Apparently I’m Really Bad Luck

Today was a really hard day.  Normally people abide by the rule “don’t mess with a good thing.”  As I described before, we’d gotten pretty good at our system: me triaging and prepping the patients with Anne and Puja doing the exams.  I loved getting to work on my Spanish and truly talk to the patients about their lives.  Puja was really getting the hang of VIAA and maneuvering the patients into the correct position for an exam.  Anne was available for colposcopy or treatment as needed.  It was going well, but today we decided that we should switch it up so that Puja and I didn’t end up getting burned out.  Seemed like a reasonable idea.

In the hospital, providers are often described as being “black clouds” or “white clouds” depending on how the service goes while they’re on call.  Today, I couldn’t help but feel like a black cloud.  It seemed like every time I came out of the room, the lab was telling me about another one of my patients with an abnormal result.  These weren’t borderline, mildly abnormal pap smears, but rather at least two high grade dysplasias with the possibility of being microinvasive cervical cancer in women under 30.  That is in addition to a few lower grade dysplasias and a possible endometrial cancer (AGUS pap, favor endometrial type) – all in the 30 patients I saw!  Instant feedback is a great thing, but it can also be pretty overwhelming.  These diagnoses, of course, come on top of the distressing stories of abuse, violence, loss, and poverty that are commonplace when we speak to these women.  

I couldn’t help but be discouraged, especially as I wasn’t able to recognize the majority of these cases as positive with the VIAA.  Anne thinks this is just further evidence that VIAA is really a poor substitute for a formal cytology program with pap smears.  A part of me knows that she is right, but also worries that it’s also my inexperience.  Again, she reminds me I can’t expect to match her 20+ years of experience after a few days in a Guatemalan clinic!  Good news is that our cytotechs are right here to screen the pap smears and guide our follow up appropriately.  In addition, Mani kept trying to remind me today that finding these abnormal results is a good thing, because we should be able to provide curative treatment for these women that they may never have had access to otherwise. 

Between patients today I learned the Spanish word esperanzar, which means to give hope.  Maybe I need to keep that in mind a bit more.  With that thought, I’m heading to bed now and looking forward to another busy, productive day tomorrow.  And just in case this whole black cloud thing has any truth to it, I think Puja and I will be switching back to our usual roles! 

First Week Recap

Sorry for the delayed postings…  there were a number of limiting factors the first week including 1) no internet and 2) no time / energy.  Actually, I had a lot of energy, but by the time I made it back to our room it had been pretty drained by work and patients and trying to semi-proficiently speak Spanish.  All of that being said, the week was wonderful, educational, productive, and moving all at once.  I just want to give a recap of the week, because otherwise I risk being perpetually behind on this blog (which I know you all would find very surprising).  

Women waiting in front of the clinic to be seen.  One day I was seeing the last patient after 6 pm and I asked her what time she arrived: 8 am!!  They just sit without complaining.  So hard to believe that getting this care is that important to them. Makes you think twice about complaining.

We spent the week at a clinic in El Naranjo, which is a small town near the Belize border.  The clinic has the greatest nurse, Glenia, that was amazingly helpful to us all.  Sometimes we get really discouraged by the health promoters and nurses in the areas we work because some seem to go out of their way to avoid making more work for themselves (and thereby avoiding doing what is really needed in their communities).  The clinic and community provided a great way to start the trip.  They are all very aware of the problem posed by cervical cancer because a young woman named Flori died in the community recently (her story to come later – she really deserves a post of her own).  We worked Monday through Saturday and did pap smears on about 210 patients, a number of whom returned for biopsies or cryotherapy treatment if their exams or pap smears were abnormal. 

 Ismael and Lisa (cytotech) doing some teaching with the women about how pap smear cytology is done.

Puja inputting some data in one of our exam rooms - note the cryo tank, table without stirrups, wood steps up to the table (the patients make me look like a giant), and the educational posters.

By Saturday we really had the flow of the clinic down – Puja and Anne each have rooms where they do pap smears and VIAA (visual inspection with acetic acid).  With the help of Orfe (Ismael’s wife, works for Sew Hope full-time) and Glenia, I work all of the patients up before they go to the exam rooms.  We have an extensive history form, because a large purpose of this project is to get data about cervical cancer, HPV, and risk factors in the region.  We ask about everything from full obstetrical histories to whether they cook with fires in the home to information about childhood sexual abuse – as you can imagine it’s not exactly easy in a busy clinic, but we’re doing our best.  My Spanish is really being pushed to the limit, but it’s improving immensely and getting easier every day.  I am starting to feel like I can just ask or say exactly what I want, rather than simply trying to find a way to get my general point across.  When I’m at a loss, Orfe is always there to chime in, which is very reassuring.  Puja and I agree that often it seems she says the exact same thing as we do, but with less enunciation, and the patients answer immediately rather than staring blankly as they often do at us.  Like I said, still lots of room for improvement!

We stayed at a beautiful little motel-type place about 25 minutes from the clinic.  It was a sort of walled-in villa that was barely noticeable from the road.  They served us breakfast and dinner each day, and we mostly had the place to ourselves.  As our first week, it was such a help to have the freedom to all be together in such a relaxed atmosphere.  

