Part 3

Morning report is a time to review, with the other doctors working in the hospital, the patients admitted and seen in the ER during the day and night before.  Jennifer quickly reviews the patients and then focuses on Miguel.  Brent arrives at 7:40, a bit late, but in time to hear Miguel's story.  The doctors then go down to see Miguel and the other patients.

Miguel is now breathing 50 times per minute, but his oxygen saturation has again dropped into the 80s.  His pulse is 180 and his lungs are tightening up again.  He is shows signs of tiring and is not able to maintain his oxygen at appropriate levels as his respiratory rate slows.

The team this morning includes doctors from Guatemala as well as from Spain and the United States.  Many specialties are represented including obstetrics, family medicine, and gastroenterology.  They realize Miguel will not be able to keep this up much longer.  They begin working in unison: continuous nebs, a phone consult to a pediatric intensivist in the US, comforting the parents, and preparation for intubation. 

Rapid sequence intubation is a process of giving sequential medications that paralyze the patient and allow for placing a tube into the trachea. This then allows the physician to take over the work of breathing for the patient.

Assignments are given, drugs prepared, high flow oxygen started.  All drug dosages checked and double-checked.

The ER this morning is a cacophony of sounds -- the bubbling of oxygen, the drone of the suction machine, voices of physicians and nurses and the labored breathing of Miquel.

The medicines are given and Miguel stops breathing on his own...... 

Seconds seem like hours during this moment as all attention is focused on placing the tube into the trachea.  

When intubating a patient you are always told to have a backup plan.  What will you do if you are unable to intubate the patient?  The last patient, Brent had intubated, was 6 years ago while working in an ER in Northern California.  Brent ran through the different options in his mind -- bag, bougie, laryngeal mask, needle cricothyroidotomy.

The first attempt is met with coughing, signifying Miguel is not completely paralyzed.  Another dose of the paralyzing agent is given and this time the endotracheal tube is passed without difficulty and taped into placed.  Oxygen is hooked up to the bag and one of the doctors rhythmically compresses the bag which now does all the work of breathing for Miguel. 

Miguel’s oxygen saturation increases rapidly to 99%.  He appears at rest now after working so hard for so long. 

The local volunteer bomberos (firefighters/paramedics) are called and Miguel is prepared for the 2-3 hour trip around the lake to Solola, the national hospital where specialists and ventilators are available.

Part 2

Julianne and Elizabeth

At 6:00 a.m. Brent awakens to the proclamation of “Daaaad, I have to pee”.  Julianne feels the need to announce this and serves as the morning alarm for the household.  Four kids to get up, dressed, fed and teeth brushed.  Somehow Jennifer is able to do this without a hitch, but for Brent it is always a challenge.  Jennifer won’t be home from the hospital until about 9 a.m.  The kids know the routine, but still feel the need to deviate at times, depending on who needs a little more Daddy attention on a given day. 

At 7 a.m. Ingrid arrives, our house helper, who makes this chaos a little less chaotic.  With Greetings of “Buenos dias,” a few instructions and an update on the activities of the day, Brent heads up the small hill, leading from the house, with Christopher and Elizabeth in tow, backpacks on, and their “chicken mask” school projects in hand.

Christopher and Elizabeth wave to Hospitalito, knowing that Mommy is somewhere inside and will be at school to pick them up at the end of the day.  No time to walk today, as Brent is on OB call and needs to be at the hospital at 7:30 a.m. for morning report.  They catch a tuc tuc.

Tuk Tuk

The tuc tuc ride is like some racing car video game as the driver swerves around pot holes, dogs, and puddles that resemble mini lakes this time of year.  Christopher and Elizabeth squeal with joy as the tuc tuc is forced into one of these “mini lakes” by an oncoming "chicken bus" headed for the capital.  After climbing the hill to the parochial school, Colegio Catolica Padre Apla’s, the kids and Brent have arrived, a little wet and all sleepiness cleared from their heads.

The kids enter their class room with a “Buenos dias, Maestra” and a “Buenos dias, Compañeros” and with a “Buenos dias, Cristobal” and “Buenos dias, Elizabeth” from their teacher and classmates, the children proceed to sit down at their desks.  The walls are lined with the alphabet, numbers, and words written in a mix of Spanish, Tz'utujil and English.  Brent is reminded of Christopher’s protest during study time at home for their last exams, “It’s not fair we have to study three languages!”  Brent leaves the kids with a kiss on their heads and a quick checkout with their teacher, Juanita.

