Babies, Sand and Machetes…AMEDICAusa interns at the National Hospital of Retalhuleu 

A child clings to life in the Pediatric Emergency Room

There can be no observers here.

 I am “bagging” a three month old baby girl. She has been brought into the hospital limp, pale and unconscious and with a obviously swollen belly. She hasn’t nursed for two days and was fussy and inconsolable yesterday. This morning her mother couldn’t wake her and rushed her into the emergency room tied to her back on a motorbike. Now she is no longer making an effort to breathe on her own.

 

She is in septic shock, likely the result of an intusseception, a rare intestinal condition that can kill part of the intestine and cause life threatening complications. Her life is dependent on a small tube inserted into her throat and continuing to squeeze the attached bag to inflate her lungs every few seconds. I took over the job of breathing for the baby when the nurse’s hands began to cramp.

The doctor and a nurse struggle to get an I.V. into the child. This is always difficult in a baby, much harder when they are in shock. I offer to start an inter-osseous line, a procedure we would commonly use in the States in this situation, but the hospital doesn’t have the necessary needles, and a regular catheter would likely break before penetrating the bone. I continue to breath for the baby. Finally they manage to place a very small IV.  It will have to do. We’ll continue this until the infant goes into surgery and other staff will continue to manually breathe for her through the surgery and over the next two days.  There is no mechanical ventilator available to take over.

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Welcome to the Hero Hospital

The Weather Worn Sign of the Hospital Nacional, Retalhuleu, Guatemala

The first thing you notice here is the heat.  Unsurprisingly, the western Guatemalan lowlands are hot in the summer. The daily afternoon thunderstorms raise the humidity to truly oppressive levels. A coastal breeze helps a little when outdoors, but it doesn’t reach into the hallways or exam rooms to provide even a little relief.  Other than in the operating room, the air-conditioning doesn’t work.

Fanning with a notebook, Doctor Lorena Yancor. and student attempt to keep cool in the ER

The commercial fans installed to compensate are victims of overuse and age and have long given up the ghost. Doctors and staff have brought in a few personal fans here and there, but they are small, and ineffective beyond a couple of feet. The patients, family and staff, crowded in to cramped spaces, provide an additional source of heat…and without ventilation, a source of smells that are best left undescribed.

The Hospital Nacional of Retalhuleu is the primary source of medical care for the poorest of the poor in this part of Guatemala. Part of the country’s two-tier national healthcare system, it serves those who don’t have a regular paycheck: the campesinos  (farm workers),  the indigenous, and the unemployed. Like it’s sign, it is worn around the edges. Nicked and dented by uncountable stretchers, the paint could use another coat.  But it is clean and kept so by a squad of mopping janitors, who make endless rounds of it’s floors. The hospital is chronically short of medicines, equipment and even routine maintenance supplies.

Reading x-rays by window light

There is one, elderly, x-ray machine to service the entire hospital and the waiting times are long. The films themselves are read through an open window…as the light-boxes generally don’t work. The lab, though reasonably well equipped, is dark…because they don’t have the florescent tubes to replace those burnt out.  CT scans, MRIs, and the other modern diagnostic tools are a wishful dream. 

The tools available here are primarily the hands, eyes and ears of the medical staff, and they are surprisingly good. Many of the senior staff have been here since the Hospital opened some thirty years ago. Eschewing the more lucrative practices they could have in Guatemala City (some 90% of all of Guatemala’s doctors reside in the capitol city), they continue to practice here where their talents can be put to the best use. All have become excellent diagnosticians and instructors for the medical students that often rotate through the hospital as part of their training.

AMEDICAusa is a supporter of the hospital, donating medicines and equipment in support of their efforts to treat the poor. (Among other things, AMEDICAusa donated most of the equipment for their gynecology clinic, where they had previously been forced to to exams on an office desk.) This time we brought several crates of pediatric medicines…and two talented students from the United States to serve a volunteer internship in the hospital.

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The Pink Sand

Four kids come into the pediatric emergency room with their father. They range in age from 4-10. All have makeshift bandages, dishtowels, t-shirts, scraps of cloth, around their hands and feet. Dad is limping a little. A medical student unwraps one child’s hand and guesses she has a nasty skin infection of some sort. I look at the family. All the kids have the same infection and only on their hands and feet? Something isn’t right.  I have another of the kids unwrap his hands. Under the dirty towel, and under the pink layer of calamine lotion that Guatemalans put on any type of skin disorder, his palms are shredded and blistered. Chemical burns?

A Child’s Chemical Burn in the Pediatric Emergency Room.