Week 1 "hotel" near Naranjo

The days were long: usually breakfast around 6:30, returning after dark around 6 or 7, then sometimes data entry or other preparations for another couple hours after dinner.  And of course, no internet – I think this was actually the first time I’ve gone for a week without checking my email!  Overall, the week was a great success and I can say with certainty that there were women that we identified and treated with cervical dysplasia (pre-cancer) that now will not progress to cancer.  The treatments and screening (colposcopy) are often interventions they cannot afford if they even are diagnosed, so being able to provide it free is a huge gift.  I can’t wait to see what the next weeks bring!

Our 15ish seat van that is often piled high with luggage.  Every morning when we pack for clinic we look like a family going on a week-long vacation.

Getting to the Petén

Turns out actually getting to Guatemala was the easy part.  The hard part was getting from Guatemala City to the Petén – but mostly because Puja and I decided to take the long cheap route.  We planned to stay at the airport until an hour or so before our bus, but it turns out the airport closes at about 7.  We didn’t take the hint when they mopped the floors, closed the stores, or stood staring at us.  We finally noticed when they said they needed to take our luggage carts – as you can see from the pictures we definitely weren’t giving those up! 

We caught a cab through Guatemala City to the bus station, which oddly sits at the intersection of a few sketchy alleys and a really crowded part of town.  We didn’t have much time to be concerned about where we were going as the radio station played both the Ghostbusters Theme and the 1992 classic “Tonight” by New Kids On The Block – both in English.  We were thoroughly entertained, although the exhaustion might have contributed.  After reassuring the people at the bus station that the whole pile of suitcases really did belong to the two of us, we boarded the bus to Flores and tried to get a few hours of sleep. 

The Trip

This trip started as a big “what if” over a year ago. It went kind of like this: “What if I could live and work in a small Guatemalan village for a year? And what if I could get school to give me credit for this endeavor?” My vision was kind of like Dr. Quinn (medicine woman) meets the Peace Corps. Puja was on the exact same page, and we first talked about it at a presentation for the global health experiences that are already offered by school. Instead of signing up for one of the existing programs, we wanted to create our own. We spoke with Anne (Toledo Ob/Gyn who’s been traveling to Guatemala for over 13 years – we had both been on trips with her already) and that’s when the trip really took off. Before we knew it, our little plan of being small town village doctors turned into a project bigger than any of us could have anticipated.

Background: (Sorry to bore you, but this is important. And I may have done a lot of research on it.) Cervical cancer is the leading cause of cancer deaths in women in Central America. 80% of cervical cancer cases worldwide occur in developing countries. Effective screening programs involve repeated screening of each woman throughout her lifetime, but this obviously requires a great deal of infrastructure, money, and training. Due to these limitations, a large proportion of women remain without access to screening. In addition, other methods have been developed that are cheaper and require less training for providers. One is Visual Inspection with Acetic Acid (VIAA), which involves washing the cervix with acetic acid (vinegar), waiting a minute, and looking for abnormal lesions, which should turn white.

In developed countries, the emphasis is placed on identifying and treating precancerous lesions before they progress to cervical cancer (a process that usually takes over 10 years). Since pap smear programs started, the incidence of cervical cancer in the United States has decreased by 90%. In countries like Guatemala where less than 5% of the population is screened to catch early stages of disease, two thirds of cervical cancer cases are diagnosed at advanced stages when the prognosis is poor. When caught early, simple therapies (such as cryotherapy) can eliminate 80-90% of lesions.

The Project: Our overarching goal is to develop a successful cervical cancer prevention program in the Petén department of Guatemala. To this end, we are undertaking a month-long mass screening campaign based in 4 communities in the region. We hope to screen 1,000 women with both VIAA and conventional pap smears. We have cytotechnologists from Toledo Hospital with us, who will read the pap smears immediately for results within about an hour – we never even get that in the United States! For patients with abnormal results, biopsies will be taken and, if appropriate, cryotherapy treatment will be provided. Additionally, we are collecting a large survey of history data from each patients, including information about exposure to a number of potential cervical cancer risk factors. We hope to compile this data to guide further work Sew Hope does in the Petén and also to help other groups doing similar work. It’s hard to wrap my head around the breadth of the issue and the impact this project could make.

Welcome to Guatemala!

I’m currently sitting in a food court of sorts at the Guatemala City airport. Luckily Puja, the other fourth year on the trip, is here with me so I have company while we wait out the 8ish hours between our flight arriving and our bus departing. We’re taking an overnight bus to Flores (northern Guatemala) to avoid paying for a flight up there (poor students). When we arrive in Flores, we’ll meet up Ismael (program manager for Sew Hope in Guatemala), who will drive us the hour or so to our first clinic site. When we arrive there, it will cap off about 27 hours of traveling for me. And we’ll celebrate with a full day of clinic. The crazy thing is that I’m actually really excited.

I’m planning to post soon (hopefully later today?) with background on the trip, plans for our project, and details of why in the world I decided it was a good idea to up and leave for Guatemala for 6 weeks. I’m not going to lie, when I was trying to pack, say goodbyes, and prepare myself last night I got kind of overwhelmed and questioned it myself. But I know that this trip is going to be an amazing experience for me, and hopefully make a huge difference in the lives of some others. Can’t wait to share it with you! I’ll try to write semi-regularly over the next 6 weeks, but sometimes the posts might come a few days apart depending on internet access.