By The Numbers

Here’s how I spent the afternoon two weeks ago before the rest of the group arrived: me, my book, and a mango/pineapple/coconut smoothie in a beautiful little restaurant in Flores.  I actually spent most of the day catching up on email, work, and preparations for the arrival of the group, but I couldn’t resist a little relaxation (and this photo op). 

Pretty far cry from the first 4 weeks I spent here.  After taking a little bit of a reprieve, I spent some time over the last couple days with the data and figured I’d share some of it with you.  Keep in mind, these numbers are still rough and based on an incomplete data set at this time.  Nonetheless, they’re pretty interesting.  (At least I think so.) 

• Total paps: 1056
• Total number of abnormals: 96 (9%)
• 14 possible cancer (squamous cell or adenocarcinoma)
• 41 mildly abnormal (ASCUS)
• 15 low-grade (LGSIL)
• 17 high-grade (HGSIL)
• VIAA (see this post for more info)
• 11.4% positive
• 13.8% unsatisfactory
• This shows one of the limits of VIAA because when you can’t adequately visualize the whole transformation zone (postmenopausal women, obese women, etc.) then you should call the VIAA unsatisfactory…  if this is the main screening method, then what do you do? 
• I didn’t take the time to do any real statistical analysis of VIAA because I want to wait for the full results, but it’s easy to see that there are a lot of positive paps with positive VIAAs and also a lot of positive paps with normal VIAAs (see this post for my frustration with VIAA). 
• Total number of (hopefully curative) treatments: 36
• 24 cryo
• 12 LEEP
• Other interesting stuff (based on data from about 350 women):
• Average age: 38.5
• Youngest: 17 years old (we tried to limit to 25 and older, but about 30 younger ones slipped in by oversight or persuasion)
• Oldest: 86 years old
• Pregnancy history
• Average number of pregnancies: 5.33
• Highest: 17 pregnancies
• Average number of living children: 4.42 (others lost to miscarriage or death after birth)
• % with 6 or more: 39.4%
• % with 11 or more: 11.5%
• Average number of children that died after birth: 0.40
• For patients with at least one that died, average number: 1.60
• Largest number of children that died: 8
• % with at least one child that died: 24.9%
• Deliveries
• % with all deliveries at hospital: 21.6%
• % with all deliveries at home: 45.4%
• % without electricity: 204/568 = 35.9%

Pediatría, Ginecología, y Medicina General

The last week was busy, fun, and productive.  Each day we were met by patients patiently waiting for us on the porch of our clinic.  It was fun to have kids in the clinic this week, even though it means a bit more crying and general chaos.  They keep things interesting and the parents are especially appreciative for the care.  We didn’t see too many kids we would actually consider sick (there were lots with colds, fevers, and worms), but the visits gave us a good opportunity to do some important education: Boil water to decontaminate it, especially for the babies.  Not all illnesses require medications (the local clinics are infamous for handing out pills for everything, so people come to expect it – in fact, I often wonder if they think we aren’t very good doctors because we don’t give prescriptions to each patient).  Just because a medication is available in the farmacia, it is not necessarily safe.  For example, a “baby aspirin” (often used in adults for heart disease protection) dissolved in water is not a good treatment for an 18 month old with a fever.  Unless sanitation in the household can be drastically improved, the kids are likely to get worms regularly and probably require treatment a few times a year. 

On the adult side, we continue to struggle with how best to manage chronic diseases in our clinic.  The majority of adult patients we saw had diabetes, hypertension, gastritis / GERD, musculoskeletal pain, or some combination of some or all of those.  While we have a pretty well-stocked pharmacy at the clinic, we don’t have enough to provide year-long prescriptions to each patient.  When patients come to us, they are often out of their meds for an undetermined amount of time (often they say they ran out last week).  Our approach is to discuss the disease with them, give them about a month’s worth of meds, and encourage them to follow up at the local Centro de Salud.  Our hope is that they can see if the meds are working, change dosing as appropriate, and receive the prescription.  Health care is purportedly free here, but I never cease to be shocked by how inaccessible it is.  Even the patients that do follow up to get refills on their medications report that the clinics are frequently out of basic medications (contraception, blood pressure meds, diabetes meds).  The balance of providing needed services while refraining from undermining the established system remains a challenge.  I encountered more than one patient that had visited the clinic in December when the last team was here, was started on a medication, and then ran out without following up until we were there last week.  There’s an inevitable belief that the “American doctors” know more than the local doctors, so we tread lightly when trying to discuss missed diagnoses or incorrect medical advice that has been given.  We try to remain aware of the sustainability of our interventions – we are wary of prescribing medications that require any sort of concerted follow up and we center everything around what can we actually treat (for example, do we really need that biopsy?  Will it change our management?).  Even though care is “free” in the government system, patients are often required to pay for lab tests, ultrasounds, etc.  One patient told me how she tried to get prenatal care at the Centro de Salud, but when she was unable to afford the blood tests they ordered they refused to see her for the remainder of her pregnancy.  Working within this system is a challenge. 