Dad is dressed in the unofficial uniform of a Guatemalan campesino, a farm worker. Worn, dirty jeans, a second hand t-shirt and a beat-up cowboy hat. A machete scabbard is on his belt. I ask if he lives in el campo. Yes, he says. He works in the fields. Do they use chemicals there? Yes, sometimes.  Whats wrong with your leg? He points to the kids hands… el mismo..the same, he says. I call the chief pediatrician over  and explain what I think this is. I ask the kids what they have been doing over the past couple of days. Playing in the new arena rosa… the pink sand…that they dumped near our house.

It is an industrial, urea based, fertilizer. Apparently, no one thought to tell the farm workers it was dangerous. The kids have been building sandcastles with it, and walking barefoot through the spillage. Dad has the same burns on his leg from repeated contact as he shoveled it into wheelbarrows. 

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Organized Chaos

The only formal waiting room in the hospital is in the outpatient clinic. All the other patients, for the emergency rooms, labor and delivery, OB/GYN and so forth, must wait patiently in the hallways, or under what little cover is available outside. Lines form in the hallways for each service, a mixture of patients and their families. All chat quietly while they wait. Well kids scurry about, playing improvised games underfoot. Mothers quietly nurse their babies while exchanging news with friends. None seem disturbed by the wait, even when the occasional fire department ambulance patient is rushed in ahead of them. They know the drill.

Dr. Gilberto Morales

Overseeing the operations is Dr. Gilberto Morales. A dapper man, he manages to appear calm and cool while nattily dressed in always-pressed shirt, tie and lab coat, despite the heat.  It would be easy to rage in frustration at the job he is required to do, taking care of thousands of patients without sufficient resources, but he remains unruffled.  He orchestrates the staff, building, equipment and patients with admirable restraint and aplomb. He has set up a rotation for our interns – Emergency, Pediatric Emergency, OB/GYN clinic, Labor and Delivery, and Surgery – where they will both learn the most, and be most helpful. After a brief tour of the hospital, the interns are handed off to the respective department chiefs.

Rites of Passage

In Los Campos, the communities of the farm workers, young boys at the age of 12 or 13 are given their first machete. This universal tool, kept honed to razor sharpness and carried in decorated sheaths, requires some practice to use efficiently and effectively.  Like a baseball player with a bat, there are a lot of errant swings before mastering the hand-eye coordination necessary to hit consistently.  The emergency room often sees those who have swung and missed.

AMEDICAusa volunteer Efim Oykhman repairs a machete wound

“Mario” is a thirteen year old boy who walked in to the ER with an embarrassed grin and his dirty, and now bloodstained, t-shirt wrapped around his right wrist. No longer attending school, he has joined his father in the fields of a local finca. He was chopping weeds out of a sugar cane field when an errant left handed swing hit his wrist, rather than the noxious plant he was aiming at. His is the third machete injury we have seen today.

It will be the first that our intern, Efim Oykhman, closes himself.  He has assisted and observed in several previous procedures, and now is ready to do it himself. Under the watchful eye of the surgeon (called in to rule out any tendon injuries), he closes the wound with eight deft sutures, a little antibacterial ointment and a dressing.  Mario goes home a little wiser, and Efim has successfully performed his first surgery. Both are happy…and a little relieved.

Treat ’em and Street ’em

Pediatrician Dr. Carlos René Jaime González, a native mexicano, very patiently explains to the parents of his tenth patient of the day that the pediatric emergency room is not where minor routine illnesses belong. First they should go to the local Clínica de Salud (Health Clinic) in their area. Second, for more serious problems, to the outpatient clinic. Only the really sick or injured are supposed to come to the pediatric emergency room. The lines to the emergency rooms are full of patients that really should be in the outpatient clinic on the other side of the hospital, but that area is full and the wait times are longer. Many of the patients have “self triaged” to the emergency room, and there is no staff to prevent that. The doctors are resigned to this, though it takes up valuable time. It also means that some very sick people are waiting outside, while less seriously ill manage to be seen first. Dr. Gonzales frequently checks the hallways to make sure a seriously sick or injured child isn’t waiting.

Dr Carlos René Jaime González and AMEDICAusa Volunteer Daria Smoliarchuk Discuss a Patient

The doctor’s at the Hospital Nacional don’t have the time to get to know their patients well. There simply isn’t enough time in a day to take detailed family histories nor fill out many forms. In Dr. Gonzales’ pediatric admitting room, the patients come in, get a quick once over and basic history, a rapid but thorough exam, then either medication samples off the shelves (yes, drug salesmen come even to Guatemalan ER’s) or a prescription for medicine from the hospital pharmacy (free) or their local farmacia if the hospital is out of medicines. Total elapsed time…maybe five to ten minutes for the average patient. 

