By Debra Glasser

Days 9 & 10: Guatemala

Yesterday was our first day off after the work week of a lifetime.  Sleeping was still not an option because Elisabeth, our tour guide par excellence, had a full plate of activities scheduled for us.  We had our usual 6:30 a.m. and final breakfast at Petrona’s and said our goodbyes to her and her family, including the dogs we had named.  I wished I could bring them all home with us, especially the puppies we named Zorrito and Don Juan and the timid and sad Sulks, appropriately named for his temperament.

Our agenda:  8:30 ‘ferry’ across the lake to Pana, unload at the hotel, back to catch a ferry to experience market day in Santiago Atitlan, then back to Pana for time at the Nature Reserve and Zip Line, followed by Shabbat services at the hotel.

The entire team had many mixed feelings upon leaving San Juan, the little village which had become our home for a week.  Having worked, slept, eaten, and shopped there I know all of us loved  being part of the community.  It was a quiet and welcoming town, and we were all sad to leave.  I will make bets many of us will be back.

My favorite parts of this day were the boat rides across the lake.  From San Juan to Pana, Santos, our skipper,  invited me to sit next to him on the little seat at the back (aft) for a fabulous view of the mountain and shoreline scenery.  From Pana to Santiago Antitlan I was the human bow pulpit loving the wind blowing my hair. What sailor does not love the wind?  Finally on the ride back to Pana, I fell asleep on a bench with my hat over my face.  That evening at our check-in time I was informed that the last boat had no life jackets aboard. To a former lifeguard and sailor looking forward to attending a Lifesling (a life-saving ‘man overboard’ sling and technique) class this summer, I was appalled.  None of the boats even had life rings to throw which would be both  inexpensive and lifesaving.  Nor do I have a clue how many people along the lake actually know how to swim.  I suspect few and many drownings.

The idea for us to attend market day in Santiago Atitlan was one of the few agendas that did not fly well for our group.  It was crowded, dirty and beggar/sellers clung to us annoyingly like glue. We were not ready for the onslaught of commercialism and crowds.  Ironically, the delicious lunch at the  tourist restaurant, in retrospect, made the 5 of us who ate there ill for varying lengths of time.

This day I hope to have an insert by a team member about the zip line.  The 5  ’zippers’  loved their time as did the 2 NP’s who had a relaxing time at the reserve.  Amy and I passed. Amy explored Pana alone while I literally passed out, chilled and  slept for the 3 hours dreaming I had malaria or some horrible illness.  The pictures of the zip liners should at least transmit the joy those 5 experienced.

Dinner and brief Shabbat services were at our luxury hotel, Utz Jay, in Pana.  The rooms were beautiful: tiled, lovely mahogany furniture, comfortable beds with hand-woven bedspreads, NICE bathrooms and for most of us, hot water showers.  The flowered courtyard added warm ambience while the 3 gorgeous German Shepherds, well nourished and entertaining, were special for the dog-lovers among us (including me, of course, if you couldn’t tell by now!) who had become accustomed to seeing bony flea-ridden dogs on the streets of San Juan and San Pablo.

Tired, well-fed, comfortable and spiritually infused we all rested and reveled in the relative luxury of this place.  We needed it.

Next we packed up and headed for Antigua on a 3 hour shuttle ride, which turned out to be the group’s favorite part of the day.  For nearly 2 hours straight, we sang.  Rosi played the ukulele, Michelle had the Rise Up Singing book on  her lap to help with lyrics when we needed.  Adding to the pleasure of the ride was that we were mostly  on a freeway, paved and smooth. It was only on the outskirts of Antigua and climbing out  of Atitlan that we were on bumpy cobblestone.

Our hotel in Antigua, Hotel Posada San Vincente has a Spanish flavor with tiled roof and a plethora of flowers and greenery  in the   welcoming  courtyard adorned with a non-functioning fountain (this is, after all, Guatemala) and 2 round plastic tables surrounded  green plastic stacking chairs.  The rooms were simple and comfortable with showers still better than San Juan. It wouldn’t take much. Plus, we were right in the center of town where the action is. The pet parrot in the courtyard was a hit with its “Ola!”s and “Hello”‘s.  When Elisabeth and I were talking in the courtyard  she  came out with, “Let it go!”