Probably a third of the patients we saw were pregnant, and obstetric care continues to be my favorite part of medicine.  The special draw for these patients was that we were offering ultrasounds.  The excitement they expressed at seeing the ultrasound (often their first, despite many previous pregnancies) made the work so much fun.  I had the extra treat of getting to have Geoff and Jeremy join me for some of the ultrasounds, which was a first for them as well.  Their excitement and awe might have been even more adorable than that of the women!  Getting to work with them this week was a wonderful experience as they were eager to learn and ready to do whatever they could to help – a perfect combination.  I think it was probably good practice for me as I move into residency where I’ll frequently need to balance learning and teaching. 

When we had made some free time to step out of the exam rooms, we had fun playing soccer with the kids on the porch, grabbing a bite to eat (Coral and I started making bakery runs each morning – only part of this was in the hopes that the woman would let us in the back to learn how they make everything!), and enjoying each other’s company.  The team was great, and with so many people to lend a hand everything ran smoothly.  (In contrast to last month, when I felt like we were constantly struggling and stretched in 5 directions at any given moment!)  It was bittersweet as we wrapped up clinic Friday and prepared it for the next group to visit, probably in June.  Should be quite the adjustment back to the hospital medicine we spend so much of our time pursuing during training.  Lucky for me I have no more inpatient rotation between now and graduation – although it might not be as great for my patients (and attendings) that have to bear with me come July…

And Then There Was One

Writing this from Antigua, an old, touristy, colonial city about an hour southwest of Guatemala City.  It was founded by Spanish conquistadors in the mid-1500s as the capital of Guatemala (incidentally, this was the third site they chose and it has since been moved to Guatemala City).  It is best known for its beautiful Baroque architecture that sits in stark contrast to the ruins that sit throughout the city as a result of a collection of earthquakes in the 1700s.  Enough history, just wanted to set the scene.  Probably would have sufficed to say that this is a beautiful city where I chose to spend my last 24 hours in Guatemala. 

A little taste of Antigua, stolen from the internet - real volcano in the background!

Friday night the rest of the group left after clinic to fly back down to Guatemala City for Saturday flights.  I maintained my budget student travel stubbornness and took the overnight bus down on Friday night.  As it didn’t leave until 10pm, I was able to spend the night with Orfe and Ismael after the rest of the group left around 6:30.  We hung out at their house (“Just like old times,” as Ismael told me) and enjoyed a delicious dinner (tamales, beans, cheese, cream, tortillas, etc.).  I played with Anita before bed and Orfe and I chatted for a while – we talked of plans for future visits, upcoming events, etc.  After a very tearful goodbye, I boarded my bus and settled in for the night. 

I arrived in Guatemala City around 6:30 and headed to the hostel where the group spent the night.  By the time I arrived, most had already left for the airport.  Jeremy, one of the medical students on the trip, wasn’t leaving until 3pm, so we decided to spend the morning together in Guatemala City!  Despite flying through a few times, I’d never ventured out into the city, so I was excited to have company.  Basically, our day revolved around eating.  We found the Mercado Central and after getting pretty overwhelmed by the sheer volume of stalls and goods (everything from traditional textiles to ceramics to fresh flowers to shoes), we found the food and decided to throw caution to the wind.  I think we figured this food looked too good to pass up, even if we did get sick.  Happy to say, I’m still feeling great.  We settled down to a pretty hardy lunch, which we selected by each pointing to a number of things, getting brief descriptions to assure they didn’t contain anything too gross (pig liver), and then splitting it all in two.  As we were about halfway through, we realized it wasn’t even 10 am.  This actually made us quite happy, because we realized we could justify another meal as “lunch” before heading back to the hostel.  The food was amazing, but you’ll have to wait for pictures as unfortunately my camera died this week, so the only pics are on my phone. 

Jeremy and I also explored some of the city (mostly to walk off the food and make room for more), and saw the Palacio National and the Metropolitan Cathedral.  We also happened into a random mall that contained a clothing store like Ross, a game store, a bakery, a cell phone store, and a casino.  We followed a trail of adorable little 4 to 9 year old ballerinas (I promise Jeremy was intrigued by them too) into some sort of building that seemed to be a combination of a center for the arts and a post office.  There were painting classes, balloon-animal-making classes, and clearly some sort of dance recital, all in a gorgeous historic building.  Again, I apologize, but pics to come. 

