she did not have any means of transportation. The tecnicas returned to clinic and documented their findings on the board, hoping that she would make her way in. Loss of fetal movement and fetal heart tones are very serious and grave signs that often suggest fetal demise (death). When Marco saw the tecnica’s note the next day, the patient was contacted, and it was discovered that that night, she had developed vaginal bleeding, a fever, and generalized malaise. “She needs to get in here as soon as possible.” Marco told the tecnicas. And so they sped off on their motorbikes to ensure that the girl would make her way to the clinic as soon as possible.

She arrived at our clinic with her mother in law, donning a blue lace top that revealed her lower back, but kept her tiny belly covered. She was young; she was solemn. We led her into the ultrasound room, where she sat in a seat next to her mother in law. Her mother in law did all the speaking. By her last menstrual period, the girl was 23 weeks pregnant. Her mother in law told us that the night before, the patient had had fevers and felt very badly. In addition, she had begun to have vaginal bleeding. They had placed an egg in her undergarments in an attempt to feed her developing fetus. The girl was sweaty and looked overwhelmed. Her paucity of words was slightly concerning, as it made it difficult to tell whether she was coherent or not. We did not have vital signs for her yet– we did not know how fast her heart was beating, how badly she was bleeding, or if her body was on the verge of decompensation. When pregnant women have vaginal bleeding, the list of potential causes is broad– including everything from a bleeding cervix to infection to a serious hemorrhage in or under the placenta that puts both the mother and the child in danger. I watched her as Marco and the nurse asked a list of questions, wondering how much longer she had until she hit the floor– preparing for the worst. Their questions ended, and we rushed to do the one test we were capable of doing that would give us the most useful information– an ultrasound. The ultrasound would tell us whether her baby’s heart was bleeding, show us if the baby was moving, and and help us to determine whether her placenta (and possibly her baby) or her uterus were the sources of her bleeding.

The girl timidly took a seat on the center-stage ultrasound table. She climbed up, laid down, and lifted her lacy blue shirt. The nurse squirted blue ultrasound jelly all over her abdomen and placed the probe over her uterus. First, we saw her bladder– a big, black window of fluid that let us know where we were; next, her uterus. The nurse rotated the probe from side to side, and shifted up and down the girl’s uterus, but all we saw was black.

Her uterus was empty. We looked at each other, muttering under our breaths– “no veo nada”– “I don’t see anything,” while the nurse continued to swipe over and over the uterus to make sure we weren’t missing anything. Nothing. At a gestational age of 23 weeks, the fetus is definitely visible. In most places, 24 weeks is considered viable– meaning that if the baby were born into the world, it had a chance of survival. But this almost-viable baby was nowhere to be found.

As the medical team, we took a timeout to discuss the possibilites– maybe it was a molar pregnancy, maybe we had poor ultrasound skills, maybe her last menstrual period date was off and she was not nearly as far along as we had thought. Or maybe she wasn’t pregnant at all. There was still a possibility this was a medical emergency and we needed to figure this out stat.

Marco took the time to ask a few more questions. We discovered that this visit by the tecnicas was the girl’s first prenatal visit. She had had a negative pregnancy test early in the pregnancy, but had gone to a holistic medicine woman who had told her that she was, in fact pregnant. She hadn’t had a true period since months and months before, but had had some light bleeding during her pregnancy. On and off, she had felt movement with her pregnancy. Her fever and malaise had been vague, and far from serious. And her bleeding the previous night had been very light– similar to that of her normal periods. We knew there was just one more thing we needed to do– a pregnancy test. However, the one little tiny problem was that our lab had recently run out of pregnancy tests. In Guatemala, things like this happen. It was difficult to explain to the girl and her mom in law why a pregnancy test was so important; however, as soon as we did, the girl’s mother in law left the clinic to go to pharmacy for a pregnancy test. Thirty minutes later, she returned and we used a urine pregnancy test to run a blood sample– sigh– NEGATIVE.

One thing in medicine that makes me grind my teeth is the term, “poor historian.” Occasionally, doctors, nurses, social workers, and other medical professionals use the term to describe a patient whose story is scattered or a patient who omits very important information from the story they tell. It’s a term laced with condescension, and I despise it because it suggests that we expect patients to sit in front of us with a well-formulated, streamlined account of their medical history. The truth is, as medical professionals, it is our job to elicit and organize important information. This was a story that evolved with time, patience, questioning, and careful analysis– muddied by the difficulties of practicing medicine in a rural area of a third world country. The level of training of tecnicas makes it difficult for them to convey pertinent information. The technology for them to notify doctors and communicate about it in a timely fashion is limited. Prenatal care is variable and not all practitioners have attended formal school; therefore diagnoses need to be scrutinized. In addition, it is difficult for patients to know what information is pertinent in their circumstances. In situations where information is scarce or nonspecific, our inclination as humans is often to point at a scapegoat. However, our job is to fight for the safety of our patients, regardless of their situation. We endure substantial training, and in these situations– it is our job– not the patient’s to compose the patient’s story. It is in moments like this when we must overcome our inclination to point fingers and focus on two critical skills– analytical thinking and patience– that can elicit one piece of information that can completely refashion our preconceived notions.

