We all dream of making a difference in the world as we travel along our path in life. When we witness that dream fulfilled it is not only inspiring, but it instills in us hope for future generations. My family and I recently found ourselves playing a small role in a larger process to make a meaningful impact on medical care for the poor. We traveled to a newly completed community clinic in the mountains of rural Guatemala, the Clinica Medica Cristiana.
Dr. Zack Self and his wife Josefina have seen their dream of providing needed medical care to the community of Santo Tomas la Union become fulfilled this year. Nestled among the coffee plantations on the volcanic slopes of central Guatemala, lies a small village of 15,000 people. After a bumpy “baile” or “dance” as they say, up the muddy roads past the brightly colored houses and spectacular vistas, the small Spanish Mission style hospital comes into view. Juan and Jesus, our drivers, open the gate to the grounds to reveal the neatly kept campus. Dr. Self and his wife live on the grounds immediately adjacent to the hospital surrounded by the small humble abodes of Josefina’s family and neighbors who have lived on these grounds for generations. The hospital is immersed in the local community, and although only open for 5 months so far, it has quickly become a focal point of community activity. Small groups of patients and families find their way to the grounds at all times of day and night to benefit from medical care that would otherwise be noticeably absent. When working here it becomes immediately apparent that the level of commitment and dedication is profound. The whole family is committed to the care of the community and keeping the hospital running is a way of life. Dr. Self staffs the hospital as the only physician present 24/7 and his wife Josefina is involved in nursing. They both take care of all ordering of supplies, maintaining staff, the pharmacy, the grounds and the many other tasks required to run a small hospital.
On our first night at the clinic Dr. Self was called at 2:00am to repair a large laceration on the forehead of a taxi driver who had crashed his rickshaw. The next day, slightly sleep deprived, there was a clinic full of patients waiting to be seen. The conditions ranged from tuberculosis to diabetes and everything in-between. The two most common complaints were abdominal pain and diarrhea primarily from parasitic disease in contaminated drinking water. Dr. Self’s clinic is a popular destination for the local indigenous peoples. Many suffer from emphysema from inhalation of wood smoke from small cook stoves in their dwellings. During the coffee harvest machete related injuries are common.
We were fortunate enough to witness the harvest of coffee, which runs from August through November, at the end of the rainy season. On the climb up the mountain we witnessed a bustle of activity along the muddy roadsides. Pickup trucks loaded with men women and children were piling up and down the slopes. They would pile 100 pounds bags of freshly picked coffee beans in lines up and down the road. The children and family dogs could be seen running up and down the damp paths of the partially shaded groves.
Juan, part security and groundskeeper, dries and roasts his own coffee on the hospital grounds. His corn grinder can also be heard in the afternoon as the local children stop by on the way home from school to pick up the masa for the tortillas for dinner. We enjoyed an unlimited amount of the freshest coffee I’ve tasted, courtesy of Juan.
Days in the clinic were a refreshing mix of user-friendly technology and appreciative patients. Although the setting is still resource limited, there was an impressive pharmacy and modern medical-surgical equipment was available. During our stay a shipment of medicine arrived. The office staff, nurses and whole family including the children chipped in to unload the shipment on a Saturday afternoon. The mood was elated as the needed supplies were unpacked.
While we visited we were able to afford some much needed time off for Dr. Self and his family. Some of the cases were memorable. My first ER case was the dreaded Dengue fever in a young woman with high fevers, chills and the feeling that her “bones were breaking”, she looked very ill but fortunately had not developed the internal bleeding that can make this disease so deadly. There were two touching cases of young patients with advanced tuberculosis, the 21 year old man weighed only 70 pounds as his fevers and chronic shortness of breath wasted away his calories. Another young woman was an orphan herself, she had two small children to care for and suffered fevers almost nightly for 6 months. She was too weak to work and too poor to make the regular trip to the tuberculosis clinic 1.5 hours away.