Eventually, Jeremy and I parted ways and I caught a taxi to Antigua.  The day was an amazing contrast of excitement, relaxation, anticipation, and nostalgia.  The city is busy and beautiful, with wonderful markets everywhere you turn and way too many opportunities to spend money.  (Don’t want to come home with a wallet full of Quetzales…)  At the same time, I’m sad to be leaving and can’t help but wonder how the last 6 weeks slipped by so quickly.  The fact that this week is Match Week doesn’t help either – it’s been nice to be in my Guatemalan bubble here, surrounded by wonderful people and a true sense of purpose on a daily basis.  I think I’m going to feel a little lost back in Toledo, although there is plenty that needs to be done. 

My day and night were spent shopping and wandering.  I watched some soccer with locals in the market and happened across a jazz concert (apparently this is Jazz week in Antigua??) in front ruins of the façade of a former church.  Despite the bustle throughout the city, it was very quiet for me and the first time I’ve been this alone in 6 weeks.  Even the other three beds in my hostel room remained empty!  Now, I’m finishing up, catching my bus, and heading to the airport for a day of travel.  Hopefully things will go smoothly – but I think anything will seem smooth after the chicken buses (picture retired US school buses with people hanging out the doors and only half the seats in working order) that seem to have no sense of a schedule or set route! 

Back To The Clinic

It was brought to my attention that an uncomfortably large number of my posts deal with babies that are the subjects of my obsessions.  I can reassure you all that the likelihood that I will be coming home from Guatemala with a child is zero negligible low.  This post will include no pictures of babies (mostly because my camera broke). 

As of yesterday, the whole group has officially arrived and we hit the ground running.  There are eleven of us in total, with 4 actual doctors – pretty big difference from the first month, when there was just Anne and two halves (me and Puja).  Funny thing is we’re not seeing that many more patients, although the clinic is entirely different.  First of all, I have done ZERO paps in these two days.  Second of all, I actually have used my stethoscope and physical exam skills targeting areas above the umbilicus, which is refreshing.  We are running a full service clinic, and the patients I saw today ranged from a 3 week old baby with feeding issues to a 27 year old pregnant woman to a 55 year old man with a frozen shoulder to a 75 year old woman with abdominal pain.  Luckily, it’s all reminding me why I’m excited to be a family doctor. 

Today and yesterday we had clinic in Las Viñas, a village about 15 minutes up the road from El Naranjo, where I spent the first week of the trip.  We were about 30 km from Belize, but despite my best attempts I couldn’t convince Ismael to take us there for lunch or dinner.  For a variety of reasons, we have faced some difficulties in holding our clinics in established Centros de Salud, so when we were thinking of coming to this village we looked for other options.  This community is wonderful (this is the one that I wrote about here where over 100 people came out to the introductory meeting about starting the Kids Against Hunger food in the village) and jumped at the opportunity to have a couple days of clinic there.  They quickly had a family volunteer their house as a clinic site!  The house was beautiful (gorgeous tiles throughout, three good sized rooms – hopefully I can post pictures at some point) and the family was unbelievably accommodating.  They offered to move out all of their furniture, insisted on cooking for us throughout the day, and even spent most of the day helping clinic run smoothly.  It was an unbelievably selfless act, as the only real benefit they got was that their family members were seen first during the day.  As I spoke to the woman, Sandra, it was clear that the motivation was to help serve a need in the community.  What a great example. 

Yesterday I spent most of the day with Carrie (family medicine resident) doing general adult medicine.  After so long I was completely caught off guard when the first male patient walked into the room – I actually thought he had wandered into the wrong place before I realized we were no longer doing female-only clinics!  Carrie is continuing on to a sports medicine fellowship and I was able to witness a lot of her osteopathic manipulation methods.  In the coming days I’ll hopefully learn joint injections and better musculoskeletal exam skills.  Today I spent the day with Gary, the pediatrician.  I thought I was mostly going to be his translator, but he essentially allowed me to work independently with him as preceptor.  It feels good to push my knowledge and abilities a bit, especially since I think there are more than a few spider webs after a long time out of clinic.  Can’t tell you too much more, since I promised not to make the post about the loads children I saw today…  Suffice to say, they were adorable. 

These two days were much busier than we expected – showing up this morning to a porch already brimming with patients brought me back to some of the clinics last month!  The desperation these patients have to be seen in our clinic (and the determination they show by waiting for hours even when we say we don’t think we’ll have time to see them) points to the myriad of problems they face in finding care here.  Luckily, we were able to work efficiently enough to keep from turning anyone away today.  The balance of efficiency and providing quality care remains a constant struggle. 

I’m looking forward to three more busy days at our Santa Ana clinic.  It’ll be nice to be a bit closer to Flores, as the days have been long (getting home around 8 or 9 the last two nights) with over an hour drive each way to clinic.  Plus, we can’t help but feel a bit at home in our little clinic.