Apples and Oranges

In your last year of medical school and your intern year of residency, your

During our busy, Monday morning, I saw quite a few “two-fers” (one of my favorite Minnesota-isms). The mom who I sat in front of now had brought her two children in– her 8 month old baby and her 8 year old gir. As I asked about her baby’s cold symptoms and poor weight gain, the 8 year old girl arose from her chair and quietly walked toward the door to exit the exam room. She looked adorable in her pencil-style, ruffled jean skirt and her striped t-shirt. She was not especially sleepy, and did not wear a grimace on her face. She very quietly announced something to her mother, who acknowledged her words and gave her permission to leave. As the door closed behind her, her mom looked at me and told me, “esta vomitando ahorita”– interpretation– she is vomiting right now. When you are a fourth year medical student and an intern in residency, your learning goals are centered around one important skill– learning how to differentiate between which patients are sick, and which are not sick. There are some clinical signs and symptoms that we use to help us identify those that need faster, more extensive medical attention. We call them “red flags.” One of the red flags in the index red flags within my brain is vomiting. Acute vomiting in a children puts that child at risk for dehydration, and among other things, can be a sign of a serious bacterial infection, a toxic ingestion, meningitis, or an infection or issue with a child’s internal organs– including their pancreas, gallbladder, intestines, bladder, kidneys, appendix… the list goes on… While I sat face to face with this mother, discussing the lively, smiling baby on her lap, my attention shifted to the girl who had just left the room. This girl was sick, and it was up to me to figure out why.

I wrapped things up with the baby and began to ask the girls’ mother what had been going on with her 8 year old. She had had stomach pain for two days now. Yesterday and today, it had gotten so bad that she had begun to vomit. Two days ago, she was tolerating bites of food, but now, couldn’t even keep water down. In addition, she had pain all over her body, which was the worst in her right hip. She had not had fevers or diarrhea. No one else in the home had similar sympotms. She did have a little throat pain. And she had told her mom that it hurt when she peed. I asked her mom whether she had had a urinary tract infection in the past– the answer was yes. I had pretty much all of the information that I needed at the moment– I would learn the most from her physical exam. I palpated her soft belly, and watched her wince with each touch. The pain was worst on her right side– from her hip, up to her ribs. I lifted her right hip up and watched her face wrinkle. To determine whether the pain was within her joint, I bent her knee and twisted her hip inward and outward. Each movement caused her pain. I did the same with her left leg– no pain. I tapped the bottom of her left foot and asked her whether it hurt. “Si,” she said. “Donde?” I asked her, and just as I had anticipated, she pointed to her belly. In medicine, there are a few physical exam tests we do in order to determine if someone could possibly have what we call an “acute abdomen,” which essentially means an acute infection such as appendicitis or organ inflammation such as pancreatitis that could turn into an emergency or necessitate surgery. One test that tests for appendicitis, known as the “psoas sign,” entails lifting the patient’s right leg. If it in uncomfortable for them, it suggests that there may be inflammation of the appendix, which can cause irritation of a muscle that lies under the appendix and extends into our thighs to help us flex our hips. The girl had pain with this maneuver– a positive psoas sign– red flag #2. Another test that we do aims to check for inflammation of the lining of the abdomen, which can also be a nonspecific sign of organ inflammation or infection within the abdomen. One of the ways that we sense it is by bumping the table or tapping a patient’s foot, as any jarring movements are uncomfortable for someone with inflammation of their abdominal lining. The girl had pain in her belly when I tapped the foot of a leg that was otherwise well– red flag # 3. She had some tenderness over her bladder, but not enough to convince me that she had a bladder infection. However, because of her history of urinary tract infections, I tapped her back at the base of her ribs– the spot where the kidneys are nestled into the space between the abdominal organs and the muscles and bones of the back. I asked her if it hurt– “Si.” she said. “A la derecha.” Either her right kidney was sore or the right side of her abdomen had serious inflammation. At the clinic, patients pay for each and every lab out of their pocket– the cost is 20Q per test– a little over $2. However, we do not know how much money each patient has– this amount could make or break their bank. Therefore, while here, I have been extremely careful to not do labs that wouldn’t give me definitive information. However, this girl needed labs. I explained to her mom that there were a few things I was concerned about and told her that labs would be very useful.

I left the room to discuss the case with Marco. I told him about my concerns and findings. I told him that the two things that I worried about were appendicitis and pyelonephritis (an infection of the kidney). He agreed, and we decided that this girl needed both a urine sample and a blood test to tell us if her white blood cell count was high– as both of those tests could greatly help us to make the appropriate diagnosis and give this girl the treatment she needed. We ordered the tests; the girl went to have them done, and I continued to hop from room to room, seeing the boat load of patients that had rushed to the clinic on a Monday morning after watching their symptoms brew over the weekend. In this clinic, we have one lab tech– tests take a while to get done, processed, interpreted, and reported. So as I continued, the girl sat in the waiting area waiting patiently.

About an hour later, as I tied up one patient, and was about to go in to see the next, the nurse handed me a paper with the girl’s results. I reviewed them– her white blood cell count was normal, meaning that a serious infection or appendicitis were less likely– phew. I looked at her urine test to see whether she had a lot of white cells, nitrites, or bactera– all signs of a urinary tract infection. She didn’t have any of those. Phew… but then what was it. Then, my attention shifted to the one thing that was positive on her urine test– red blood cells. “Oh my gosh.” I thought…. Kidney stones. When a person has kidney stones, the “stones,” a collection of one of many precipitates that is filtered out of the blood and into the urine, are relatively sharp. As they move from the kidney, through the ureters, and into the bladder, they irritate their lining and frequently case tiny micro-tears. Therefore, in people who may have stones, we often check a UA for blood. Kidney stones are relatively rare in children who are eight years old unless kids are very dehydrated or have an underlying condition that causes their blood cells to break up, so that certain components of the blood cells are dispersed into the blood and precipitate into stones or if the kid has a metabolic condition that causes the amount of calcium or oxalate in the urine to be high enough to precipitate into stones. In Colorado, we would have likely done quite a few more labs for this girl. In Colorado, we need definitive answers. However, here in Guatemala, what we really need to know is whether a kid’s condition is serious enough for them to go to the hospital.