I was grateful to take part in the care of a 5 month old baby from the local indigenous community. As is common in this population, his parents had waited until the last moment necessary to bring him in as they have far to travel and the hospital can be a scary place for young parents. He was breathing at 80 breaths per minute and his oxygen concentration was 78%, well below normal. He had marked wheezing when he was breathing and unfortunately, he also had vomiting and diarrhea. His parents looked desperate and I could tell by their faces they were preparing themselves to lose him. We were able to slowly stabilize him with diligent nursing and an oxygen concentrator over a long night with little sleep by any involved. Slowly, with medicines and life-saving medical equipment his condition improved and the fevers broke. He started to vomit less and his diarrhea stopped. His oxygen came up to 94% and after 2 days of almost constant care, he was ready to leave. His parents took a lot of reassurance that he was ready to go as they had witnessed him so close to the brink. I felt extremely gratified in seeing the family two days later in clinic. He was back to his baseline and was finally acting himself again. His parent’s faces were beaming with gratitude and we all knew that his life had been saved. I have been a part of similar scenarios many times in the US but for some reason there in the mountains of Guatemala it seemed more real. There was a tangible understanding that had this small clinic not been there, they would have likely lost their child. There are no other reasonable options for intensive medical care for the families in this community.
It is moving to think that this type care is provided here on a daily basis. It was a privilege to work on this small island of hope in the clouds of Guatemala. Even though we were only there for a week, in relieving Dr. Self for just a few days we became part of the process of enabling longitudinal care for a community through this amazing facility and family.
Working in this clinic was a difficult but rewarding challenge that I welcomed with open arms. With my arsenal of newly learned Spanish, I ran the outpatient clinic, seeing 20 patients each day and alternating 24 hour call with Dr. Self every other day.
As I stumbled through using my Spanish to communicate with the clinic staff, they then had to translate my Spanish into K’iche to speak to the patients! The breadth of patients that presented there were vast, including elderly patients that had never seen a doctor and complaining of neuropathy for 10 years or headaches for 20 years, versus young children brought in by their families for diarrheal illnesses.
During one of my 24 hour calls, I was able to use my suturing skills taught to me by our plastic surgeon to sew up a facial laceration on a 2 year old boy who had fallen and lacerated his face with a stick. Even though he cried the instant he saw me on his post op visit, his parents were so grateful for my help.
My time at this clinic was not only a learning experience that expanded my clinical skills, but also a great opportunity for practice management and all of the hundreds of details that go into starting your own clinic. Some of the many tasks that I learned the importance of include how to perform point of care labs, how to manage a pharmacy, how to organize your medical supplies and how to train your staff to perform certain duties that help your clinic run more smoothly. Throughout my time in the gorgeous country of Guatemala, the most profound lesson I took away was how absolutely necessary it is to educate people because without health literacy and understanding the importance of treating illness, people may improve morbidity but not mortality.
On so many occasions, patients were under the false impression that “any medication” was a cureall and chronic diseases such as diabetes and hypertension would only be treated for a month at a time because people did not understand that they would have these diseases for life. A prime example of this was a 14 year old girl who was admitted overnight for diabetic ketoacidosis and was given insulin throughout her stay. She had been taking insulin a few months ago but felt better so she stopped taking her medication.
Additionally, her mother could no longer afford the medication and they had no refrigerator to store the insulin. Another equally important lesson that was reinforced is that every person has a story. We must always think of the whole person including their personality, social situation, educational background and resources when making medical decisions to give people the most realistic chance at surviving. If a mother has to choose between feeding her children dinner versus paying for her antihypertensive medication, there is no fault in that decision.
Finally, during my stay, I provided Dr. Self with a powerpoint presentation of malnutrition that he presented to his staff. I am so grateful for the opportunity to visit such an inspiring place with the help of the FMED fund and thank you all for your generosity in helping family medicine residents like myself explore international opportunities that are making this world a better place.Download Dr. Yee’s Report
After a week-long Spanish immersion course in Antigua, I embarked to St. Tomas la Union for my international medicine elective. There, I had the privilege of caring for patients in Dr. Self’s clinic. After orienting me to the clinic, he left the clinic duties in my hands so he could attend to administrative and hospital development projects. The patients I met were remarkable. Many would travel for hours to be seen. I was most struck by diligence, gratitude and patience of these remarkable people. While I saw plenty of medical pathology, the most abundant problems I saw were lack of resources and education. For example, water-borne illnesses like parasites, giardia and E. Coli were so common, that we often treated empirically. Beyond treatment, Zack had also partnered with a water purification program by which he could distribute personal water filtration devices from the clinic to prevent further infections.