Antigua is a cultural experience of its own as different as possible from our Mayan village life last week.   This is a Spanish town and except for Mayan peddlers of weavings and wooden flutes in the street, could very well be in Spain.  It is charming, European, the Guatemalans are Westernized (something we had not yet been exposed to), and tourists abound.  There were many Americans.  Rosi and I ran into a medical team from California in Frida’s restaurant (where we had delicious mole and a virgin margarita) where I noted a large man’s red HELP name tag, M.D. surgeon.  The interaction was superficial: ’15 hernias, 5 gallbladders and lots of lumps and bumps’ which added to my appreciation of our team (see separate entry on the team).  Our team’s connections were deep and collaborative with no hint of hierarchy or egotism.  I am sure this was not the case on this team based on my two minute interaction.

The team dispersed for wandering, shopping and a handful had a paid tour with the famous Elizabeth Bell and enjoyed it very much.  We gathered for our last night as a  full team at an Indian Restaurant, sharing our highs (singing in the shuttle) and lows (this time together being over) and last reciting of the Omer.  This spiritual foundation that Elisabeth created for us morning and evening, set a deep  tone and higher intention for our work and time together that I am sure made the experience beyond exceptional for us all and hopefully our patients.

On our walk back to the hotel after dinner, exhausted most of us, was an open air concert in the a square with a band of infectious energy.  Elisabeth, Lauren, Julie, Amy, Michelle, Rosi and I could not resist.  We were  dancing in moments for at least an hour.  The most amazing thing was that this band that spoke Spanish, did not look Latino, sang in Spanish, French, Yiddish and a little English (that was Bei Meir Bis Tu Shein) playing some unique blend of Klezmer and Bohemian Jazz. I felt like I was at a Jewish wedding.  Our group was full of energy, the life of the party, dancing in circles, pairs and alone,  picking up on the Jewish theme.    The band was fantastic with 2 guitars, drums, accordion, and clarinet; they were entertainers par excellence.  Turns out they, Zumbido, were from France and apparently none were Jewish.  Rosi was itching to jump up with her violin which she regretted not bringing and Julie went wild dancing.  It was a perfecting ending for us all, especially Elisabeth who I discovered was a dancer by training!

Exhausted at long last having got a workout most of us athletes had missed, we returned to the hotel to sleep for a few hours to see off 6 members of the team were leaving at 4 a.m. to fly to Tikal.

By Debra Glasser

Days 7 & 8: Guatemala

The last 2 days were, as the others and perhaps more so, overfull and exhausting by day’s end.  I had no energy left to write but there is too much not to share.  Thanks to the daily alarm of bird song that is exotic to my North American ears I awoke early enough to document the final day of medical service.

This day was at an outreach at a small village high in the mountains, ‘a day’s walk’ to the ocean we heard.

The first and last part of this adventure was the ride to and from.  We traveled by private shuttle (think 2 red Toyota vans that seated 10 with roof racks for our MASH unit suitcases), each driven by a young man with an assistant, ours was his approximately 10 year old son.  The way was a windy  mountainous ‘road’ , sometimes paved with good cement brick, sometimes cobblestone, at least half deeply rutted dirt which although was bumpy (is there a word for REALLY bumpy?) kept down the speed.   We were driving at least half the distance on the edge of cliffs dodging people, dogs, trucks and motorcycles.  Horses, goats and 1 cow were tied and grazing by the side of the road. The passage up or down the mountain from the village to the lake level had 15 hairpin turns in but a few miles.  My view was spectacular sitting in the front seat next to the driver which almost prevented me from becoming motion sick.  For someone who is anxious being a passenger in a car around home, I was remarkably not terrified.  Perhaps that is because on the way to had decided that if we went off the cliff it would be over quickly.  Lois I found out later had been strategizing ‘what to do if’ such as duck and roll.  Others held on to a good degree of terror, for good reason.  All that said, the trip offered spectacular views of dramatic mountain scenery in the mist as well as poverty at a level we had not yet witnessed.

In the small village we set up in a large quonset hut building.   Birds’ nests were in the rafters, there was a stage with 2 rooms on each side.  We emptied one of those rooms for Linda to use for GYN privacy. It was full of elementary school desk chairs like the ones I grew up with.  When I said I hadn’t seen desks like these since I was in school, Gaby quipped that they may very well be the desks from our schools.  The other 3 of us providers each took our corner walls while the nurses were in the middle and the pharmacy on the stage.  My ‘exam room’ consisted of a small table no more than 4′ long (for an exam table), a tiny school desk and 3 chairs.  It was a slow day with less patients than in the other locations.  Apparently recruiting patients in the villages is a problem for a myriad of reasons the greatest of which are getting the word out and cost.  The clinic charges 10Q ($1.30) for the consult and all medicines prescribed and even that is unaffordable for many.  Though the pace was slow, there were some dramatic cases.

