I’ve been in Guatemala for over a month now. The last few weeks were action-packed and things have shifted a lot since my last post. I feel calmer and steadier. I spent the first 3 weeks or so wondering if I could do this and often fighting against being here. Fighting against what IS created a lot of anxiety and took me out of the present. Self-doubt crept in like the sneaky ninja that it is. I lamented over not feeling grounded, as I talked about in my last post. A wise woman in my life told me that while I may not be able to feel grounded in the Earth, maybe I could feel fluid, like water. The water metaphor resonated deeply with me. Water has always been a comfort to me, growing up surrounded by the ocean. I can be flowing and adaptable and open to everything that is constantly changing here without needing to feel too solid or fixed.
With water as my ally, over the past few weeks I’ve felt a new sense of clarity, confidence, and purpose. I’m slowly but surely dropping in to this experience and remembering that I have much to offer (and much to learn). I no longer have thoughts about leaving or wishing I was somewhere else. I’m starting to feel at home here. It’s amazing how powerful time is. I’m developing a routine during the week and I know the personality of every midwife. I know who likes who, who DOESN’T like who, who is receptive to learning new clinical skills, and who can teach me.
I don’t mean to suggest that everything is now a piece of cake. Whew! It’s still hard. But the challenges I’m feeling most acutely have changed from internal to external struggles. By external I mean challenges here at ACAM such as helping the midwives develop a system of medical record keeping, teaching them to take vital signs and do more monitoring in labor, convincing patients to go to the hospital when they’re high risk, and dealing with the broken Guatemalan healthcare system.
A highlight of the last few weeks was our site visit from Every Mother Counts on June 28th. EMC is a non-profit organization dedicated to making childbirth safer on a global level. It was founded by Christy Turlington, a former supermodel who experienced a difficult childbirth herself. She became interested in maternal global health after her daughter’s birth and went back to school to get her Master’s in Public Health before founding EMC. EMC provides almost half of our operating budget and provided the grant that allowed ACAM to launch its mobile clinics program this January. Christy and several other EMC staff members along with a group of Mothers (friends of Christy) and their teenage daughters came for the day to visit ACAM. The midwives gave them a tour of the center and Imelda and I gave a power point presentation on the history of ACAM and its current projects. Then, we ate a big lunch with the entire group. It was such an honor to receive that group of women here and I felt really proud of the midwives. Thankfully, we learned that we’ll be getting the grant again next year so we can continue (and expand upon) our mobile clinics program. SUCCESS!
A few days after the site visit, I took off for a relaxing three-day weekend at San Marcos La Laguna, Lake Atitlan. I couldn’t wait to be on the water. It’s a couple of hours from Concepción and that particular town is mostly Maya indigenous people but its also known for lots of hippie foreigners. There’s a beautiful yoga center out in the woods called the Yoga Forest that I was looking forward to visiting. A dear friend from Seattle, Mike Mantell, spent several months in San Marcos during his six-month Central American odyssey and was spending a final weekend there before heading back to the states. Fortunately, we coordinated and spent a few days catching up.
As I got off the boat that dropped me at the San Marcos dock, I passed 3 different healing and meditation centers within the first 100 feet on the path that leads to the town. Essential oils, massage therapy, reiki, reflexology, and one holistic healing center after the next saturated the beautiful foot paths. There is only one main road in San Marcos where cars drive. The rest of the roads are just narrow walkways for foot traffic only. I found my way to my guest house, owned by a lovely Guatemalan couple, where I checked into a room that had a comfy bed, an outdoor patio, and a shared kitchen for only $7 per night. Mike didn’t arrive until the following day, so I spent that first afternoon exploring on my own. I had a delicious vegetarian lunch at Medicine Foods, where a statue of Ganesh the elephant god greeted me where I ordered. There were lots of spiritual books and oracle cards to peruse while I waited for my food. After my belly was full and my tantra tea had warmed me up, I walked through the San Marcos nature reserve and sat down by the lake to take in its beauty. Lake Atitlan is surrounded by 3 large volcanoes, none of which have been active for as long as anyone can remember.