After clinic, Dr. Self and I took turns taking call for emergency services overnight. It is well known in St. Tomas and surrounding communities that the clinic is available after hours for emergency visits. There, I treated patients with motorcycle trauma, burns, acute dehydration from gastrointestinal illnesses, febrile seizure, along with many acute respiratory infections. I then followed up with many of these patients in clinic. This availability to his community is an essential element of his ability to provide continuity of care. He also has equipped his emergency room to take care of nearly every acute presentation. Furthermore, he has trained his staff to use the emergency equipment so that when patients come in with acute pathology, they will be able to assist him in acute resuscitation and stabilization.
Dr. Self’s clinic also provides a significant amount of women’s health services. I addressed common problems such as post-menopausal bleeding, dysmenorrhea, routine pregnancy care, pyelonephritis during pregnancy and even more uncommon problems such as ectopic pregnancy and metastatic gynecologic malignancy. Due to a lack of resources, cancer screening in Guatemala is very fragmented and not standardized. To address this, I developed a presentation for the hospital staff on a method of cervical cancer screening and preventive treatment that is both accessible, effective and sustainable. Routine screening that takes place in the US actually requires a significant amount of infrastructure. For example, pap smears require special equipment, preservative and denaturing solutions, expensive laboratory tests and a pathologist. In resource-poor settings, most of these are either not available or prohibitively expensive.
My time with Dr. Self was very transformative. He has been working towards his vision for many years, and has constructed his life around making it happen. Aside from the medical knowledge I learned from working in his clinic, I came to understand what it takes to develop a sustainable and effective clinic and hospital for an under-resourced community. Moving forward, I am inspired to construct my own path in global health. I may never build a clinic from nothing, but I have come away with many ideas for focused trips to help train staff on sustainable, effective methods for delivering high-quality healthcare to patients with limited access. I am further motivated by the reminder of how rewarding it is to care for such a hard-working and gracious group of people.
I was fortunate enough to spend 2 weeks in May working with Dr. Self at his clinic. We shared clinic responsibilities and alternated afterhours and overnight ER call. It was a history-making and precedent-setting 2 weeks. We delivered the clinic’s first baby, had an ever-expanding clinic panel, performed a tongue-mass excision procedure, diagnosed fractures with ultrasound, set bones and joints, provided much primary care education, and had a lot of fun sharing ideas and thoughts.
The level of care already being provided in the first weeks is impressive but the potential for expansion and growth is exciting. Dr. Self’s clinic is prepared for the resuscitation, stabilization, and rehabilitation of a wide variety of critical and acute illnesses. The operating theatre is well-stocked and has the potential to provide life-saving interventions such as C-sections, procedures necessitating sedation, and maybe even future simple surgical interventions. The clinic has the ability to reach the entire community with foundational primary care education and interventions not just via individual clinical consultations, but also potentially through public health talks and group meetings.
It was such a privilege and inspiration to spend time at Ajkun Pa Le Qatinimit. The philosophy and care provided springs from the core of our training as VCMC family medicine physicians: full-spectrum, high-quality care to under-represented peoples. Though it was the first weeks of its existence, it is obvious that the clinic will have a huge impact on the lives of those in the community it serves. Coming at the end of my residency, it felt like a validation of the work and hours spent at VCMC and was a true capstone to my residency experience.
Dr. Joanne Kim, Dr. Anna Rogers, and myself shared call with Dr. Self, caring for patients during regular clinic hours, but also in the middle of the night, when patients came in for everything from hypotension and severe dehydration, to viral exanthems, medication reactions, and pregnancy. The clinic is both high and low technology, working with limited resources and diagnostic capabilities, but with several high-tech but simple to use interventions. Labs are limited to point of care hemoglobin, electrolyte or blood gas panels (which are limited in number as they are shipped from the United States), and multiple ultrasound machines for imaging, including a small portable ultrasound that served as a constant companion at clinic visits, something I don’t have easy of access to at my own clinic. Despite limitations, Dr. Self and his staff are committed to high quality care in this low-resource setting, and have chosen the highest impact resources to provide this care.