Linda saw a toddler with severe burns on his buttocks, severe enough to be hospitalized in the US.  She cleansed the wound and sent them home with

Silvadene and dressing materials.

I saw Marguerite, a petite 60 year old woman with a guaze tied around her chin and an ironically infectious smile.  She unwrapped her gauze dotted with pus to reveal her massively swollen cheek and temple, extending into a red  fibrotic mass in her left neck. Embedded in this huge lesion were multiple necrotic areas lined with foul smelling green exudate.  Marguerite was calm and sweet all the time I was looking and working with her.   Two months ago she was given two antibiotics and one month ago Lyrica 75 mg 3 x daily which was controlling her pain.  I’m not sure whose idea that was as the notes were incomplete, but it was no less than brilliant.  Joanna, the clinic founder, told me the swelling by her eye was new.  I prescribed 2 weeks of Augmentin and a tapering dose of steroids, the latter of which I hoped would decrease the swelling and inflammation around the tumor. The clinic is committed to keep her stocked with Lyrica, no small feat as this is a very expensive medication.  There was something very sad and yet very uplifting about meeting her.  In the US, this tumor would likely be treated with drastic and disfiguring surgery (confirmed by Lauren who just took care of man with just that who could no longer speak as a result) followed by radiation therapy and its ensuing fatigue, mouth lesions, and perhaps even esophageal obstruction.  Though there is no pretty outcome for such disease, I wondered if in this case the lack of ‘care’ and treatment was perhaps a blessing.

As we were packing up for the disappointingly slow day, Gaby had talked to a woman who came into the courtyard carrying a small infant in the fabric tied around her chest.  She thought this was odd as she had learned, as our maternal social worker, that mothers keep their infants inside for 3 months.  She learned that the ‘infant’ was actually 6 months old and encouraged the mother to come in for care.  The mother had not come because she did not have the 10Q to pay.  Linda and I converged on the child who was hot, sneezing and had a snotty nose.  The baby looked like a 1 week newborn and I took her into my arms to weigh on the scale any of us would have in our bathrooms: 10 pounds with ‘clothes’ on. She was wearing a little shirt, wrapped in a gorgeous woven fabric as all the women are, with a thin black cloth between her legs (no diaper).  She felt hot but was alert and moving though her fontanelle was the size of a newborn and sunken.  I could not find anything more severe wrong with her other than an upper respiratory infection.  Instead it was clear that she had severe failure to thrive.  Now, this was Linda’s department. While she took this situation deeply to heart and did what she could, I wrote up the medical record appreciative of the kind of attention to detail and patient teaching a nurse practitioner offers in contrast to me as a  physician. We discovered, to no surprise, that there are no infant formula or bottles available in the village with the closest pharmacy being at least an hours drive over those poor  ‘roads’ and she clearly had neither money to travel or buy formula.  Joanna told us about the lone ‘local’ hospital for severe malnutrition where children can only be admitted when there is another complicating problem which this child did not have.  However, Ashley the clinic administrator, remembered that a child nutrition specialist was coming on May 8.  Joanna signed her up and will cover the  transportation costs.  Linda wanted to take the child home.  I wanted to tell my colleague who would adopt her in less than a minute, revive this child and give her a life of privilege as we and our children have been given. The mother had 5 other children.  But life and the world does not work that way.

That little girl was our last patient and the end of the long, full and exhausting week.  The drive home went thru the villages and towns of abject poverty. Dirt floored shacks where whole families lived in 1 room, the lucky ones with a chimney for the wood fired tile stoves again for the lucky ones. The forest is disappearing as a result of these cooking methods and clearing land for crops. Coffee is grown on slopes so steep they look impossible to climb much less farm.  Small pieces of land everywhere is planted with corn, beans, coffee, and cabbage including the dirt alleys of the village.  It reminded me remotely of the garden plots dotted all over the Eastside of Portland.  The people in the small towns are still beautiful, dignified and strong.  The women wear traje, feminine blouses (different styles for different villages) and woven wrap skirts tied up by gorgeous belts.  In most of the villages the belts were woven; in this poorest village they were beaded and exquisite. Only in the poorer villages the people and the clothes are not clean.  The 3 part sinks with cold running water sit by the cemet gulleys on both sides of the steep roads for water runoff.  The fortunate ones have toilets.  The home next to the quonset hut where we worked actually had a tiled toilet room, next to it a shower room also ’tiled’ and ‘plumbed’ with a pipe coming out of the ceiling where the water came out.  No shower head, just a1/2″ pvc pipe. This was one of the fanciest facilities in this village.

