yesterday...

Good morning!

6am and all is well. I have a steaming cup of coffee as well as a potential day off, in front of me. I can’t believe I have been here a month. The constant exposure to new illnesses and problems has broadened my knowledge and made me feel more confident. When I am practicing here, it is humbling to realize, on a global scale, just how limiting a formal pediatric education is. At home, I can’t think of a better job for me, but here, I encounter so much that I haven’t seen since medical school…Jumping from one environment to another has kept me on my toes.

This is my second 6-month stint volunteering with health care promoters. Last year I spent my time in Colombia, and now I am in Guatemala. Both sites are affiliated with a non-profit organization in California, Concern America (concernamerica.org). Concern helps find volunteers and supports programs around the world. The programs themselves are run locally in the specific country by people from the area. Health care promoters form the basis of an effective health system especially in geographically challenging regions were finances, and distribution of medical care is scarce. They are lay-people that are elected by their communities to serve as the local health provider. We are one of a few groups that educates promoters, helps establish sustainable and affordable pharmacologic access, and acts as a consult service for more challenging cases. The educational site in Petén has been functioning in this capacity since the mid- 1990’s. In addition to teaching classes to the learning promoters, we also teach advanced courses to sustain and improve the abilities of the promoters who have been practicing for years. Some of the advanced promoters also learn how to teach and slowly take over the teaching of the newer promoters. Above the lectures we also have clinic 4 times a week. This not only serves the local people here, but also, more importantly, allows more experienced promoters and asesores (me) to work alongside learing promoters and teach along the way. There are many parallels between my work here and the learning and teaching I do with medical students and residents at the children’s hospital in Salt Lake City.

I love waking up early the days when we have courses here. Two wonderfully colorful older women arrive the night before to start preparing food for the promoters coming to learn. They get wood and start the fire, begin to cook the beans and corn and also prepare homemade chili (hot sauce). On the day of the course, the corn gets ground into masa, shaped into tortillas, thrown over the heat and eaten…Hot off the comal (a flat grittle-like metal surface). As of now my tortillas have steadily improved, but I am still WAY behind the curve. Not only am I on the slow side, but also my pre- and post-grill tortillas are misshapen with sub-optimal thickness and uniformity…kind of like the ugly ducklings of the litter…the kind ladies move my “art” a little to the side, I think they want consumers to know these tortillas were clearly not their product or responsibility. The Spanish verb for this act is sensibly “tortillar”, well, it is when done properly, I think the word for what I do is probably too obscene to print.

(can you guess which two are mine?)

As I mentioned in the last blog, I am feeling like a kid in a candy store in the clinic. We are responsible for everything. From history taking, vital signs and the exam to laboratory evaluation, microscope studies and treatment. It is really fulfilling. Especially when you realize that we are teaching people to do this in their home communities, far from more official care. I mentioned that people come from all over and at all hours. The environment is stressful, as there is not defined “down-time”, but it has formed a cohesive unit for the people that live and work here. There is partnership in everything.

In clinic yesterday, I saw a 70+ year old woman who really scared me. She was sick. I have been seeing and getting used to taking care of lots of bleeding and painful injuries, but I haven’t seen to many legitimately sick older people. She was accompanied by her husband, who was very caring and concerned. Her grandson walked with her everywhere and wouldn’t leave her side. Despite her high fever and ill-appearance she smiled when I mentioned how attentive her family was. I did everything I could think of; in the end, I couldn’t find anything treatable wrong with her. I told her I would come by her house later that night. “I think she needs a doctor.”

Clinic wound down and we were cleaning up from lunch. I was in the yard when a young girl ran around the corner of the clinic. “My friend just took a medicine and now she blew up like a balloon and can’t breathe.” Hmmmm…sure enough. A miserable looking, swollen-faced teenager came surrounded and led by a large group of family and friends. I have never given epinephrine for a severe reaction before; that usually happens before I am involved. For awhile, I think my heart was racing faster than hers, I was certainly sweating more. I gave it and she gave a massive inhale/gasp…I nearly fell over…was that a good gasp?? a REALLY bad gasp?? then her mouth turned up into a smile and her eyes lit up below swollen lids…ok, kind of romanticized, but it seemed that way to my relieved self. Her friends relaxed and there was a social gathering outside the clinic around her cot. Teenagers and family just hanging out, talking about their swollen friend. We watched her for 45 minutes, gave her meds and education about allergies and sent her on her way, with instructions to come back quickly for any signs of repeated swelling or problems breathing.

