Reflections on Pediatric Rotation in Guatemala

A good friend of mine, Jenny McKinney, is currently living, researching, and traveling in/thru Guatemala, Costa Rica, and the Dominican Republic.  A soon to be U.S. medical doctor, she kindly offers her observations and thoughts in her original post here

Hello all,

I hope you are all doing well! Since I am in my 6th (already?!!) week of my pediatric rotation here in Guatemala, I thought it was about time to update you all on my experiences [update: I am actually finishing this post on the last day of my rotation… lost track of time!] [update of update: I am in my 5th week of my OB rotation in the DR, I REALLY lost track of time, sorry!].

Anyway, it really is about time to update you all on what I have been up to! The following post details the trials and tribulations of medicine in a resource-limited setting such as Guatemala as I think it is important for people to understand what life and medical care is like for a great many people in the world. However, I hope to any add in some beacons of hope for a better future.

To place the following observations in context you have to first understand the very basics of health care in Guatemala. From my understanding there are three general types of healthcare. For the top few richest people in the country that can afford to pay for services out-of-pocket, there is a private system of clinics and hospitals that are well stocked and have all the modern medical conveniences. Then, there is the Social Security system of clinics and hospitals. These serve anyone with a certain type of job. Each worker must pay a significant amount every month into this system, but are rewarded with decently stocked hospitals and medical resources. The drawbacks of this system though is that by all accounts it is very poorly organized and poorly run system, so people end up with insane waiting times for everything from check-ups to surgical procedures. Finally, the rest of the country, who cannot afford private care and do not work for a company that is part of the social security system, is left to go to the public national hospitals, like the one at which I completed my pediatric rotation. These hospitals only receive money from the government so there are always shortages of even the most basic supplies. To illustrate this point, I was in the newborn nursery one week and saw a nurse bring in a new baby just after a delivery. Seeing the towel splotched with blood in various places (not normal after the initial cleaning) I asked what had happened. She told me that the hospital had run out of umbilical cord clamps, and the gauze tied around the stump was not working properly.

With that little bit of background, I would like to tell you a few stories. These are not meant to be depressing, but I just felt like these are stories that don’t get told often and deserve to be told.

Resource deficiencies

This first story was an eye-opener for me about the unfairness of life. It was my first day in the newborn nursery/ NICU in Antigua, Guatemala. The place was packed. There was a room of healthy squirming bundles of joy in basinets waiting for their mothers to recover from their C-sections. There was a room of basinets with desk-lamps providing heat for some ‘normal sized’ babies (term newborns but with various forms of respiratory problems). And finally there was a room with typical incubators with the tiniest preemies. Unlike a NICU in the States where you see babies born in the 20s (weeks) of gestational age, the littlest one here was 31 weeks. I was so happy to be back amongst the littlest patients, I did not at first realize the differences. However, five minutes into morning rounds, when one of the newborns with meconium aspiration syndrome went into respiratory failure, the supply/equipment shortages became blatantly obvious. After hand ventilation for many hours, he developed bilateral pneumothoraxes (when air gets out of the lungs into the chest cavity and messes up the pressure balance causing stress on the lungs and the heart). Without portable x-rays, the team tried to release some of the tension by guessing where to place a butterfly IV needle to act as a chest tube. They were unsuccessful and ended up running down the stairs and across the hospital to obtain a STAT chest x-ray. In the end though, there was just too much pressure on the heart, and the baby ended up passing away. There is no saying definitely what could have happened if his family had been able to pay for treatment in a private hospital in Guatemala, but you have to wonder.

The next story is not mine to tell, but is a story written by Amy Gridley, the coordinator at Casa Jackson, a home for severely malnourished children in Antigua.Thank goodness I did not run into a case like this during my time here, but I wanted to comment on it as a person who has had some experience with the system.

“Frank arrived at Casa last Friday, very weak, in a tremendous amount of pain. He was transferred to a local ICU on Tuesday night after having several large seizures. We found out yesterday that he had a large brain tumor pressing on both sides of his brain that was causing his constant vomiting, loss of appetite, and subsequent malnutrition. The local ICU stopped giving him medication, food, or oxygen, and told the family to say their goodbyes. We brought him to a private neurologist in the city this morning, but he was unable to see Frank. Frank returned home with his family around noon and passed away shortly after. 