We decided to use our ultrasound machine to look at her kidneys. None of us in the clinic had enough confidence in our ultrasound skills to know how big a stone was; however, there was no way in which the information from the machine would hurt. We stood around the girl– who at that time, and over the last hour, had been vomit free, with minimal pain. We found her right kidney and worked our way down it. Her renal pelvis (the area where your ureter– a urine tube– joins your kidney to collect and carry urine to your bladder) was enlarged. And downstream from it, there was an area where her ureter narrowed and the dilation of her ureter stopped– we were likely looking right at the stone. We had not way to determine its size with confidence, so now, as a rookie in Guatemalan medicine, I looked to Marco for answers– did this girl need to go to the hospital, or could we send her home?

Kidney stones can be very painful, but usually pass on their own. Therefore, the standard treatment is usually dilaudid– a strong pain medicaiton– and high volumes of fluids to wash the stone out. Even if we sent this girl to the hospital, that is likely what they would do. And her pain was well-controlled. The only caveat was that she was vomiting and would not be able to drink the necessary fluids by mouth. We had her drink a cup or ORT (pretty much pedialyte) and take some ibuprofen. She vomited. We didn’t have any anti-emetics, which are medications to stop nausea and vomiting at the clinic. We would not get the reassurance of seeing her take one and hold fluid down. But it would be very difficult for this girl to get to the hospital. We needed to try everything else before taking that route.

We ended up writing a prescription for her to get zofran– a strong anti-nausea medication used in patients getting chemotherapy– from the pharmacy. We told her to get the medication, then to drink large amounts of fluid. It was still early in the day, so the most important thing, we told her, was that she must return to the clinic if she was still vomiting or if her pain got out of control. With a little unease, we sent her out the door.

This girl had been sick. She had many signs pointing toward kidney stones, and many signs pointing away from serious infections. But we still did not know for sure that that is what was causing her pain. In addition, if they were stones, we did not know why she had them. We hoped she would be able to get zofran and that it would work, but we had no way to know that those things would happen either. And yet, we sent her home. In America, things would have been much different. She would have stayed in the ED for observation for much longer, we would have waited until we were sure she could tolerate fluids, we would have run more tests. But here, time was limited; she needed to go to the pharmacy and these things were not options. We needed to be satisfied with fuzzy answers and hopeful plans. We needed to be satisfied with our triage skills. We needed to trust our diagnostic reasoning.

The girl did not come back that afternoon, which means one of three things–either she got better with her medication, and was at home drinking fluids, passing stones; she did not get better, and was at home in pain, getting dehydrated; or she had gone to the hospital. We would never know for sure. Here in Guatemala, I always think through our decision-making– I think about the potential errors, potential ramifications, and things I would have done differently. And that is all I can do. Things are not crystal clear, but the systems are different, and definitive diagnoses are frequently out of our hands. And so, another lesson is learned, a critical skill in being a doctor in a rural, third world country is trusting yourself and your diagnostic skills, and equally as important– letting go. Medicine in America is apples, and medicine in Guatemala is oranges– sure they have a few fundamental similarities, but when it comes down to it, really, there is little comparison. In Guatemala, at the end of the day, you have no choice but to go to bed and get some sleep so that you can wake up the next day, refreshed– and ready to do it all over again.

A story about jello and limes

When my friends from Colorado, Andrea and Becky, left the finca for the United States, I joked with them about losing my mind in Guatemala without them. The weekend prior to their arrival, after only one week in Guatemala, I had started to write a “Magic School Bus Story” for a blog entry. However, I put a hold on continuing and “publishing” it as soon as they arrived and I had the revelation that submitting such an entry might make my friends and family send a psychologist my way. Andrea and Becky were my reality control– Andrea verified that the Spanish words that flew into my ears were real, had meaning, and were worth listening to; Becky confirmed that the lighting bugs I saw in the forest by the finca were real and that the psychedelic pattern that reflected onto the roof at that clinic existed, and was likely due to rainfall that had collected in some mysterious architectural pocket. Today, after dinner, I sat at the head of the 8-person table house at the finca, holding my spoon parallel to the table with a generous bite of beautiful, purple-red, translucent jello on top of it. I twitched my hand 1/8 of an inch and watched a small peninsula on the jello jiggle at a rate faster than the rest. Now that I am writing about it, I realize it would have been a perfect time to think about the laws of physics and why the variously-sized pieces of jello moved at different velocities. However, instead I giggled. I just sat there, jiggling my jello, and giggling.

Solitude and new experiences are both circumstances that challenge our minds. I have found that over the last few days, while lounging in solitude at the finca, reflecting on my new experiences, and studying Spanish, watching movies, and waiting to see what Rosa put on the table for me to eat, I have felt much like a child again. I have repeatedly compared my actions and experiences to those that I experienced in childhood. At the finca, Rosa plays my mother– she makes my bed for me, creates beautiful meals for me, washes my clothes, and responds to my short, silly attempts to communicate with her with a smile that is so warm, comforting, and sincere that every day, I feel more and more at home. I have felt like a child every morning, as I sit in a giant passenger van, with my ear buds in my ears and my iphone in my hand (for the sake of this theme, no one needs to know that I’m really listening to Spanish lessons or a novel on tape), tuning out the world around me, knowing that I do not even need to open my eyes until I feel the van come to a halt. I also feel like a child at clinic, where every single patient is a new mystery– a game–with clinical scenarios that I navigate through with a new, exciting language, attempting to utilize skills that I have learned, and to ensure that I don’t miss any of the red flags (signs of serious, life-threatening illness) that would lead to those dreaded words–“GAME OVER”–flashing across my field of vision. When I feel I have solved the mystery, I run to tell Marco– who plays my dad, of course– all about it, hoping that he will be filled with pride. I repeatedly find myself fantasizing about childhood and have wondered, for a lack of better words– what gives?!