Upon return to San Juan, I felt like we were in Lake Oswego. The dirt path to Patrona’s compound where we ate our breakfasts and dinners as well as a similar winding mud alley to the clinic which initially almost made me sick, looked neat and groomed in comparison.  The relative wealth of San Juan (and I use the term wealth relatively) was palpable in comparison to the last 3 days where we worked.  We were tired, all somewhat shell-shocked by both the ride and the last case, sad yet relieved it was our last night of work and ready for some fun ahead.

Our last spiritual evening in San Juan was, as always, rich, deep and connected.  Those experiences as well as reflections on our group, now a closely knit community of women connected by purpose and service, I will share in another entry. It is now Shabbat and our first free day in Pana is winding down.  Stay tuned!

By Debra Glasser, MD

Day 6: Guatemala

Today was our third clinical day and there are so many highlights in a single day that I will choose just a few to share and along with some reflections on one of the most exhilarating and enlivening experiences of my life.

The Guatemalan Adventure ride

Today the team went on the road to the outreach clinic in San Pablo, a much poorer village about a 30 minute drive from San Juan.  We traveled there by pickup; 2 pickups; 1 for the clinic gear and the other for staff.  How many medical team members can you pack in a pickup bed surrounded by ornate metal tubing?  The whole team of 9 of course!  Imagine the entire group standing in the back of the pickup holding suitcases and backpacks in with our legs while the bus careened down steep cobblestone streets and narrow dirt roads (aka paths) along mountain cliffs.  The screams from the group would make Walt Disney proud.  Dr. Amy and Nurse Lauren (now donned with the team bravery awards) were in front holding up their cameras shooting pictures the whole way.  It was early morning and the views of the lake villages with mist on the mountains were exquisite.

MASH Unit

The group hopped out of the pickup and formed an assembly line (it was Linda NP’s idea… “just like unloading a raft,” she said) for unloading and delivering the dozen suitcases that contained our clinic and pharmacy for the next 2 days.   Everyone jumped in to transform a church with rows on benches into a functioning 4 provider clinic as fast as possible.  Benches were lined up vertically down the middle of the church to become the waiting room.  4 bench units were set up in squares around the room for the clinical exam/treatment rooms.  The GYN room was set up on the stage for maximal privacy.   The pharmacy and nurse’s stations were arranged on a large and small table respectively inside the front door.  Support staff and young men showed up to help hang sheets from the ceiling taped or clothes pinned at the corners on 3 sides to separate the 3 other clinic rooms for a semblance of privacy.

It took about an hour and as we were just beginning to relax Joanne ‘blew the whistle’ and we were off and running a full day’s clinic … in a box!

• We’re tired but we’re not worn out
• Deep well of energy and commitment
• Health care challenges are universal
• There is nothing new under the sun

Today’s most challenging patient was the one from whom I could not a history.  He was a high strung man in his early 30′s, neatly dressed with hair styled with some gel  product.  His chief complaint or complaints were completely elusive.  No matter how I asked the question and it was translated twice by Rosi (English to Spanish) and Josephina (our 21 year old darling health educator/nursing student Spanish to Tzutujil, he gave the same vague and unhelpful answers.  I listened intently trying to come to some conclusions or reasonable assessment with little success. We even pulled in Ashley, the clinic administrator, to help with English to Spanish translator when Rosi thought ( incorrectly) that it was her translation that was the problem.  After at least half an hour, I decided his vague complaints were due to indigestion for which I had few to no  treatments in our formulary.  My suggestions were Peptol Bismol and finding an indigenous healer for Aloe Vera (it grows everywhere) and herbs to help with digestion.  In my clinic I would have prescribed digestive enzymes and  DGL empirically but those were not available.  Later in the evening Rosi and I discussed him, our most tiring case of the day, and her observation of how tightly wound he was, was enlightening.  His repetitive answers I found to have the flavor of a personality disorder/narcissism.

