By: Carol Sullivan
Sights and insights abounded in the 2019 Guatemala trip in March 2-10. Team members included a first-year student who described collaboration among fellow medical students as well as a sense of being daunted and undaunted:
Valentina Sarkisian, OMS I, attests - “When I decided to go to Guatemala, I was not sure what to expect. What if I was unable to do anything? My stroke of genius—have no expectations. Until the day to go finally arrived, I continued to live my life on autopilot—sleep, go to lecture, study, eat, repeat. Spoiler alert—it all worked out.”
Val recalls the first clinic when she was asked to do a HEENT (head, ears, eyes, nose, and throat) physical exam on a patient: “I froze. Could I remember a single step? No. I almost wanted to cry. Instead, I asked to be walked through it, and all went well. It was at that moment that I reconnected to my medical education. I was learning things not just to pass exams, but to do what I always wanted to do— help people through a medium, [the practice of medicine], that I absolutely love.”
At one of four clinics, the 26 persons on the team worked in a crowded, noisy room atop a community building. Patients were registered and seated according to their time of arrival, advancing from seat to seat, closer to white-coated student doctors and attending physicians.
One young boy started crying loudly and no one seemed able to calm him except Tim Rose,"Big Papa,” as he was known by the medical team. The boy sobbed into his mother’s chest as he sat on her lap, and Big Papa realized, “He was very scared!” So Tim Rose leaned his body over the boy as if creating a shelter and began gently massaging his back. Soon the boy quieted, and 30 or so persons settled back in their chairs with what felt like a collective smile.
In triage, "Big Papa" offered kids the snacks that had been provided by local officials—sweet drinks and cookies. True to his pragmatic nature, he later suggested that more nutritious snacks might be encouraged on future visits. He also observed interaction between the team’s medical students, physicians, and their patients—the students’ faces and gestures indicated keen interest in using what they had learned and were now practicing, and they seemed to communicate well with each other when working in pairs.
Tim is the dad of Katie Rose-Borcherding, an osteopathic-manipulation fellow. He grins, “When she and I get into deep discussions, sometimes I have to remind her that I’m the one who taught her how to use a spoon.”
Katie worked with second-year students, and she was also adept at teaching and reinforcing the nascent skills of Valentina. After the first clinic, Val declared, “I can’t thank you enough.”
Katie responded, “You already have. You handled yourself well today.”
Chris Canario, OMS IV, dubbed “The Tall One” by fellow students, would scrunch down at eye level with patients. He savored having more time to talk with each patient than is typical in school or other medical settings. Guatemalans he described as “welcoming, responsive, warm—it makes the whole process of treating them better.” During a painful procedure such as a knee injection, for example, they might be scared, and yet “they talk and laugh, smiling and shaking your hands afterwards.”
Catlin Caines, OMS IV, is interested in full-spectrum family medicine and the practice of obstetrics-gynecology. He has seen the impact of education and supplies in his international trips. Young women who had quit school at the onset of their menstrual cycles were taught how to make sanitary pads, and they were able to return to school.
In clinics, pregnant women could choose to get ultrasounds, and Catlin observed that “They were so excited to see the ultrasound of their babies even if they’d been at another clinic and had an ultrasound two weeks earlier.”
Each medical student presented to a physician-mentor, and in some cases worked directly with a physician to practice a particular medical procedure such as suturing or injecting steroids into an inflamed joint.
Nazar Dubchak, OSM II, relieved joint pain in the knee for one patient, and for another patient in her trigger finger. A native of Ukraine, Naz appreciates the value of medical intervention and supplies—even something as simple as tourniquets, which were in short supply during military conflict in Ukraine when he was there in 2016. Targeting emergency medicine as his field of study, Naz values being calm in the midst of turmoil, and says, “It’s important to see and experience things and to practice that inner calm.”
Kelli Tichy, OSM II, avidly approaches clinical experience, and expresses a fondness for infectious diseases—that is, treating them. She remains unruffled, a demeanor she attributes in large part to a lifetime of keeping company with horses. In training, can redirect a horse’s behavior--more effective than reprimanding.
Brandon Bealer, OSM II, was the only non-global track student, and he glided into teamwork even though he confessed that it was tricky working with medical student peers; he focused on collaborating rather than insisting on doing it “my way.” He finds it intriguing to work with patients who have non-specific symptoms and may be anxious and fidgety. “You learn to ask simple questions,” he said.
Photographing shimmering moments in the Guatemala trip, Shreyash Pradhan, OMS III, senior pre-doctoral anatomy fellow, was once a professional photographer. He created an online photo box for the group. At home in any group, Shay brings a keen appreciation for medicine. Nepalese, his family moved to the United States so that he could have surgery on his spine. He attests, “I had such an amazing time and could not have asked for a better group to experience my first international medical trip.”
Valentina spoke of the refreshing resonance of the trip: “Now, back in school, my education finally feels real. While I may get caught in ruts again and turn on the autopilot to get through things, going to Guatemala reminded me of one thing I will not ignore anymore: my medical journey is not about me.”