And today, as I sat down to eat my dinner, which was meticulously laid out and made me feel like a queen as it welcomed me to the table…

I took a second look at my plate of limes, and had a revelation

The skin on this fruit looked like lime skin. The pulp smelled like limes. But… these limes were orange in color. Needless to say, it blew my mind. So simple, but they were so beautiful that I sprung up, ran to my room, and got my phone to take a photo. I didn’t have Andrea or Becky there to be my reality controls– I needed to document that this was happening.

And it was this experience that made me realize that beyond the sense of helplessness, vulnerability, and desire to please that were making me feel like a child, there was even more depth to my childhood analogy. Here in Guatemala, every day, I experience that feeling of wonder and discovery that I felt every day as a child. I continue to discover things that were unbeknownst to me in the past– new infections, new Spanish words, new Spanish grammar points, new fruits. The world around me is mysterious, waiting for me to catch on to its nuances and discover its secrets. Half of my brain feels 28, but the other half is 8 years old.

I went into pediatrics because I greatly admire children for their imagination, curiousity, and sense of wonder. I admire their desire to learn and the implications that their discoveries have on their futures. I may be an adult, and many of those qualities may frequently lie dormant inside of me, but I went into pediatrics because I want to be surrounded by that energy so that I can continue to feed those same qualities within myself. When I signed up to come to Guatemala, I knew it would be special. However, some days I wondered if I had bitten off too big a bite– I wondered if my head would be under water. And I still have a ways to go, and it has been quite a ride; however, today, as I sat at a giant dinner table in a finca in the mountains of Guatemala, giggling at my jiggling jello, with those orange limes gleaming in the corner of my eye, I realized that I feel like a child because I am growing. I reveled, knowing that even as adults, we can embark of endeavors filled with new, apparently scary situations; and every time we do so, the curious, explorative inner-child inside of us will relish in their freedom to run wild.

This One’s For (and From) Tay

Stories of Malnutrition: Third World Problems

In Guatemala, people dress well. All of my patients look nicer than I do in my baggy, frumpy scrubs, with my wild, untamed wild woman Guatemalan hair. When people leave their homes to go to the market, walk on the street, or go to the doctor’s office. In many cases, you would never know the level of poverty in which the people that you encounter live. However, the reality is that many people are living in very extreme conditions. Becky, the fellow with whom I was staying at the Finca this last week, spent her week going on home visits with the clinical workers called tecnicas. These workers track the growth of young Guatemalan children by going into their homes and obtaining anthropometric measurements such as height and weight. They see these kids in their home environments. I have not yet traveled with the tecnicas, but Becky described a few of the homes to me, which helped me to better understand the level of sanitation in the homes around our clinic. Per what described, the homes are made of slabs of aluminum, with sticks propped up to hold up the slabs that comprise the roofs of the homes. Their homes have one room with a bed propped up on a board, maybe a table, and floors made of dirt. The children who live in each home run in and out of the home, as do the household’s chickens and pigs and dogs. Babies play in the dirt. There is no running water or sewage. There is no electricity. Women cook over fire. And to add to that, in Guatemala, it frequently rains. One day, Becky came to me to tell me that she and the tecnicas had told one of the babies from their visits that day to come into clinic, as she had looked very sick. Her name was Maria*. As Becky described her, she was emaciated and dirty, with purulent (pus) discharge from her eyes. She had little energy, and had looked very sick. I welled up with anxiety. Our clinic is loaded with antibiotics. We have oxygen and an ultrasound machine. We have dental chairs with fancy equipment. But despite malnutrition being the number one issue in Guatemala, we have little equipment to address it in the clinical setting. I knew this girl was coming, but I didn’t know what I was going to be able to do for her.

Every day at clinic, I sit at this central station,

wait for children to come through these doors

and then see them in these rooms

We see anywhere from nine to 16 patients each day. This week, we saw a total of 60 patients. Some of them are adults, some of them are women who come in to get ultrasounds, and the rest are children. We see kids who come in with common viruses, serious skin infections, asthma, diarrhea, and pneumonia. For those things, we can often offer easy treatments. But the remainder of the children who we see represent Guatemala’s most prevalent pediatric health condition, one that is considered a crisis within the country– Malnutrition.

At Children’s Hospital Colorado, we occasionally see patients who are labeled as “failure to thrive,” a term that was more recently changed to “growth faltering” in an attempt to be politically correct. However, the former term better depicts the way the children present and the associated issues. Failure to thrive is defined with the help of pediatric growth charts. Any child whose growth is consistently <3% when compared to others their age, or any child whose growth crosses two of the lines that demarcate various percentile ranges is considered failure to thrive. FTT is often associated with wasting (poor weight gain) and later, stunting (which is poor linear (height) growth), and in the worst cases, poor head growth (which is demonstrated by head circumference in the first 2 years of life). The underlying cause of failure to thrive is undernutrition or malnutrition (the difference in the terms being that undernutrition defines inadequate caloric intake, while malnutrition includes deficiency of specific vitamins and minerals that our body needs for us to get from foods). Our "workup" (diagnostic studies done) in Colorado is based on the the medical knowledge that malnutrition can be based on three things– 1) poor absorption of nutrients (e.g. diarrhea, impaired intestinal integrity), 2) increased metabolic demand (e.g. a heart or lung condition causing the heart to need to beat faster and use more energy), or 3) poor intake, which in America is usually due to poverty, complex social situations, or parents having poor comprehension of their child's needs. We do panels of labs and watch kids eating in the controlled hospital setting. We weigh them daily and track their progress, and after days and days and thousands of dollars, in America, poor intake usually ends up being the reason for poor growth. Failure to thrive is often secondary to horribly complex social situations, and even in the setting of Medicaid and established support systems for these complex social situations, failure to thrive admissions are frequently very trying for all of the members of the care team (doctors, nurses, dieticians, occupational and physical therapy) who are involved. Luckily, in Colorado, these admissions comprise a relatively small portion of our hospital admissions.