Few make it beyond the anteroom and into the three treatment beds in the pediatric ER. Those are reserved for those truly in need of emergency care. A asthmatic child working on his fourth nebulizer, a ten year old with a fractured arm, and our 3 month old with sepsis.

Our “Countess Dracula” Gets Her First Case

AMEDICAusa Volunteer intern holds retraction during surgery at Hospital Nacional Retalhuleu

Back in emergency a young woman comes in with severe abdominal pain, nausea, vomiting and fever. She has been suffering symptoms for two days. Dr. Lorena Yancor, Chief of Emergency services, checks in on the patient demonstrating techniques for abdominal assessment for our interns, while I translate and explain what she is looking for and why.  This is why our interns are here, to learn to examine patients without the diagnostic tools available in the States. The patient has all the classic signs of appendicitis .  A surgeon is called and he demonstrates again the same skills, as well as a couple of advanced techniques to confirm the diagnosis. Off to surgery she goes for an emergency appendectomy. The surgeon asks our intern if she would like to assist. Daria, drawn to blood like a moth to flame, and who appears magically when ever a patient comes in with an open wound, readily agrees. As it turns out, the surgery was just in time, and was more complicated than first thought. As the surgeon opens the patient, her appendix ruptures.

Twin Problems for Hospital Births

Prenatal care is still a rarity for most women in Guatemala, particularly in the poor and indigenous communities. Often a woman will go through her entire pregnancy and delivery without any medical care at all. Health and sex education is lacking, brought here only by NGO’s like AMEDICAusa and it’s partners. 

Birthing in Guatemala is often attended by midwives, comadronas, who are largely untrained in modern medical techniques. They often rely solely on traditional indigenous practices and beliefs. Some are very good, and have received additional training from NGO’s and limited government programs. As a consequence, many of the births done in the hospital are complicated, referred here by midwives skilled enough to recognize problem pregnancies.

During our intern’s rotations in the OB/GYN clinic, labor and delivery, and surgery, fully half of the births were cesarean and most of these births were performed on an emergency basis. Prematurity, age of the mother (both very young and very old) and undiagnosed maternal medical problems are common issues.  

“Maria” is a 19 year old woman who came in to the OB/GYN clinic with painless vaginal bleeding in what appears to be her third trimester of pregnancy. She doesn’t know exactly when her last period started, but she thinks it was last November or December, either eight or nine months ago, and she has had no prenatal care. 

Healthy twins delivered by emergency C-Section at Hospital Nacional Retalhuleu

This is her second pregnancy – she had a healthy baby girl two years ago. Maria has been “spotting” off and on for a couple of days, but has more bleeding today and is having some irregular contractions. Her external abdominal exam reveals TWO fetal heads and possibly two sets of  heart sounds. She is sent for an ultrasound, which reveals not only twins at about 36 weeks gestation, but also Placenta Previa, a condition that threatens both her life and those of her babies. An emergency c-section is called for and our interns are there to assist. 

 

Medicine in a Disaster Zone

Once delivered, our twins are moved to the neonatal ward. Like all the other wards, the patients here are grouped together in large rooms without walls or curtains to separate the beds. The neonatal ward is a stark reminder of the disasters that are often visited on Guatemala. A large fissure has appeared, running vertically down a structural wall. The crack is the result of a 6.6 earthquake that occurred in June and effected the stability of the structure. The epicenter of the quake was 35 miles from the hospital. One man was killed, crushed by a wall collapse about a kilometer from the emergency room. The entire neonatal unit is going to have to be moved for safety until repairs can be made.

Earthquake damage in wall (L) of the neonatal unit of Hospital Nacional Retalhuleu

Outside the hospital, ash and steam clouds can occasionally be seen rising from explosive  Volcan Santiaguito some 15 miles to the northeast. The hallways in the hospital have discrete triage system markings denoting catchment areas for patients in case of mass casualties.

They are as prepared as they can be, but shortages of supplies and equipment are worrisome.

 

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Did you know?

AMEDICAusa provides support and equipment to the Hospital Nacional of Retalhuleu and other medical facilities for the poor and indigenous peoples of Guatemala. We can’t do it alone. Your donations are what make our programs possible. Please give generously.

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AMEDICAusa, inc. is an I.R.S. 501(C)(3) registered charity, headquartered in Frederick, Maryland.

We are always looking for volunteers who wish to help in Guatemala. Get the details here.