Although I speak Spanish comfortably, I was challenged in my communication skills during my stay. Although many locals speak Spanish, many are most comfortable or primarily speak K’iche, a Mayan language that varies in dialect based on region. I started many of my clinic visits in Spanish only to quickly realize that an interpreter for K’iche would be needed. The clinic staff were indispensable in providing language assistance, and in many cases, cultural context, to many of my clinic visits.
Teaching and emergency preparedness were vital parts of clinic education. Dr. Self holds education and administrative time for the clinic staff on Wednesday afternoons, allowing for much needed training and enrichment, as although instances of such emergencies are not common, Dr. Self’s clinic takes all comers and emergencies do present themselves. We had the opportunity to participate in and assist with modified NRP and ACLS training sessions, learning how to use the LUCAS chest compression system, and a dirty epinephrine drip. At VCMC, our many healthcare providers are eager to jump in and provide chest compressions, but at Akjun Pa le Qatinimit, where often there is one provider and one nurse, the more free hands the better. I greatly enjoyed applying emergency interventions, usually smoothly running and plethoric with staff in our level 2 trauma center, to a low resource clinic focused on the most life-saving interventions. We also practiced our difficult airway skills.
Overall, Akjun Pa le Qatinimit is a low-resource, but high impact, clinic tucked in the coffee plantations and hills of western Guatemala. Dr. Self has dedicated himself to building a clinic/hospital with the capabilities to providing the highest quality care possible despite low resources, so that quality of care is not predicated by geography.
Ajkun pa le Qatinimit/Clinical Medica Cristiana
10/1/2016 – 10/15/2016
Driving up the bumpy mountain road, I stared out the window and a stream of questions ran through my mind: what is that tree that seems cultivated across so much of this part of Guatemala (coffee), what is the name of that volcano (Acatenango), where do people go for healthcare? The poverty was palpable, both in Guatemala City and in the rural countryside.
We arrived at the family compound and site of the clinic in the early afternoon. Family and extended family came to meet us and get us settled into our rooms. We got to work the next morning, following a cup of fresh brewed coffee that was grown, dried and roasted on the compound. The clinic was impressively efficient and had a well stocked pharmacy; we were able to treat most diagnoses that presented during the two weeks I was there. We saw everything from anxiety to severe zoster of the eye and most importantly we did not turn anyone away, regardless of ability to pay. Having a background in women’s health, I took care of a number of pregnant women, for their pregnancies and for pregnancy related complications. It was the heart of medicine, pure and simple, seeing patients and treating them with the resources we had available. Yes, there was electronic medical records, but it did not overwhelm our time. We were practicing medicine, the way we imagined we would in our idealistic medical student dreams.
The vast majority of patients were from the local community, though some travelled from hours away to be seen. Most spoke some Spanish, but a number of patients spoke only their native Qui’iche. Luckily Dr. Self’s brother in law could act as translator for those of us who are only bilingual. It was incredibly rewarding serving this incredibly underserved patient population, and their gratitude was apparent in their faces and kind words. At the end of each day, the work was fulfilling.
When we weren’t in clinic we were on call for the acute care facility, or ER, which is remarkably well stocked with equipment for everything from advanced airway management to automated chest compressor for cardiac arrest. We did a training session on fiberoptic intubation and luckily did not need that skill while we were there. In the ER we took care of very ill patients, sometimes for a few hours for IV antibiotics and fluid resuscitation and sometimes for days managing severe sepsis and dehydration from diarrheal disease.
As residents we had enough autonomy to feel like we were learning how to manage critically ill patients, but had enough support to feel like we always had backup. Dr. Self not only believes in providing high quality, evidence-based medicine to the marginalized and vulnerable indigenous patient population, he also believes in providing high quality education to his staff and community. While we were there we did a review of ACLS and PALS including a simulation lab. We had education sessions on bedside Echo and point of care ultrasound. This level of education raises the overall level of care of the facility and the quality of care provided to the patients.
My days started out sitting on the balcony watching the sun rise over the nearby volcanoes, listening to the sound of clucking chickens and barking dogs and ended with a sense of fulfillment and joy in the work we were doing in beautiful rural Guatemala. This will hopefully be just the beginning of a long term relationship with this clinic and community, providing the best healthcare to the patients who need it most.