In third world countries, failure to thrive is more prevalent, and more severe. Many children have frank malnutrition, meaning they are not getting adequate amounts of the many vitamins and minerals that our bodies need for building blocks and to catalyze the reactions that aid appropriate and functional growth and development. In Guatemala, half of children fall under the category of chronic malnutrition, with the prevalence in some areas of Guatemala as high as 90%. Half of children under 5 years of age are stunted, meaning they do not have the nutrients they need to grow tall. Many children exhibit signs of the long term effects of malnutrition, which include goiters (not enough iodine), scurvy (not enough vitamin C), rickets (poor calcium/vitamin D intake), as well as weakened immune system, which makes body more vulnerable to attacking pathogens, or even the common cold, and anemia, which leads to poor brain development, lower cognition, and difficulty obtaining jobs in future

In Guatemala, malnutrition is most prevalent in rural, indigenous Myan communities (a few of which are served at Trifinio Clinic). The rate of malnutrition among these populations is twice the rate of the remainder of Guatemala. However, impoverished children from all over the country are affected.

There are multiple complex reasons why malnutrition is so common and severe here, and why despite Global efforts to address it, which have worked for other countries with even less money, such as Brazil, Honduras, and Nicaragua are cities that are much poorer than Guatemala. Money does play a large role in Guatemala's malnutrition crisis, as there is a big disparity between poor and rich– 20% of population receives 60% of country's income. Because of this, Guatemala's tax base is low, and the government has very little to work with to address poverty (in addition to the fact that money is often shuffled toward other issues within the country). The web of intertwined environmental and social factors is thick and sticky, with other contributing factors including low levels of education; 24 indigenous groups who all speak different native languages– which is an issue in a country in which many of the efforts to address malnutrition are published in and communicated in Spanish; increased prices of beans and eggs (main sources of protein); lack of clean water, which leads to diarrheal diseases; and because the country recently had a 36 year Civil War that greatly affected the country's structure and control, a poor, nonexistent infrastructure. In addition, it's difficult for individual parents to see signs of malnutrition, including stunting, in their own children, as their severely stunted and wasted kids look the same as their neighbors.

When Maria presented to the clinic, she was all cleaned up. There was no goop in her eyes, and she was in a clean dress. However, her size and development were remarkable. Maria weighed 5.5 kg. She is 14 months old; however, based on the WHO standard growth char, she weighed as much as a healthy 4 month old child. She could not sit up (6 month milestone), and could definitely not walk (12 month milestone). She had barely said a single word (at 12 months, babies start saying Mama, Dada, and a few other words with purpose). She appeared tired. Her eyes were sunken in. Her arms and legs, as well as her tiny belly were thin, emaciated, and covered by thick, doughy skin. She did not look around, she just clung to her mother, consoling herself with the comfort of her mom's breast. I examined her and discovered that her heart was racing and her lips were dry. When I pressed on her fingers, the blood took multiple seconds to refill her capillaries, suggesting that she had a very low blood volume due to dehydration. She was not eating, was not drinking, occasionally vomited, and had been having mucousy stools for months. Upon talking with her mom more, I learned that for the last 7 months, she had plateaued in regards to her growth. Every day, she had less and less interest in eating, and when she did eat, she took only one food– potatoes– a food with carbohydrates, but none of the proteins her body needs to grow. She had been malnourished for a long time. And today, she was moderately dehydrated, which meant that she had only a little ways to go before her blood volume would be too low to provide oxygen to her organs to help them function. She looked terrible. We used our limited resources to get a blood count and urinalysis to look for infection. Thankfully, we identified an acute-on-chronic issue– she had a urinary tract infection. And her white cells were elevated– not suppressed– meaning that she still had some semblance of an intact immune system. We could give her an antibiotic for her UTI, but then what? She wouldn't just go home, eat a meal and get better. And she was dehydrated… now. We tried to put an IV in her veins to rehydrate her back to a safe level, but her veins were tiny and frail, and because she was so dehydrated, they were impossible to find. We tried to offer her some oral rehydration fluid, but she did not want to touch it– she was used to her mom's milk and only her mom's milk. We couldn't send her home like that, and it was even more dismaying to think that at home, her mom might not be prepared to force her to drink as much as she needed and that the water she would go home to had a high likelihood of being contaminated. I grabbed a syringe from the back room, and drop by drop, we dripped the fluid onto her mom's nipple as she sucked on it. Drop by drop, she swallowed the fluid, and after 2 hours, had taken enough to be equivalent to the fluid bolus we would have given to her. Now, she could make it through the night. We showed her mom how to give her fluids and emphasized– over and over again– the importance of giving them to her. We gave her an antibiotic, and sent her home at 5:30 pm– long after the clinic had closed. We told her she must come back the next day for follow up. But what would we do then?