I remembered the older lady. I asked my colleague the way to the cemetery, she told me she lived there…next to it at least…”alongside” being the critical part). She told me to go straight down the street all the way and then turn right. This was much more funny at the time, but the word for straight and right are so close in Spanish, that I got pretty lost. After a completely meandering course, I found her home eventually. Her husband was outside and concerned. Her fever had stopped, but her diarrhea had gotten a bit worse and she had started vomiting. When I asked for a poop sample earlier in the day, I had a nagging feeling the container might be an issue. The family had cut off the bottle of a clear soda bottle and tied a piece of paper to act as a cover. She actually looked a little better. So there I am…riding down a rocky, dusty dirt-road on a tired bike with 2 half-inflated tires…one hand on the handle-bars and one holding a crinkled, worn plastic bottle containing what I hoped were answers. I was avoiding the jarring rocks and divots in the road, gazing at the purples and oranges of the sunset, and balancing the slushy sample. I was actually feeling really content.

I swerved to avoid a toddler learning to walk. I approached three dogs that began to eye me fairly ominously. “no way”…yep…All three simultaneously erupted with bared teeth, aggressive barking and nipping at my heels. “really?!?”…As I stood on the rickety pedals, the sample somehow did not leap over the edges and I managed to stay vertical and just far enough ahead of the dogs to make them loose interest. I arrived home feeling like I needed to finish my work with the sample before I ate dinner. It made sense at the time.

As I was looking under the microscope, one of the cooks tapped me on the shoulder and gave me a big hug. “don’t forget to eat.” The sample looked ok, nothing too ominous. I would go visit tomorrow morning. I washed my hands at the outdoor sink (pila), and turned around. The cooks had left my black beans, cheese, steaming tortillas and coffee on a plate next to the smoldering fire.

a pretty great day...

I hope this finds you well and happy. Sending positive thoughts…

Brian

Where´s the shade??

Hello, hello…

I hope this finds you all well…I am happy, healthy and content here in Las Cruces, Guatemala. Although…I am hot. Super hot…

I’ve been wondering how to continue this letter to you guys. I was really tempted just to jump right in, but my sister reminded me that I haven’t ended the Colombia part yet. Good point.

As a reminder, you can read the previous entries at briangood.blogspot.com or on my facebook page at the bottom left. I haven’t reread them so I am not exactly sure where I left off. I hope I didn’t leave a big cliff-hanger that I am neglecting.

My last month in Colombia was incredible. It seemed nearly like a final exam, with the stressful preparation, the execution and the quiet feeling of achievement. I was nervous leading up to it, as I was to be the primary medical care-giver for the project. Alan, Julie and their son Gregory had left the country as had been planned. Melanie and I kept the program going. I designed and taught a course in childhood illnesses and then Melanie, Ismael and I traveled up a river basin and visited 5 communities. This photo was taken by Melanie as Ismael, a promoter and I spent an hour clearing debris to get our boat upriver.
The people we met and treated were fantastic, and the scenery unique, but we got back to Riosucio completely worn out. For me this developed into a pretty lousy illness that made my last few days in Riosucio full of napping and hazy memories. By the time I flew back home, I was starting to feel better.

(side note…Everyone has been asking about Ismael and my feet…Ismael is doing well and is happy as ever and my feet healed well…eventually. There was a small bump in the road with one of my feet. I developed a pretty unique (to me) ulcer. I had a doctor colleague look at it and take some samples. She wasn’t as impressed as I was, and the microscopic testing was negative for anything noteworthy…and it has since completely resolved…I didn’t take a photo.)

Though I hadn’t been away for very long, the return home felt surreal. I was happy with what I had accomplished, excited to see family and friends, but scared to death about working and teaching in the children’s hospital. I wasn’t sure how interested the residents were going to be about my improving knowledge of health promoter training and low-resource medicine. I knew that was not going to be the priority for patients’ families. After a few days in Boston with family and attending my high school reunion, I arrived in Utah late Sunday night. My truck registration was WAY expired. Despite valiant efforts from a close friend, the Utah heat had done a number on some plants. Besides that, I was sort of late for work. I went into the office on Tuesday and started taking care of kids again on Wednesday. Wow. A huge leap.