“We are here as a team”— clean corners, ultrasounds
Guatemala 2019 marked Dr. Camille Bentley’s fifty-ninth trip overseas in pursuit of her steadfast goal of “providing free care for those who would not otherwise receive it.” She epitomizes a physician-teacher who both coaxes and cajoles medical students to learn and practice skills they never knew they had or thought they could hardly learn on-the-spot.
Matching her zeal for teaching, caregiving, and service are demands that she articulates from the start: “We are here as a team. What one person does affects everyone else. There are no personal agendas in the clinics. I expect 110 percent from each of you when you work. I will not tolerate anything inappropriate out of your mouth or something physically. At all times you represent the United States and Rocky Vista.”
Around the breakfast table where she spoke the first morning, eyes widened, and silence reigned. She paused, then added, “I don’t want you to be miserable. Your expectations of what you can do are not correct. You can do more. Ask for help when you need it.”
One way to focus, she said, is to consider why you are asking a patient each question. Another way is to organize thoughts according to the way you will present each case to an attending physician: patient complaint, pertinent history, review of systems, physical findings, and differential diagnosis. While second years will struggle with such presentations, practice brings ease.
Dr. George Ceremuga of Rapid City, S.D., mentored students and emphasized holistic approaches to healing, including drinking sufficient quantities of purified water, eating vegetables and fruits rather than sweets, exercising, and avoiding cooking on a wood-burning fire indoors while also being careful about ventilation of gas-fueled cooking.
Dr. Phil Sullivan, emergency department physician, worked with student doctors to evaluate a patient who had a swollen foot. The patient denied any injury. “We asked her if she had stepped on anything.” At first, she said no. “Espina (thorn)?” No. “Clavo (nail)?” Oh, yes, six months ago! An ultrasound revealed an abscess in the forefoot, and a needle was introduced to withdraw infected fluid. She was placed on antibiotics, and arrangements were made for her to see a surgeon for definitive treatment.
More details from Dr. Sam Plesner, who oversaw the ultrasound station, reveal educational significance and dramatic turn the treatment took. “This patient came in with a chronic swelling of her foot that had been bothering her for several months with a vague history otherwise. Using the ultrasound, we were able to pinpoint a small amount of fluid and successfully guide a needle to aspirate a tiny amount of frank pus. This one brief procedure, which without image guidance of the needle would have probably missed the tiny fluid collection, drastically changed the management of this patient. Given this, we knew she had an abscess in her foot and with some additional questioning she remembered stepping on a nail about six months prior, and the swelling seemed to start not too long afterwards.
“With a chronic abscess surrounding and interposed between the metatarsals (bones just before the toes in the feet), the concern was raised for osteomyelitis. Since we had the sample, we were also able to coordinate with local government health officials to get the patient referred to a lab for culture of the pus and referred for appropriate follow-up.
“This also ended up being a fantastic teaching experience for multiple students who were able to see the procedure with the drastic change in diagnosis and management as well as the subsequent discussions between all the doctors working to figure out the best course of action based on the available resources that we had and that local government could provide.”
For other patients, in addition to diagnostic exams, Dr. Plesner also used ultrasound imaging to administer therapeutic soft tissue and joint injections.
An RVU graduate, Dr. Plesner is in his second year of radiology residency at Providence Sacred Heart Medical Center, a 719-bed medical facility in Spokane, WA. Gentle, humble, and erudite, he took every opportunity to satisfy students’s thirst for learning. On the group bus, a couple of zealous students were asking him about suturing techniques. He grabbed some string and guided them to practice as they anchored the thread on seat backs.
Dr. Jennifer Goodfred, known for her resourcefulness in the midst of dwindling or no medical supplies, recalled treating one elderly woman who had terrible arthritis. “We were out of BenGay. I simply talked to her, put my hands on her back, rubbed her muscles, put a patch on her back and an ace bandage on her aching knee. Short-term we can offer touch and care.”
At one clinic, Dr. Goodfred noted the irony of “my corner of cleanliness” where she saw patients in a schoolroom, but the bathroom there was filthy, as if hepatitis were stalking the bathroom. Why is it not connecting? The local health department offers vaccines and carries screening tests.”
She mused about ways to enhance the long-term health of Guatemalan patients. Working on-site at local health clinics and donating supplies to these clinics might be explored. What about hiring a Guatemalan to coordinate trips with local health care facilities? Hand-outs on how to combat and defeat such health problems as scabies could be created. She encouraged medical students to submit abstracts for presentations to the American Academy of Family Physicians Global Health Summit:https://www.aafp.org/events/global-health.html
Attracting physicians from all over the country, this year’s annual conference October 9-12, 2019, in Albuquerque, NM, is “a great opportunity to learn and share global health experiences [including] photography, art, or poetry. You could be selected to present or have your work on display at the conference! Or just attend! And meet people and learn!”