Miguel: Hebrew origin: one who resembles God, Part 1

It’s the rainy season, but more so this year than in the past few years.  The rain seems relentless at times.  Downpours last for days at a time, a constant drone on the metal roof.  Roads resemble rivers more so than streets.  Mudslides have replaced villages with mud and boulders and there is a general sense from the populace of a heavy coat blanketing all the senses.  But even with all of the rain a "Buenos Dias" is never far from the lips of all we pass by.
 
Miguel’s parents were up with their child late into the night reflecting on the past few days.  It started as a runny nose, followed by a dry hacking cough and then the rapid breathing, each breath an effort to get more air.  They went to the local health center and received various remedies that seemed to help initially, but now, as their child looked up at them with a plea for help and fear of the unknown, they knew he was getting worse.

They say an asthma exacerbation is like trying to breath through a straw, as it worsens the diameter of the straw grows smaller and smaller........

Jennifer had just laid down in bed during a 24 hour in-hospital call.  She’d seen and treated numerous patients that day.  Routine stuff mostly, but now as she laid down at 4 AM she heard the unforgettable "clack, clack, clack" of the tuc-tuc coming down the dirt road to Hospitalito.  At this hour of the day it could mean only one thing -- a patient in need of acute care. 

She gets up before the guardian can knock on her door, fumbling around in the dark in a place that is becoming less foreign each day.  She hears a rooster crow, a dog barking at some unknown nemesis as she puts on her doctor’s coat --loaded with all the “essential” paraphernalia from 15 years of practice.  She grabs her stethoscope, a close friend since her days in medical school, and heads down the stairs to the ER. 

Andrea, the nurse, had already placed oxygen and gotten vitals when Jennifer entered the room.  Miguel’s eyes were bulging and wide with panic as his chest wall heaved with every breath.  Sensing the acuity of the situation, Jennifer questioned, examined, and gave orders almost simultaneously -- pulse oximetry, intravenous access, nebulizer treatments, I.V. steroids.  With treatment, Miguel’s pulse oximetry began to rise from the low 80’s to low 90’s.  His respiratory rate began to drop from the 80’s to 50’s and his lungs began to open up.  He looked a bit better now.  

It was almost 7:30AM and time for morning report. 

A Family Affair

We wanted to share with you an article from the Hospitalito, July Newsletter.  

"We don't need Sherlock Holmes to figure out that Brent Burket and Jennifer Thoene don't event fit the description of your usual medical volunteer. The evidence is everywhere upon entering their home: two pairs of kids-sized rain boots, swirly blue and pink, a bookshelf of children's literature, tables loaded with crayons and coloring books, the movie choice of the day is Toy Story 2, and the final clue, a small voice saying, "mama, it's not fair".


So, why do two US physicians with four children under the age of eight, choose to move to highland Guatemala..." read the rest of this article interviewing Brent and Jennifer on the Hospitalito July Newsletter.

Our Days are Full

We started working in the hospital in mid May. We are excited and happy to be seeing patients again and working with the very dedicated staff at Hospitalito.  As always with new work, there are unforeseen challenges.  We studied Spanish for our first three months here so that we could communicate with the staff and patients, but are finding that a vast number of patients speak no or only a little Spanish.  It is hard not being able to communicate with patients directly in their native language.  There is something lost in the history taking, in the patient education given, in the encouragement we want to impart.  Unfortunately, our Spanish is still not proficient, so learning Tz'utujil will have to wait a little longer. 

There are also many things about the culture, the cultural practices and beliefs, and the people’s day to day living that we need to learn.  This is a slow process, because you really don’t know what you want to know until a situation comes up that provokes questions.  Someone can’t sit down and tell you that these are the differences between our culture and their culture.  Some things may seem so natural for one culture that it is hard to even explain what provokes a particular belief or practice.  For example, several patients have asked if bathing in cold or hot water will affect their medical condition, but we have not yet been able to figure out what concern perpetuates this belief.