When I finally got him to leave (and that wasn’t easy), I walked out of my sheeted cubicle completely drained and found a similarly drained RN Laura and a smiley face in MSW Gaby.  Taking a deep breath I said I was going to the bathroom (in a squalid shed to the right of the church’s front door), wash my hands (under the pipe sticking out of an adjoining wall left of the church’s front door and just aside a sink that was not functional or attached to the pipe so the water ran out at hand level to rocks on the ground splashing my feet as I washed)  and  gulped some water.  I walked back into the church, took a deep breath and said I was ready (and I truly was) for my next patient.  Amy asked how she could help so I sent her on a cold Diet Pepsi run which when returned revived me enough to see a few more patients and helped (the Pepsi and me) Lois FNP with her complex last.

Self- imposed limitations and other illusions of perceptions

Flying by the seat of your pants

Just before lunch Lois came in and asked if I could inject a knee.  Normally I am  reticent to inject joints in my clinic because I am timid and lack confidence.  Having 2 physical medicine doctors at my office who do this as second nature, makes it even easier for me to defer these procedures.  Here there is no deferring.   “Sure, ” I said, “but after lunch” after eyeballing the 76 year old man’s hypertrophic arthritic knee. I was tired and hungry after 8 morning patients.   Immediately  after lunch RN Julie had the Depomedrol and Lidocaine drawn up according to my orders and all the materials set up on NP Linda’s ‘pelvic table’ (think dining room table covered with a dark purple sheet) . I grabbed the man and got his pants off and him sitting up on the table (no easy task for an old man with a bad knee thru 2 translators).  He told Elizabeth, who was translating, that he was there for an injection.  When I started palpating his left knee, he told me it was his right knee that hurt and that knee was covered with varicose veins.  I was confused and wondered if my memory was failing me.  Fortunately, someone figured out in the knick of time that I had the wrong patient!  It was his twin (or younger we never knew for sure) brother who was here for the injection.  Lois found him and away we went without a hitch!  Did this boost my confidence to do knee injections?  Darn right!  Here without sterile gloves I just went for it.  Will my patients at home benefit from my new found confidence? Darn right!

Ask my colleague Dr. John at home about my touchy sensitivity and he will no doubt tactfully concur.  I’m the one who could not share an office with he and his Dr. wife because it was too noisy to concentrate.  The Family Practitioner’s  screaming baby patients drive me nuts with irritation.  Here in San Pablo it was complete chaos and commotion all day.  Only once did I ask the men talking loudly outside my curtain (aka sheet) to speak quietly because we could not hear each other in the exam room.  Noise  was the least of my problems!

Today I found myself confidently diagnosing parasitic infections by clinical history alone. I did look up some clinical signs in Medscape regarding the woman with months of bloody diarrhea which confirmed this is common in amebiasis and that amebiasis and giardia are the main causes of diarrhea in Central America.  I now even know the treatment regimens by heart for both.  My last patient with Giardia I dispensed a course of treatment for husband with the same symptoms.  Wow!  Talk about clinical confidence or as NP Lois so aptly put it, it’s ‘flying by the seat of our pants’ medicine.

Teamwork

Stay tuned for the next entry for this one is gelling more each day….think bonding….

By Debra Glasser, MD

Days 4 & 5: Guatemala

These have been the first 2 clinical days and I am finally sitting down to write and reflect on the highlights.  The first evening I was most exhausted, the night of partying in the street outside my hotel room by the locals adding to the day’s fatigue.

At our evening group meeting the first night we shared highs and lows.  My two highs were: the top notch proactive job the young RN’s in the first 5 years of their respective careers were doing with triage and vitals.  They foresee the need for fingerstick blood sugars, urine pregnancy tests and took on doing all the urinalysis, hgb A1c’s and h. pylori fingersticks, teaching themselves to use the testing equipment.  My second high was the incredible appreciation the patients expressed for the care.   Low was the 32 year old woman who presented with 2 weeks of increasing right lower quadrant pain and had a huge right pelvic mass.  Stay tuned for Day 2, however.

At the end of today, Day 2 in the San Juan clinic, I feel compelled to catalog the day’s patients though I’m not sure why.  Is it that I don’t want to forget these people? Or share with other teams ‘a day in the life’? Or simple pre-occupation with myself?  Most likely it is a bit of all.  Nonetheless I will not bore the general reader with these details.

Let’s instead infuse this blog with some humor and we have shared plenty.  First and foremost, our team is doing the heaviest of work yet infusing the experiences with humor.  I haven’t laughed this much in a very long time in general, much less with clinical colleagues.