The biggest problem with kids who are not eating at all is that even if you do get them to eat, their bodies have slowly adapted to inadequate vitamin, electrolyte, and mineral intake. If they eat, their body responds by rapid changes in electrolytes, which can be very dangerous. In Colorado, we monitor kids who we are "refeeding" with frequent lab draws and IV electrolyte replacements. However, here, the hospitals are far away, and many families refuse to go. Many kids are not bad enough to be admitted, and we have no option but to send them home. Multiple Global Health groups have developed re-feeding formulas that come in prepackaged from and introduce electrolytes in a stepwise process that is essential in order to maintain stability. But at our clinic, we don't have those. Instead, we send kids home, knowing that their water is sparse and likely contaminated, and they either don't have food, or have not been eating for so long that they have developed an aversion to eating, which in the U.S., would take months of therapy with an occupational therapist to address. Third world problems.

Thankfully, Guatemala does have health posts that have treatment for malnutrition, including the packets and follow up. It is something I do not know a lot about at this time, but it is something that gives me hope. The next day, Maria was hydrated. She had taken her UTI medication, and had even eaten a little soup. She had made it another day. We gave her a referral to the health post and told her she must go. In addition, she would need to come back to our clinic to be weighed the next week. Her malnutrition took a very long time to get this bad, and it would take a very long time to get better.

I have seen other kids with the bodily manifestations of malnutrition, too– patchy, coarse hair, poor development, no weight gain. I have seen a broad spectrum, from Maria, to another girl who came in at 9 months, weighing 6 kg– more than Maria, but significantly less than optimal, who had still developed well and was interactive and bubbly. I have seen quiet older kids who are thin and refuse to eat as much as their brothers and sisters. I have seen 3 year old girls with beautiful smiles comprised of yellow and black teeth. Each kid has their own story, but poverty, poor access to water and food, and the dangers of their condition remain the same. One thing that I have learned, and will definitely take time to work on, is that our clinic needs a plan for addressing malnutrition. We need re-feeding formulas. We need education materials. We need an algorithm, and it needs to be feasible in a community without sewage or running water, a community in which diarrhea is common and childcare is sparse.

* name changed for privacy

references, google:
Guatemala's Malnutrition Crisis– World Report
Malnutrition and Undernutrition

Concussion #6– Guatemala

When I was a second year medical student, I decided it would be a great idea to run up the backside of a muddy mountain in an area I didn’t know at all. Prior to that run, I had had 4 concussions in my life. After slipping and face-planting into a pile of rocks, I added another to my list of lifetime accomplishments. My recovery was slow. I was frequently confused, and tired, with disjointed words flying through my mind at all times. I would stand face to face with people who were trying to hold conversations with me, but could not follow what they were saying beyond the first three words. Confusion became the underlying tone of my life story. Learning Spanish in Guatemala feels much the same.

At Celas Maya, my lovely teacher took the time to articulate each and every word– very slowly– to aid in my understanding. And listening to even the best Spanish-speaking gringos was much the same. Everything moved at a pace that enabled me to process and ergo learn from my encounters.

Until today, I had been sheltered within a bubble of American (-ish… that’s for you Andrea) friends/colleagues from CU– an awesome girl named Andrea from Peru who works at CU and is now working for her PhD, and is one of the most hilarious people on earth, as well as Becky Gaensbauer, a resident from my program who recently graduated and is doing a fellowship in Global Health at CU. They were my rocks, my comfort blanket, my friends. Becky’s warm Minnesotan accent made me feel at home (since Minnesota is my second home), and Andrea, whose first language is Spanish, was able to interpret conversations for me and communicate when my skills were ahemmmm lacking. Together, we traveled, ate meals, ran, and sat around chatting about the needs of and plans for the people served by our clinic. However, this morning, they left.

Enter Coatepeque, BANASA, and Trifinio, exit fantasy garden filled with teaching gardens, exit American comfort blankets.

White chocolate snow stands alone.

Every day, I continue to feel more and more comfortable asking patients questions, conveying plans to them, and trusting my physical exam skills. However, that being said, there are surely many useful factoids that are being overtly expressed to me during my interactions, but are slipping through the cracks as I work to interpret conversations in my mind. The nurses at the clinic– especially a very, very sharp one whom I love– have been very helpful by pouring figurative glue into the cracks in the messages I try to convey. In clinic, I am getting by; I feel like I am still making headway.

However, outside of the four walls of the clinic rooms in which our interactions take place lies the real world. The staff at the clinic, including the lab tech, the nurses, the receptionist, the tecnicas (who visit patients at home), and the cleaning lady are all happy, friendly, and great. But they get together and talk so fast that I have virtually no idea what they are talking about. After work, we had a meeting where the staff discussed concerns and we debriefed about the week. Everyone spoke quietly, mumbled, and spoke extremely quickly. All that I could do was listen for the two words that might mean that I had done something royally wrong this week– “residente” and “doctora.” Thankfully, I never heard them (which means there is a 75% chance they weren’t said). My new friends at BANASA are on a boat, and I am doing vertical scissor kicks in deep water with my hands up in the air.

Today, since my colleagues were gone, I ate lunch with our clinic director and the head honchos at BANASA. I met Gustavo, one of the brothers who owns AgroAmerica, the extremely rich company that owns BANASA and funded part of our clinic. I also met the other important men of BANASA– the engineers, pilots, and accountants who handle their money. I ate shrimp, calamari, and fish curry while I sat in their company. I analyzed the dynamics of the group and confirmed the well-known fact that money equals status; however, when I tried to comprehend what the happy group of men discussed as they slurped down their lunch, my brain became a seive. I was able to catch one word for every 20. Not enough to get by.

