Halloween in Santiago Atitlan

Although Santiago Atitlan does not really celebrate Halloween, it is one of our kids favorite holidays.  So, we thought that maybe we would make it our annual tradition to have a Halloween party.  We hosted about a hundred people (hospital employees and their families, neighbors, friends, and hospital volunteers) for lunch and a piñata.  Jennifer began cooking the week before and made the biggest pot of chili she’s ever made and thankfully had enough food to feed everyone.  The kids enjoyed a lot of hot dogs.

Christopher was a Power Ranger in a costume we found for about a dollar on the street near the market in Santiago where they sell used clothing from the US.  Elizabeth was Mulan and Julianne was a cat.  Both girls were able to wear both costumes, so they each got to be both Mulan and a cat.  Nicholas was a superhero (yet to be named) and also a princess (also yet to be named).  We all had a great time!

November 1st is All Saints Day and the 2nd is All Souls Day or the Day of the Dead (Dia de los Muertos). In Santiago, as in the rest of Latin America, it is a time to remember family members and friends who have passed away.  Many thousands fill the cemetery to pay respect to their loved ones.  The day before is spent decorating the local cemetery with pine needles and cut grass to cover the graves, flowers, candles, and incense.  It is supposed to be especially beautiful at night with the lit candles as people hold a vigil in the cemetery overnight from the 1st to the 2nd. 

Cojolya

We have found a number of organizations working here in Santiago that are helping the people of Santiago.  One of these we have recently been introduced to is The Cojolya Association of Mayan Women Weavers.

This organization employs local weavers which provides work for up to 80 weavers and runs a social program aimed at improving the lives of its workers, their families, and the local community.  They also have a small museum about weaving that goes through the process from making the thread to the finished product.

They have a great web site which gives more history and some options for Christmas gifts that will make both the recipient happy and help the people of Santiago.  www.cojolya.org

Part 4

The trip from Santiago to Solola at any time of the year can be difficult, but especially this time of the year with mudslides and road closures.  Brent is elected to go with Miguel.  Diego, a new nurse to Hospitalito, is assigned to go, as well, and along with Miguel, his parents, the bomberos and Brent, they begin their journey.  

After about 15 minutes, Miguel’s father is dropped off in Cerro de Oro, the village where they live, to tell relatives what is happening and to get money to help pay for their expenses in Solola.  The hospital in Solola is a public hospital so the care is free, but there are costs for the parents to eat, etc.  
 
Every jolt and bump seems to tug on the endotracheal tube and Brent and Diego look at one another hoping not to have to re-intubate on the way, but each tug confirms the nurse’s taping job was excellent.   Brent is providing Miguel’s respirations methodically reciting “squeeze, rest, rest, squeeze, rest, rest...” trying to maintain 20 - 30 breaths a minute and watching Miguel and the pulse oximeter.  The pulse oximeter has been going down 99, 95, 90, 88.  Brent notices the bagging becoming more difficult and gives a dose of albuterol (a medicine that helps to open up the lungs) via the endotracheal tube.  This appears to help as the oxygen monitor increases to 97 again.  The bomberos note another one to one and a half hours to go.

Diego observes Brent looking queazy and offers to take over the ventilations.  There are so many 180 degree turns on the road that you begin to wonder if you are really going forward and not just going in circles.  Brent is reminded of a similar curvy road growing up, the Green Springs, and the many times his father pulled over for him!

Diego sees the oxygen saturations dropping again and a quick look at Miguel shows him moving his mouth, a sign the paralytic agent is wearing off.  Another dose of that, his saturations increase, and he is resting again.  They finally arrived to the Pan American Highway and a direct shot to Solola.

Arriving at the National Hospital in Solola, a team of Guatemalan physicians greet and attend to Miguel and his mother.  The Hospitalito team stays with Miguel and his mother until they feel comfortable with the change over and begin their journey back home.

Miguel did well during his hospital stay there, was extubated (endotracheal tube removed) after three days, and after 8 more days in the hospital he returned home.

Thinking now of our time with Miguel and the people he brought together from different parts of the world, working together for a common good, his name seems fitting -- one who resembles God.

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.