Yesterday’s case: 2 year old boy came in with Mom and older brother.  Bro pulled  pants down, swollen penis, treat for yeast and cabbage leave, like the rolls at dinner….

Today:  Julie, one  of our triage RN’s decided to explain to a man how to collect a clean catch urine.  Note this all goes on at the front door of the clinic and in the same room where dozens of people are lined up in teal plastic chairs (yes, think $10 at WalMart) waiting to be seen.  Communicating how to wipe, start to urinate, stop, then urinate in the cup.  This explanation (difficult enough in English) she decided to make clearer with gestures and whooshing (for peeing of course).  The man sheepishly took the cup and  walked toward the back of the building to the toilet when the entire group in the waiting room, mostly woman, broke into laughter they had been holding back in his presence.  Unfortunately in earshot.  Hopefully a reenactment of this will be on our trip’s video so stay tuned!  Honestly, being a beneficiary of the woman’s movement, a little payback in this patriarchal society was touche!

At the end of this long day, my things packed up for tomorrow’s trek to the village, Dr. Amy our team’s chiropractor evaluated a late patient together.  He was a strapping youngish man who had a severe head injury in an auto accident 6 years ago, was comatose for 4 months and spent 2 years in bed.  He now walks and teaches primary school but aches to resume his athletic passions, basketball etc.  Feeling weak on his right side and limping has made doing so very difficult. We did the neurologic exam together and though he was strong on the right side he was not nearly as strong as on the left and there was muscle wasting of his right leg. Since he walked by lifting and listing his right leg I suggested she check his gluteal muscles.  As he was already standing Dr. Amy put both hands on his butt and asked him to walk.  I said totally out loud in English, “Don’t worry, he probably likes it.”  Immediately, the patient and the indigenous translator both cracked up with us.  So much for not understanding English…and having fun  with medicine.

The clinician cooperation has been phenomenal.  Linda, the nurse practitioner, talked thru her 32 year old G9P7 woman with severe genital condyloma, vaginal yeast and new onset diabetes.  I talked her into starting the diabetes treatment instead of referring her to me.  Yesterday I was shocked by diagnosing 2 new cases (is that how many I find in a year in my private practice?) on the first day and by this time diagnosing diabetes was like doing PAP smears, routine already and I knew Linda could get her started on treatment.  I had my first case of acute diarrhea and dehydration in a young woman.  With no diagnostic tests I had no clue how to treat her. Timotea, the clinic’s regular nurse who functions as a practitioner, shared the clinical pearls to start empiric treatment and electrolytes.

Lois, our family nurse practitioner,  helped me assess an ankle ulcer in a diabetic man and Lauren, triage nurse #2 par excellence, dressed the wound and did the clinical teaching so that he could are for the 2 month lesion himself until followup.

Finally before I fall asleep, the woman with the pelvic mass returned with her ultrasound result.  She had a 7 x 11 cm simple cyst most likely a cystadenoma.  After taking 1 Vicodin after our visit, she slept and awoke to no more pain though I was glad she had 8 more left just in case.  The clinic director and founder, Joanne, got her a GYN appt the next day and with flower essences and no pain had become comfortable with the idea that she needed surgery for her problem.

Too many more stories to tell yet with more patients to see the village tomorrow where the director said to expect more poverty, less education and worse pathology,I will sign off for sleep hoping the town’s fireworks will stop forthwith!

By Debra Glasser, MD

Day 3: Guatemala

This was our ‘free day’ before beginning the 6 consecutive days of work.  The day was far from free.  It was full, fun and fascinating.  Now the at the end of this long day, I type in my hotel room while Lauren, RN, Gaby, MSW and Rosi my daughter and pre-med student sit on the beds reviewing medical terms they might encounter in Spanish tomorrow, our first day in the San Juan clinic. My medical books, stethoscope and magnifying lenses are ready to be packed when I awake at 5:45 a.m.  There is anticipation and trepidation in the air.  I’ve never seen patients with the only diagnostic tools being me, 2 translators (1 from native Mayan to Spanish and the second from Spanish to English), and the clinical evaluation.  There is a microscope, strips to do urinalysis and blood sugars and a pharmacy of limited generic medicines that we brought in our suitcases.  No chemistries, chest Xrays for those in whom I suspect TB, or parasitolgy to sort out the diarrheas.  I learned this week that 37% of adults have H. Pylori but no way to diagnose this disease that causes ulcers and over years, gastric cancer.  Tomorrow’s entry no doubt will reflect  clarify about some of these questions looming but will no doubt have new and different musings.