  

Our days are full.  We’ve been busy balancing the new work schedule, family, and involvement with the church.  The kids seem unfazed by it all and wake up each day with smiles on their faces and ready for a new day (unfortunately usually before 6AM).  We have no after school activities, no TV, etc., yet we are busy.  Our two first graders go to school from 7:30 until 12:30.  By the time they get home and we eat our main meal about 1 or 1:30PM and they have a little time outside to play, it is 2:30.  Just enough time for a couple of hours of homeschooling, then it is dinner, a shower, reading and bedtime.

All the activities of daily living are very time-consuming and less so for us than for most of the local people because we are very fortunate to have a washer, refrigerator, and gas stove (so we don’t have to have gather, cut, and burn wood for cooking).  Shopping is an almost daily necessity as we can only carry so much home at a time.  Meal preparation is very labor-intensive as almost everything needs to be made from scratch and raw fruits and vegetables need to be prepared specially.   

Christopher and Elizabeth continue at the local Catholic School.  They are learning Spanish, the local Mayan language, Tz'utujil, and a little English as part of their school curriculum.  They had exams recently and while we were studying, they had some practice tests at home.  In one day, they took tests in all 3 languages.  Christopher thought that this was very unfair :).  We’ve participated in a number of school events including a field trip to the beach on another part of the lake (we paid for this thinking it was going to be at a local beach and then the day before found out it was a boat trip away, after which the teacher allowed Brent to tag along as a chaperone), Mother’s day celebration which was a huge, wonderful celebration complete with tamales as a treat for all the mothers, and a school birthday celebration.  Christopher’s birthday was at the end of May and so we brought a little snack for the class.  We were completely surprised when Christopher was inundated with gifts and hugs from his classmates.  He received a couple of toys, but most of the gifts were completely practical: socks, towels, cups, bowls.  This was so generous and thoughtful as we are sure these students’ families do not have money to spare. 

Julianne and Nicholas are both in a local preschool two days a week and really enjoy their time with the other kids in the community.  Many little art projects are covering the walls in our house and are providing creative decorations.  

Peace

Brent, Jennifer, Christopher, Elizabeth, Julianne and Nicholas

Gratitude

We are writing to thank you for your support of MDA that, in turn, gives us the opportunity to be messengers of your love for many of the forgotten ones in Guatemala.

We realize more and more each day that our time here is a reflection of the love and support you give and have given. 

Your prayers are heard as Jennifer manages a 15 year old, scared pregnant girl in labor, providing a safe and caring place for both mom and babe. 

Your love is seen as our child asks why the elderly women is picking up the pieces of corn off the ground and with our answer of “because she is hungry” our child gives the 2 Q she had for ice-cream to the woman. 

Your teachings of love, knowledge, patience and hope are felt each day as the challenges in front of us dissipate with a hug and thank you from a patient.

Your kind words are heard in the early morning as the birds, singing outside our  window, tell us a new day has come with new hope of a better day for the forgotten ones who will not be forgotten today. 

Peace

Brent, Jennifer, Christopher, Elizabeth, Julianne and Nicholas

Happy Mother's Day

Mother’s day in Guatemala is celebrated on May 10th every year.  It is a time to reflect on and give thanks to our mothers (and all mothers of the world) for their love and devotion to our children and to our families.    

The life of a mother in the developing world is very different, in many ways, from what I have seen back home.  The daily routines of cooking, washing and caring for the children is an all consuming endeavor.  The gathering of wood to cook, the fetching of water to drink and wash, the carrying of laundry to the lake, the making of clothing for the family, the trip to the clinic with a sick child.... the day is endless and the next day the same.

At times it is hard to find many similarities between the world I came from and the world I am living in now, but in a “mother” I can see a commonality with the mothers I’ve known best: my mother, my children’s mother, my sisters and my mother-in-law.  Their primary desire being the wellness of the family, is a commonality of mothers I see here and the mother’s most dear to my heart.  

This commonality is shown in their unique ability to focus on the day to day needs of the family and exemplified by the gifts of calmness and directness at achieving those needs, often times in the face of great adversity.  What underlies these gifts is an undying compassion and love for their children and families.

So today I wish to say “thank you” to my mother, the mother of my children, my mother-in-law and to all the mothers of the world for their love, support, compassion and care that they gave yesterday, give today and will give tomorrow.

peace and love,

Brent

P.S. I wonder how much better the world would be if a few more mothers of the world were leaders of the world?