And ten minutes ago, the interaction that prompted this entry occurred. Rosa, the wonderful woman who prepares meals for us at the Finca daily, stood over me as I ate at the giant 8 person dining room table. I told her that I didn’t need her to make breakfast or lunch for me tomorrow– that I would get by– and in response, she shot at me with rapid fire a string of words that my Swiss cheese brain let right on through. I caught one for every 10– an improvement, but walked away, knowing that something will happen at 5 tomorrow, that something can happen with pancakes, that I can use the microwave, and that I can prepare my own food. It is as if the constant rapid fire is what is causing my brain to gain more and more gaping holes. I know I will learn grammatical details, slang, and more and more vocabulary with time. However, in the mean time, I will go to sleep and let my aching brain dream about how on earth I am going to make pancakes in the microwave.

Mis pacientes

This is beginning to feel real. This is work. I am getting paid (by my residency program, of course). I am a doctor in Guatemala, and I am doing things that would have been impossible nine days ago– I am speaking to nurses, my patients, and their parents in Spanish. I can understand what they’re saying, I am seeing things I’ve never seen in American clinics and treating kids with medications we never use at Children’s. This is why I came here.

Prior to arriving, I had only read about the pediatric conditions, diseases, and problems I would find in Guatemala. It was difficult for me to conceptualize what I would see in this clinic– I wondered, What would the kids be sick with? How will it differ from what I see in America? Will I be able to help them? I had read a lot about Guatemalan children’s most prominent health issues, including malnutrition, and resultant anemia leading to poor brain development (a.k.a. kids not having enough blood cells to carry oxygen to their brains leading to poor brain growth and development). I had read multiple articles about health surveys that had been done here to identify Guatamala’s problems, one done by Dr. Asturias (whose Finca I’m staying at) and Dr. Gaensbauer (an I.D. attending whom I worked with here yesterday). Prior to leaving for Guatemala, I spoke with a doctor who had worked here in July on the phone; she told me that “kids do not come here until they are very, very sick.” I imagined that all of the children would present to the office either severely dehydrated and sick from their diarrhea or about to decompensate (go into a dangerous medical state called shock, in which the body’s important organs are not receiving enough blood to function well) from serious infections. What I have found is that the children here are equally (well, who am I kidding– they are more…) adorable, and that as seems to be a theme in life, many are the same as American kids, coming to the doctor with similar sympoms, fears, and complaints. However, that being said, there are definitely things about this clinic that differ significantly.

One of my best friends, Jane, has a philosophy that the first three days of everything blow. The positive message behind her philosophy, though, is that the first days alway entail adjustment, but are worth pushing through because after you adjust, things undoubtedly begin to flow.

Yesterday (my first day) was quite an adventure. I felt like a first year medical student again. We started the day with a tour of the lab, where we heard about the lab’s capabilities (currently limited to blood cell counts, stool sample analysis, urinalysis, malaria tests, HIV tests, and pregnancy tests). When we were done with our tour, the patients who had been waiting after checking in at the front desk and were escorted to the clinic rooms. The nurses checked their vital signs and called for me to work my magic– “Doctora, su patiente es listo!” The very first patient I saw was a 18 month old girl who was SCREAMING from the moment she walked into the clinic. Screaming patients are hard enough to see and examine in the United States, but the plot of this screaming child’s encounter was especially thick, as this was the first time I would need to see a Spanish-speaking patient and actually speak in Spanish, myself. I yelled over the child’s crying to talk to her mom in basic Spanish, with robot-like cadence. She barely seemed to hear, let alone comprehend the questions I asked. And even worse, I could hear very little of what she was saying. I was able to gather that her infant had developed an isolated cough (no nasal congestion or other upper respiratory symptoms) 15 days ago, and that she had a significant amount of phlegm that was coming up, especially in the evenings. She had not had overt fevers, and had also been complaining of pain in her ear. She was also inordinately irritable. No vomiting, diarrhea, or extreme sleepiness. No one in the family had the same cough. I reached the limit of my history-taking abilities and proceeded to examine her. She screamed through the entire exam and both of her ears were impacted with dark yellow/orange cerumen (wax), meaning that I was unable to examine the two most important things in this child– her lungs for signs of a pneumonia, and her ears for signs of an ear infection. I left the room feeling confused about where to go from here, with the words of the previous pediatrician haunting me, screaming– “kids only come in here when they’re really sick.” I felt completely helpless. And that is why I recruited the help of Dr. Marco Celada, our clinic director…. and that is why he’s here! Marco also talked to the mom through the child’s screaming and elicited a fact that I had not known to ask about– the mother had taken the child to a pharmacy 15 days ago, and she had been treated with ceftriaxone. (Here, parents frequently bypass clinics and take their kids to pharmacies, where they are either given an antibiotic based on the pharmacist’s best guess, or they have the option to bring labwork from other, unconnected labs, not connected to the doctors, and the pharmacist will prescribe a medication based on those results. Slightly sketchy…) Marco couldn’t see her ear drum either, and we discussed her case. In Colorado, we would have calmed the girl down, cleaned out her ears, checked her pulse ox (which indicates whether a child’s blood is carrying enough oxygen), and would likely have gotten a chest xray for her. However, here, none of those things were options. She would not calm down. We ended up treating her for an ear infection and giving her an expectorant for her cough. In Colorado, I would have done neither– I am skeptical of antibiotics, as we have not studied their long term effects on children’s gut flora, and some studies have linked early antibiotics to changes in absorption of nutrients, therefore, longterm obesity. Most ear infections get better on their own; they are really only dangerous in babies, who cannot tell us if they are feeling worse, confused, or having severe headaches linked with rare complications of untreated ear infections. However, here, we had no choice. In addition, I vividly remember an entire lecture that I received during residency on the futility of expectorants in young children. This medication would not help– the child’s cough would likely get better on its own. However, this baby was crying, her mom was worried, and the mom expected us to give her something to make her child better. The way that this patient presented and her complaints, were the same as those we would see in Colorado. However, the treatment we had prescribed defied all of what I had learned. Welcome to Guatemala, Doc!