My day started with a short walk for exercise and the early morning energy of a city awakening.  The women were carrying plastic bowls of recently mixed masa for tortillas on their heads.  I saw one leaving an open door of a dirt-floored shack where there was very loud racket.  Inside was a large machine with a fan-belt presumably running a mixer for this wet cornmeal batter.  I also found the SuperQuik where I got all the little items on my list: a water bottle to put in my woven holder, batteries for the camera, a knife and peeler for mangos which are in season (hallelujah!) and a Spanish English dictionary in too small print.

The group piled into Took Tooks after breakfast and a spritual time for the beach.  The water was calm and inviting to swim, kayak, or sunbathe for a most refreshing morning.  After lunch was our tour of San Jaun with Santos.  We learned about the towns founding in the 1600′s with John the Baptist its patron saint, starting at 2 walls of murals depicting him and the town’s history and culture.  The Mayan murals and art are amazing and it was most enlightening to have the meaning behind these massive pieces of art translated for us. We visited a cofradia with an altar adorned with  flowers  and statues of Mary and  Boy Jesus. These organizations take care of the dead and spiritual celebrations in town.

The tour would not have been complete without stops to share the art of the community, first to the home and shop of a painter, Galleria Maya.  There he shared Mayan Nawal signs for a number of our group based on birthdate and year.  This included a guardian animal and Mayan symbol. For what it is worth, my daughter’s Nawal was eerily accurate and she as well as others left with necklaces and acrylic paintings  of their symbols. I left with an acrylic piece of art.  Things slowed down considerably at the woman’s dying and weaving cooperative where we were treated to a demo of spindle spinning, dyeing of cotton which was growing on a tree outside the large workshop, and weaving.  The fabrics are spectacular and the products were captivating.  Many special keepsakes were purchased from scarves to skirts, earrings and native style pants.  On the walk back, tired and hungry we visited with an elderly midwife who showed us her group’s herb garden. With the sun setting and the cool air we arrived back the hotel to wash up for a simple dinner of beans, rice, boiled plantains and the usual and irresistible fresh tortillas at the thatched hut ‘dining room’ of our cook, Petrona.

By Debra Glasser, MD

Day 2: Guatemala City to Pana to San Juan

Amazing, full, exhausting first complete day in the country of mountains and mist.  Breakfast at the Evangelical Seminary securely gated in Guatemala City was delicious and simple: beans, ‘nachos’ (cornmeal, tortillas and cheese), scrambled eggs, white cheese, cereals, cantaloupe and coffee, of course.

The 12 person luxury van with a roof (compared to the eve before) was waiting.  The driver stood on the roof as the youngest and tallest team members handed up the lightest bags.  The 3 hours to Pana went quickly (truth be told I slept at least an hour of the ride) and mostly up and into the misty mountains.  Elisabeth, our host,  found us a little cafe with a bathroom we could all use in Pana. Here I learned that she lived right across the street and some street it was. The place was full of color: colorful shops one after the next, artisans pushing their beaded and woven bracelets and carved flutes (‘beautiful flutes; only 60 Quetzals or $9 down to 20 Quetzals or $2.50 by the time we jumped back into the van).  The shops sold woven bags, tapestries, clothing and I bought a water bottle holder for $2, 6 bananas for 75 cents (sweet and yummy) and looked at a leather backpack. There were many Gringos in town, lovely cafes, bookstores, and fantastic shopping.  The town was hopping.

Once back in the van we were moments to the dock where the skipper of our water taxi loaded our group’s nomadic pile of luggage onto the bow of his 25′ foot skiff with a huge motor and steering wheel aft.  The rows of seats were covered with a plywood roof where the ancient orange PFDs were stowed and thick plexiglass windows hung on the sides.  The lake was choppy with white caps and it was rocking as we boarded.  Our getaway was immediately interrupted as we had to take Elisabeth back to tip our van driver and to pick up our skipper’s wife who came aboard in traditional  garb of woven wrap skirt, belt and apron with solid color blouse, called traje.  The ride was fast, bumpy and gorgeous ringed by volcanoes shrouded in clouds and took 30 minutes with one stop to pick up Joanna, the director of the clinic.  Her smile and energy were infectious with  only her gorgeous white hair suggesting that she had just celebrated her 70th birthday.

