Hospitalito- Week 1

This week, Jing and I began the 2nd half of our mission in Guatemala, to work in a healthcare facility. Here, we treat patients and learn medical spanish unde the not so watchful eye of other physicians. Unlike the US, few physicians here will want to see the patient after the students see them. More ofthen than not, they just sign off on the chart, your prescriptions, and a return visit date. The 1st day of work was, how do you say.....useless. Initially, Jing and I were wrongly sentenced to work in the farmacia and bodega under false assumptions that we spoke little to no spanish. While I am by no means suggesting I am the next Cervantes, I believe Jing and I have more than enough spanish to listen to a patient´s story, ask pertinent things, and perform a complete physical exam by using the word ¨asi¨or like this, in spanish. I therefore spent the morning bitter and packing gloves and alcohol swabs into bolsas for easier storage. While the original idea of our sentencing was so we can talk to the people there to learn conversational spanish better, I spent the morning talking to no one but grumbling to myself. Everyone worked there is from the region and spoke Tz´utujil, the regional Mayan dialect. Jing did not fare much better. While we initially thought the farmacia would be a better learning experience only taught us that Jing has an allergy to dust. She sneezed the morning away as she wiped shelves in the farmacia and putting packs of medicamentos on the shelves after they were spotless. Did she talk to anyone? No. After an unproductive morning doing tasks unsuitable even for the lowliest premed looking to gain something that resembled medical experience, our volunteer coordinator, Rebecca, at Hospitalito recognized our unsatisfaction with our tasks. She approved of our Spanish after a short conversation and wondered why we were subject to the aforementioned labor in the first place. We were placated by our fastidious placement into the clinic and we began seeing patients. With the supervising physician at first, then alone.

Front view of the hospital

Not all hospitals in Guatemala look like this. In fact, people have said it´s VERY westernized compared to other hospitals in the country.

Side view of the hospital

The hospital is a newly built hospital for the local population. It´s not big by any standards hence giving it the name hopsitaLITO. There are roughly 6 rooms for patients. 2 ¨sala de parto¨or birthing rooms with 2 beds each, 1 inpatient male room with 3 beds, 1 inpatient female room with 3 beds, 1 inpatient pediatrics with 3 beds, and 1 septic room with 3 beds. The emergency room has 4 beds total. This gives a grand total of 18 beds. Right now, as I sit in the hospital typing at 10pm on a Monday night (because I´m on call....lame) there are 2 inpatients and no patients in the emergency room. Busy eh? On a normal day, consulta external (walk in clinic) begins at 8am and ends at 12pm, resumes after a siesta at 2pm and ends at 5pm. I would guess the clinic average 40-50 patients in the morning with 3 or 4 providers each morning. Afternoon, one would generally see 10 patients total between 2 providers. This is because right now it´s Guatemala´s rainy season and the rain is a large deterrant for patients. The waiting room is jam packed in the mornings and eerily silent in the afternoons. The walk in clinic sees the majority of the subacute/chronic patients. Patients with wheezing, high fevers, and other problems that one would generally in the ED in the US goes to the clinic where they are taken care of and sent home. The ED tends to see the very acute patients, or patients needing procedural treatments such as minor surgical procedures, suturing, nebulizor, etc. Pregnant women with abdominal pain are a huge fan of the ED. On average the ED will see 6-10 patients in a 24 hour period.

One of the 5 clinic rooms. Here the sheets are not changed after each patient and the doctor washes his hands maybe two to three times a day.

However, the Hospitalito gets a small piece of the excitement pie. Last week, Jing single-handedly (no doctor was watching or present) drained a large abscess from a 15yo´s inner thigh. This thing was at least 5cmx5cm and BIG. That same day, Jing and I did 90% of chest compression on a poor guy that decided to kick the bucket. Our resuscitative efforts proved useful initialy as the man regained a cardiac rhthym but decompensated a few hours later and died. Just tonight, a 27wk premature neonate was rushed into the ED after being born at home by a Guatemalan midwife (comadrone). Unlike midwives in the US, the comadrones here do not need and most have no formal medical training. It left the hospital breathing in a rudimentary incubator and no formal breathing assistance. It´s a sobering fact to what outstanding medical capabilities we have to utilize in the US.

Sala de Emergencia

The most shocking disparity is the lack of tools of the trade and how much guess work comes into medicine in a 3rd world hospital. Practicing medicine in an environment such as this relly allows you to take a step back and ask how medically relevant a lab test is to the patient´s care. In the US, we follow guidelines and standards of care that we all hope works out best for the patient. Tests are also sometimes ordered out of intellectual curiosity and not medical necessity. After a slew of hopefully medically relevant tests, images, and consultations, we end up with thoughtful diagnosis like FUO or Fever of Unknown Origin. (I firmly believe that one of the reason why so many extra tests are ordered in the US is not due to medical incompetence or the doctor has fun wasting patient money, it´s because of the darned lawyers and disgruntled patients that decide to sue for everything. While many medical errors are preventable but hindsigh is always 20/20. A patient has the right to shop for doctors as much as I have the right to shop for a computer. When my Dell craps out in 3 years, I don´t turn around and sue Dell; I go and buy a Lenovo. If you child get Autism, it´s not because I gave him a LIFE-SAVING vaccine, it´s due to a myriad of other causes.) But I digress.....

Cultural practices are also interesting. While many people in the surrounding communities have adapted to be more accepting of western medicine, many still prefer to be treated at home by a community and spiritual healer. This wariness changes the way we practice in the hospital. One example is that no matter how subacute someone´s breathing difficulty, very low grade fever, and dry cough has been, he or she will always leave the hospital with a form of antibiotics. While part of this is due to the culture of medicine here (unlike the abx-phobia we have in the US), part of it is that all patients EXPECT to walk out with a cure in hand. No one will accept the wait and it´ll pass method. If it gets better on abx, great, western medicine ROCKS. If it doesn´t get better and the pt wasn´t given medicine, then they will ask themselves why did they pay to go to the doctors? Another example is nervios, a specific psychiatric illness found ONLY in latinos. Accorind to the DSM:

In Latin America, some people suffer from something called nervios (nerves). They feel a great deal of anxiety, insomnia, headaches, dizziness, even palpitations. It usually begins with a loss of someone close, or with family conflicts. Since family is everything in many cultures, family problems are often at the root of psychological problems.

The treatment? A nice healthy dose of Acetaminophen every 8 hours. Tylonel carries MUCH more weight here than in the US. When they come back in a week, they´re magically cured! Placebo was it´s best.

Beautiful mural that adorn the waiting room