The other patients I saw yesterday had a variety of things– I saw an adult with a URI, a 12 year old girl with (what seemed to be) strep throat, a boy with persistent diarrhea, and the rest have already blurred together. I fumbled with my Spanish and graciously accepted help from the assisting nurses. For every patient, I had to broaden my differential (the list of medical conditions that we, as doctors, need to consider when asking questions and making a diagnosis). I had to think outside of my previous comfort box, knowing that there are different and more serious diseases here, and that I could not just ask patients to return the next day, or trust that they would be able to identify true distress and/or be able to get their child to a hospital fast enough. In fact, rumor on the streets here is that the hospital in Coatepeque– the hospital closest to the clinic– recently had an outbreak of a dangerous, slimy, hard-to-kill bacteria called pseudomonas, and that it had killed 12 patients. As a result, many people are hesitant to even go there to seek care. Guatemala has many different problems and many fewer resources– it was already proving to greatly affect the way that I practiced medicine. In just one day, I transformed from a confident resident into a bumbling character named Doctora Kraynik. However, all in all, what I did still felt worth it.

Today, day #2, I arrived at the clinic, ready to do it all over again. I had gotten sleep and had my fill of caffeine in the morning. My conversations were still choppy and limited to the words in my very-limited vocabulary. However, I did notice a difference. I prefaced every encounter with the disclaimer that I am learning Spanish, and asking parents to speak slowly to help me understand. They humored me and seemed much more patient when I asked them to repeat or clarify things. I saw a baby with a URI, a kid with an abscess, a kid with impetigo (a superficial skin infection), a kid who had had abdominal distention the day before, but was better today after pooping, and then came the patient that fulfilled everything that I had hoped for here in Guatemala. He was a 10 month old with.. diarrhea. (Disclaimer– if you think poop is gross, stop reading).

His mom carried him by me and into the clinic room where he would wait to be seen. He was thin, with stick arms and legs. His eyes were slightly sunken, but his lips were moist. I smiled at him, and he smiled back with 4 beautiful white upper teeth and 2 middle lower teeth. He was adorable. However, the most notable thing about this baby was his little belly. His mom held him across her chest, and her arm compressed the area below his belly button. Over that, his abdomen was grossly distended, significantly out of proportion to his size.

I followed him and his mom into the room and introduced myself with my disclaimer. This baby had had diarrhea for 3 days, just constant, runny, clear, yellow-tinged diarrhea. He was not vomiting, and his diarrhea was not bloody. He was able to drink “sueno,” which means “serum” in Spanish, but is ORT here– in the U.S., we call it pedialyte. However, today, he was refusing to eat. His mom was worried, and after examining him and finding that he was mildly dehydrated, so was I. I told the mom we would be collecting a stool sample and looking at it in the lab. The nurses gave her a stool collection cup and sent the mom to the waiting room, waiting for him to fill his diaper. Ten minutes later, the mom came back, holding her baby, who was now half-naked from the waist down. “His stool is too liquidy to collect,” she told us in Spanish. As quickly as he stooled, his absorbent diaper had soaked it up. The nurses and the lab techs trouble-shooted, and ended up putting a black plastic bag in his diaper. Ten minutes after that– success! His mom was right– his stool looked the same as water. We suctioned it up and put it in a cup and Carlos, the lab tech and I walked it over to the lab. I watched as he centrifuged the sample (spun it very fast in a machine so that all of its dense components would sink to the bottom), then placed it on a microscope slide. Next, he looked at it. As he looked over the slide, I crossed my fingers that we would find something. Not because I was curious or wanted to see something under the microscope– although that was a bonus– but because I if this was a virus (which not being able to find something would likely mean), there was no way of knowing how long this baby’s symptoms would persist, and he was at risk of becoming very dehydrated. “Aye!” the tech exclaimed. “Mira!!” I looked into the stethoscope, and wiggling at the base of the slide, were two giardia protozoans, appearing picturesque, exactly how they had appeared in my medical school textbooks. The kid had giardia.

Giardia is well known in the United States as to protozoal pathogen that campers fear and dogs occasionally get from drinking contaminated water. It is notorious for causing abdominal distension, flatulance (gas), and malodorous stools. It is very uncomfortable to have, and is one of the many pathogens that resides in the stagnant waters that surround us in Coatepeque.

Here is its lifecycle for those of you nerds:

The best part about malaria– it is completely treatable, and we stock the treatment here in our clinic. I eagerly walked to our pharmacy and fetched a bottle of nitazoxanide, the anti-protozoal medication that I would give to the patient. In our pharmacy, we store it in bottles as dry powder, and we have to mix it up as a solution for our patients. I added the water as the directions instructed, and carried it to the patient’s mom. I gave her the medication, which her kid only needed to take twice a day for three days, and told her how giardia is aquired. I emphasized the importance on hand-washing and boiling water for 15 minutes, and gave her return precautions. Then, I watched as she walked away. This was my patient. I has seen him from start to finish, had functioned as his doctor, his lab tech, his pharmacist, and his informer. Suddenly, I felt like I actually could make a difference here.

Don’t get me wrong– my Spanish is still relatively AWFUL, I have difficulty comprehending speech when people speak quickly, there are many things I do not know or understand. But days one and two are over. Day three still waits, but I have twice the experience that I had yesterday. Shit will undoubtedly get crazy here (literally), but this is why I came here and suddenly, I feel like a doctor.