Another Week

Hard to believe another week has flown by – half way through this pap smear intervention project and a third of the way through my time in Guatemala.  This week we were in La Libertad, a larger city of around 90,000 people about 45 minutes southeast of Flores.  The community was pretty different than El Naranjo in that it had an actual downtown with vegetable markets, clothing stores (really just random clothes from the US), “pharmacies”, schools, and tons of shops.  The streets are crowded with people, dogs, bike-taxis, and cars.  I didn’t manage to take any pictures, but I’ll try to get some and post them soon. 

The bustle of the streets was completely eclipsed by the chaos we found each day upon arriving at clinic.  The clinic is a functioning Centro de Salud that has weekday clinics run by a couple Guatemalan doctors and a 24 hour emergency room.  The doctors and nurses were all very helpful and supportive the first day, but not quite as happy the following days when their waiting room was flooded by over a hundred women wanting pap smears!  Some of the women traveled up to 4 hours to see us – leaving as early as 4 in the morning because if they weren’t there by about 8 am they wouldn’t be seen.  

As women arrived, they were given numbers and each day there was a cut off past which numbers were no longer distributed.  It was absolutely heartbreaking to have women begging me to let them be seen and having to explain we were already overwhelmed by the number we’d promised to see.  Luckily (for me, although probably not for the women because I’m way more of a pushover than most), the numbers were controlled by the nurses or social workers at the clinic.  I think the clinic technically closed at 4:30, and thus they tried to limit our patients even though we were there past 6 most nights.  Puja was amazing, doing 60+ paps some days so that we could see over 90 women.  When Anne is available to do paps she can be so fast, but much of her time is taken up with counseling, colposcopy, biopsies, and treatment – often up to an hour per patient.  Puja and I are at once jealous of the time she gets to spend with the patients and their families and so relieved we aren’t the ones delivering the news of a cancer diagnosis.  

Puja making friends - couldn't resist a pic of this shirt

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Earlier in the week I urged patients to come back another day to try to be seen.  Yesterday, we didn’t have this option and the pleas got much more urgent.  We were all exhausted and had to get to the airport to pick up our reinforcements (a new cytotech and Anne’s husband Randy), so Anne made the decision to cap our patient load at 70 for the day.  While we were approaching number 70, it became clear that there were a number of women still waiting to be seen without numbers.  Despite being told numerous times that we couldn’t see more than 70 patients, these women waited all day with the hope that we might change our mind.  As we finished up with the first 70 around 4:30pm, Anne still had a couple patients with abnormal results to see.  Anne was adamant that we not see more patients because she worried they’d just keep coming, but Puja insisted we see those that had been waiting.  I prepped the remaining patients and we tried moved through them quickly, but found that almost every one had a story of childhood abuse, family members that were killed, or domestic violence. 

The cytotechs worked quickly to get the results for the patients, but things came to a halt as they confirmed that one of the last women had cervical cancer – the same one I’d spoken to at least one time earlier in the day explaining that there were just too many women for us to see them all.  She was a wonderful, friendly woman with a relatively toothless smile that sat patiently all day with her granddaughter.  I held her result in my hand (it just read “carcinoma”) for at least 30 minutes while waiting for Anne to finish with her last patient.  Finally, I told the patient her results were ready while ushering her into the exam room.  Puja entertained the granddaughter, getting her to help us pack up our supplies while also convincing her to study hard and maybe become a doctor.  As the patient emerged, she was clearly shaken, but still mostly just thankful.   She came around to each one of us, hugged us, kissed us, and thanked us for helping her.  It’s so upsetting to think that this diagnosis should have been completely preventable.

Now we wait for biopsy results, hoping that they show the cancer isn’t invasive so that a LEEP procedure in the next two weeks is an option to remove the cancer.  It’s very unlikely she’d be able to travel to Guatemala City for the limited treatment they have there if her cancer is invasive.  At the same time, we are left with the unbelievable lesson of just how much we are needed by each of these patients.  Despite the fatigue, it’s hard to not see as many patients as possible when you know that our exam could save the life of the next patient.