Vistas and Markets Enchant and Exhaust
In clinics and elsewhere in Guatemala whether riding on the group’s bus or ambling along cobblestoned streets, the senses of seeing, smelling, tasting, touching, and hearing are heightened. In the open-air market where farmers bring their harvests, a buyer salivates among red apples, yellows bananas, leafy and spiky green herbs. The country itself seems to sing, chant, hawk, holler, enchant, exhaust, and delight.
Catlin Caines, OSM IV, noted prominent shapes, hues, and sounds: “The colors are bright—orange and pink with deep blues in the backgrounds and bright blues and some greens. The shapes are round and blunt—few hard angles or jagged corners. The art isn’t abstract—it’s all drawn from the surroundings—animals, churches, volcanos.”
Bartering in the market is commonplace, and Catlin found it to be “a battle of will. The internal battle is the real one—a conflict of my desire to win-to consume-and my fear of taking from someone who is in greater need than I. The culture is different—I feel guilty and ashamed if I think I’ve outwitted or taken advantage of someone... it keeps me from meeting [the seller’s] cutthroat skill.”
Swirling around any negotiation are what Catlin characterized as a “cacophony of sounds—flutes, aggressive beckons from the vendors, and the dull roar of conversation—and a palette of colors—bright, verdant vegetables and fruits, vivid flesh of slaughtered beasts, and swathes of covered cloth”
Ashley Woodworth, OSM IV, spoke of “the death cabs,” the motorized dune-buggies that jam the streets. At a crossroad, they may threaten to grind the unwary pedestrian into the cobblestones.
After working in four clinics, Parker Stocking, OMS II, trekked up an active volcano, Pacaya. He spotted fellow student Austen Anderson, OMS II, coiled around his camera lying atop a lava field. Seeing a photo of this moment, Parker remembers conjuring up another career path for his friend—"Austen should just work for National Geographic photograph wildlife and write articles on feeding/mating patterns of small tree birds.”
Christopher Canario, OMS IV, celebrated a milestone birthday one night after a clinic. His big grin during the evening celebrations seemed undiminished the next morning even though he had scantly slept. He said, “I could not have picked a better place or group of people to spend my thirtieth birthday. I had never met most of the [team] on this Guatemala trip. We clicked as a group immediately, not only working as a team to treat as many people as possible, but also through other exciting activities like zip-lining over Lake Atitlan, visiting a coffee plantation in Antigua, singing on the boat/bus rides and exploring the different cities we visited. Visiting new countries is always an amazing experience but being with a great group of people makes it even better!”
In San Antonio Palopó, several persons finished the day there at a small restaurant-bar-hotel. A doctor and two young women sat side-by-side as they gilded back and forth on a wide swing overlooking the harbor and Lake Atitlan.
Dr. Goodfred, medical director of the Family Practice Clinic at the University of Tennessee in Nashville, was one of the trio: “I remember this moment on the swing so fondly. I will always call this place ‘the monkey hotel’ even though the monkey is long gone. Tenley [Viñas] had just impressed us by counting to 20 in Kaqchikel—with a very credible indigenous accent. Alma [a Guatemalan translator who speaks Spanish and Kaqchikel] counted to ten in her brand-new English! Then Alma taught me how to say, ‘Let's go,’ the Spanish equivalent of ‘vamos,’ in her native tongue...so hard for me to emulate. After three or four tries I finally spit it out: ‘ka -tom-pa!’”
Scott Viñas, a firefighter from Summit County, has reason to call this same place “the monkey hotel.” Years ago he trod up its steep steps to a restaurant-bar that opened to the sky, as well as to birds or other creatures who happened to alight. Scott saw a monkey resting on a palm tree next to a spiral staircase. Scott’s black hair offered the monkey an inviting perch, and he jumped. Suddenly a swarm of shouting Guatemalans surrounded Scott who was crowned by the monkey. He understood that his was not good. What Dr. Seuss’s fish once said about the Cat in the Hat was true of the monkey: “He should not be here/ He should not be about.” The monkey, wild and dangerous, was coaxed outside. Scott was liberated.
Rarely could Scott be found alone—Guatemalans are drawn to him, as he is to them. He spools out stories that place listeners at ease. Yet he had no caption for scenic photos that he took of the setting sun at Lake Atitlan, because, as he said, “No words needed!”
As for this writer, I remember the remote pueblo where the wind had scooped up dust and scoured eyes, and a wizened woman greeted my “Buenas tardes” with a warm smile while her lips and chin caved toward a hedgerow of yellowed teeth. Her nine-year-old granddaughter wrapped an arm around her “abuela.” Her grandmother wanted glasses to help her see when stitching, and the young girl wanted to protect her eyes when she walked to school in dust-storms. A student doctor fitted the “abuela” with reading glasses. We had no dark glasses for the young girl.
Several students as well as volunteer Keven Meyer have vowed to have an ample supply of reading and sunglasses for our next trip. Meanwhile, Guatemala awaits—visions and vistas, hugs and hopes.