The 5 Took Tooks (little electric golf carts) met us as we deboarded to pick up our luggage.  Checking into the simple hotel a few blocks up from the lake went smoothly with but  a moment to catch our breath.  Most of the team walked to the clinic for orientation (a good walk UP)  except for me and Joanna who hitched a ride in the back seat of 2 Took Tooks in order to conserve our waning energy. By this time I was exhausted and asked Juan (yes, another Juan) her Took Took driver if there was any coffee nearby which there wasn’t.  Instead Joanna suggested we ask him to go back to town to get me a coffee which by that time sounded perfect at any price.  By the time Juan took off and Joanna and I had headed down the long winding dirt alley to the clinic, the rest of the group got wind of the plan.  As we began our orientation, Juan and Elisabeth arrived with ceramic espresso cups and a thermos of espresso for the group.  It was strong and delicious and completely redeemed my evening.

The clinic was simple, clean and well organized.  We heard the story of its founding and Joanna’s commitment  to the cause and these people.  The team began to organize  around how we could  do our jobs best with the 2 young RN’s taking the lead.  I was glad I brought my needlepoint being terribly impatient with meetings.  We all learned some key cultural pointers around language and gestures as the reality of the work ahead sunk in.  The patients are poor.  They are asked to pay 10 Q or $1.25 per visit including medications, supported by donations like the ones we brought along in that pile of suitcases.

Next we returned to the hotel for a brief transition, face wash, and a relaxing swing in the hammocks outside our rooms.  It was fun and getting cool with impending rain, a relief to this Pacific North westerner after a day of heat and humidity.

The evening event was just a few blocks up the street a the restaurant of Elisabeth’s friends, Jews from Guatemala City a generation removed from Spain to Sweden and

Eastern Europe.  Elisabeth had prepared the Shabbat Service with her husband Steve on guitar.  Our hosts did a traditional Sfardic Kiddish and Motzi. He had made us 2 gorgeous challot, 2 gluten free breads, and 2 french bagguates.  The meal consisted of 5 gourmet vegetarian gluten free delights from rice with mayonnaise, eggplant wrapped goat cheese or tofu and Manishewitz wine.  At least 3 fascinating conversations went long into the eve, the one I was closest to was in Spanish with our hosts. My daughter was kind enough to translate some so I at least felt a part.

Well fed, spiritually nourished, senses full of the colorful and exotic Mayan culture we walked down to the hotel in small groups exhausted and enriched.

By Debra Glasser, MD

Day 1: Travel Portland>Houston>Guatemala

Leaving home for a 2 week trip was hectic and full of dizzying details as expected.  The lists written, items checked off, mind full of details of what still to do and not forget, the last minute run to Fred Meyer for a few more eggs for breakfast and rawhide chews to keep the puppy happy in my absence.   Finally the last list was recycled, bags loaded and off to PDX.

It was all smiles and hugs to meet 7 members of our team of 9 at the gate.  We barely know each other so far yet are already bonded by our commitment to fulfill this mission together. The mood was expectant with anticipation and excitement.

The first flight was full and uneventful.  In Houston we met the 2 additional members coming from Denver and Seattle at the second gate, a quick Mexican dinner in hand from the airport  La Salsa.

The second flight was less than half full so the team was able to sit together and stretch out, a welcome relief from the sardine can before.  In addition, the level of excitement was rising.

Touchdown in Guatemala City was fast and furious, our leader’s much dreaded pass thru customs passed like a breeze and without a hitch.  Out of security our smiling hostess hostess awaited with a 10 person white van which we were (supposedly) going to get all of our bodies and luggage into.  I watched dubiously leaning against the smooth- barked giant birch-like tree.  “How many Pnai OR Healthteam volunteers can be squeeze into a van?” someone asked when we were (amazingly) all in, with my daughter and I holding a couple of bags in place.

It was brief drive thru the city certainly Latin America.  The seminary dorm we stayed in the first night was simple and funny for the majority of us who hadn’t shared a room with 3-6 single beds.  It was also fun.  Elisabeth gathered us for a welcoming circle helping us to remember the blessings that brought us here, the divine inspiration  that moved each of us to sign up, as well as the many who have supported our trip in ways financial and otherwise.  Tired and expectant we turned in for the quiet Guatemala night.

 It’s not too early to protect yourself from the upcoming flu season!