Frank and his parents both held on and fought hard for two months, even when all of the public clinics and hospitals were turning him away and telling them to give up hope and let him go. Frank wanted very badly to get well again so he could go back to school and play fútbol with his friends. His parents went without food many days, just to afford the medication he needed to fight the infections he developed after the first botched surgery, and tried desperately to find a place that could help him in time.”

This is a heartbreaking story, and I can imagine people thinking, “those terrible hospitals, how could they possibly give up on a child like that”. But, let me for a second offer a different view of this situation. National hospitals in Guatemala have to make choices, every day. They have a very limited number of resources in general, and are especially limited in areas of intensive care such as ICUs. When there are only a certain number of respirators or a certain number of doses of a strong medication, hospitals have to decide whether to continue treating the patient who does not have a hope for return to health or to treat the patient that has the potential to get better. I am not saying that this is in anyway right, but under the constraints of the current system, this is reality. It does not mean that the medical staff does not care. They care a lot. In fact, they are some of the most innovative physicians I have ever seen because they have to be. But, seemingly-extreme triage is a necessity here.

Malnutrition

The final story is of a young girl. Her mother is mentally ill and so this girl (supposed age 1 year 8 months) was brought into the hospital by a neighbor. She was covered in dirt, painfully thin, and literally was covered from head to toe in a desquamative rash (basically her skin was peeling off). It did not take much to diagnose this textbook case of pellagra, the deficiency of B3/Niacin. She was given nutritional treatments and antibiotic therapy, but even so, after fighting for her life for 9 days in the hospital she ended up passing away, most likely due to consequences of severe malnutrition.

This is by no means the only severely malnourished child I saw during my 8 weeks of rotations. The local newspaper printed a paper on malnutrition rates a couple of weeks ago that listed the top 80 most malnourished towns of Guatemala. What was really astounding was that these 80 areas ranged from 60-91% malnutrition rates. A whole thesis could be written on why these numbers exist in Guatemala, but for now I would just like to make a comment. Food makes kids grow physically. But food is also absolutely essential for brain development. In a society where it is already so difficult to improve quality of life between generations, malnutrition and the consequential lack of maximal brain development can be another barrier to these children having the chance for a brighter future.

One of the organizations that is trying to break down some of these barriers (including malnutrition and lack of education) is an NGO here in Antigua called Integral Heart Foundation. They have many programs that attack barriers on all levels. They build schools for children who would otherwise be left to run around by themselves while their parents are out working during the day. They install solar panels in schools and in homes to enable students to study past 6pm in the evening (especially important as some of the older children need to work in the afternoons). They find sponsors for children and pay for them to continue schooling and encourage them to go beyond secondary school to various trade schools. They also buy the most basic of food supplies and medications for their sponsored kids. This is a shameless plug for this organization, but more than that, I think it acts as a story of hope for these children. Here is the link for their next big project in Panorama, Guatemala (outside of Antigua). They are raising money to build a kindergarten for children of the area. These kids are usually stuck on their mothers’ backs while their mothers are collecting coffee or firewood until they can walk, and then  start helping out at as young as 3-4 years of age. As you can imagine this provides little intellectual/emotional stimulation. The idea of this kindergarten is to provide a place that can stimulate their young minds, as well as ensure basic hygiene and nutrition for the children. See more information at the link.

Another beacon of hope for the children of Guatemala, and especially the newborns, is the development of a “Banco de Leche” (human milk bank) at the National Hospital here. This milk bank collects milks from donor mothers (who donate out of the goodness of their hearts), pasteurizes it, tests for bacteria and then parcels out the milk to the little ones in the newborn area of the hospital. This process means the difference between life and death in many of the little ones. Also, part of having this milk bank is that the hospital is required to promote Lactancia Materna (breast feeding). By heavily promoting breastfeeding by all who are able, the hospital ensures the new babies a steady supply of nutrition for at least the first 6 months.

I hope that you have learned something from reading this. My aim was not to depress anyone with the realities here, but rather to open eyes. Take a few minutes some time to just think about how lucky we are to live where we live, do what we do, and to have the freedom to change our circumstances. I hope all of you are doing well, and are enjoying a wonderful spring. I am currently finishing my OB rotation in La Romana, Dominican Republic and so will (eventually….) get a post done on that too!

¡Cuidense! (Take care all),

Jenny

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