The easiest part of the winter turned out to be the work at the hospital. I loved it. The kids were pretty sick, but teaching and learning along-side the residents and med students really made me happy. I had difficulty juggling my new job, trying to re-connect with friends, and continue to do the activities I enjoy. Looking back, I had an amazing winter. I met some great new people, made some incredible new memories with old friends…egad…bordering on cheesy, huh?? Moving on…

I arrived in Guatemala over a week ago. Due to my new-found contentment with hospital work and Salt Lake City, I was reticent to leave. My last few weeks at home were fun, but had a definite somber overtone. As did my arrival here, despite the wonderful welcome.

I am currently in Las Cruces, Peten, Guatemala. It is in the Northeast portion of the country, not too far from the Mayan ruins of Tikal and the neat little town of Flores. Looking back, when I first took the bus to Las Cruces in 2002 at the recommendation of a friend of a friend, I had no idea I was meeting people that would eventually become such close friends and teach me work that would form such a large part of my career.
We had planned that I would return here this year to help with the large number of health promoters that are being trained in this region. I will be working with Susan, who visited Colombia last year and about whom I wrote. She is a wealth of tropical health knowledge and enthusiastic about clinical medicine. Her life and approach to clinical care are inspiring. I am fortunate to be here working alongside her.


Our home here serves as a clinic, pharmacy, teaching center, as well as a spot for sleeping, cooking and cleaning. Here is the view as you walk up our driveway. The teaching area is on the left; Susan’s room is on the right, kitchen straight ahead. I have my own room in a building in the back. Mira is currently living in a room behind the kitchen.

Mira was 7 when we first met; she had just moved from the US to the clinic with her mom. She loved to dance and sing and was well on her way to being bi-lingual. She has grown into an energetic, grounded woman, who is actually an accomplished health promoter as well. On our way home from dinner last night she identified a child who needed sutures, injected local anesthetic and stitched his chin. Pretty impressive. She also has been very helpful in advancing my Spanish. “Mira…why did the instructor just say the man gave HIV to a half an orange??” When she stopped giggling she clarified that the saying meant “his better half…” Thank you Mira. She is leaving here next week to live with her mom in the US and finish high school there. We will miss her energy and attitude. (here she is picking lemons for lemonade, you can just see her white pants.)

We have clinic at our home four days a week. (ok…this might be funny to those who knew that my paid full-time job required less clinic days than that…)…On a recent “off- day”, Mira and I volunteered…umm…were volunteered…to clean the water tank. There weren’t many people vying for the opportunity. We drink rain water that collects from our gutters and gets stored in a massive tank.
As the current hot, dry season is wearing on, the water level was slowly decreasing, and the water itself was getting fairly funky. It was kind of brown and didn’t smell all that good. A huge flood this winter had deposited an abnormal amount of mud in the tank (the last time I checked, there were some impressive flood photos on our website, concernamerica.org). Mira and I got some ladders, buckets, brushes and bleach, went over the top and into the muck. It wasn’t the most romantic view of international medicine, but we felt productive. After clearing out 5 large frogs, Mira shrieked…”something just sucked onto my foot!”…the small windowless cement tank didn’t allow her voluminous proclamation much escape. As our hearing recovered, we emptied the rest of the water out, muddy bucket-full at a time…and found nothing…the exact form of the ankle-kissing beastie is still unknown…

Each clinic day, we have patients lining up in the early morning to be seen.
Running a clinic here allows the continual opportunity to train the promoters clinically, as an adjunct to their lectures. Yawning, stretching, shuffling outside in pj’s, toothbrush in mouth…I bet we look pretty good, and certainly professional and completely reputable. When we don’t have active clinic we are trying to prepare courses or medicine (or clean water tanks, do laundry…fun stuff). We are always available for emergent cases. People come to our kitchen door from miles around with most problems, urgent or otherwise. I can’t believe the amount and severity of trauma I have seen, just in the past week. My suturing and microscope skills are improving. Yesterday in the midst of a busy clinic, I realized that I was completely happy. I am being challenged. The ability to practice medicine here with limited resources is effective. Working this way and passing whatever knowledge I have on to others are both rewards in and of themselves. Somewhere in the past week my reticence about leaving has faded and I am looking ahead to 6 amazing months…stay tuned…