The next morning I woke up early to catch the 7am class at the yoga forest. I knew it was out in the woods, but I’d been told it was only about a 20-minute walk from town. I started climbing up the steep hill and took a wrong turn on the path. I ended up climbing up the wrong side of the mountain and ended up at the Fungi Academy instead of the Yoga Forest (yes, the Fungi Academy). I was a little lost, confused, and sweaty when I saw a small building (too small to be a yoga retreat center). It was a house and gardens settled into the hillside with panoramic views overlooking the lake. A gorgeous man with blonde dreadlocks was doing yoga on the roof and turned to me and smiled. He seemed to radiate inner peace.
“I’m looking for the yoga forest?” I said.
“Well, you’ve made it to the fungi academy”. He replied in an easy Australian accent.
Hmmm…..well maybe I should just stay here and study mushrooms with you forever, I thought. The Australian yogi then gave me directions to the yoga forest and I begrudgingly turned around without being invited in to live at the fungi academy for the rest of time. I found my way back to the right path and eventually making it to my original destination. By that time, I was too late for yoga class, but fortunately for me yoga classes abound in San Marcos, so I found another later class at a yoga platform right on the lake.
Mike arrived later that day and we had a few wonderful days talking about our adventures. Mike is one of those friends with whom I can talk about anything and he just picks up the thread and gets it. He is truly a special person. He took me to the yoga forest’s DANCE temple the following day, where I got my first taste of ecstatic dance. It started with an opening circle of about 40 people. We were all given a cup of cacao to drink, but there are no mind-altering substances allowed (no alcohol, no drugs). Then, a DJ started playing an incredible assortment of world music for the next 3 hours. Ecstatic dance is a form of moving meditation and you’re encouraged to completely let go and let your body move as if no one is watching. It was such a high and a release for me. I grew up doing ballet and modern dance, so dance feels like a familiar and comfortable form of expression. The facilitators of the dance pick a theme every week for the dance and interestingly enough, this week’s theme was death. It felt appropriate because the following day (July 3rd) was the anniversary of my older brother Brian’s death, so death was already on my mind. During those three hours of fiery dancing, I felt Brian so present with me. He would have loved the experience. I imagined him doing back flips in the middle of the floor. The dance experience also released something in me. I felt my anxiety and self-doubt about being in Guatemala melt away over those several hours. The dance experience was the death of a part of my ego that was holding me up and it felt really damn good to let that die.
With that, we walked home and the sky completely unleashed into a downpour. It rained heavily for the rest of the day so we holed up in our guesthouse and cooked dinner and shared a bottle of wine, thankful for the day and for the company of a good friend in a faraway place. The following morning, Mike left for the airport and I rented a kayak and spent an hour on the water thinking mostly about Brian and the 15th anniversary of his death.
I returned to ACAM on Monday afternoon. The following morning, on the 4th of July, Fabiola the midwife peeked her head into my room at 6am and told me we had a patient in labor. YES! Even though I have seen and assisted with several deliveries since arriving at ACAM, I had yet to be the primary midwife throughout the labor and delivery. I went downstairs to do labor support for a first-time Mother, who was laboring with the support of her Grandmother. That is one significant difference about the care at ACAM vs at the hospital. In the public hospital, women are not allowed to bring a single support person with them into the labor and delivery room. They are completely on their own and often don’t understand Spanish, which is the only language spoken by the hospital staff. At ACAM, they can bring as many support people as they want. The whole family is always invited!
She was 3cm dilated when she arrived and progressed nicely through her labor. I helped her into multiple positions and rubbed her back and squeezed her hips, just like I would do at home. I have noticed that the midwives here don’t do customarily do labor support measures and that the women are very stoic throughout their labors, but I figured I would try it out and see if the patient was receptive. I asked her to tell me to stop if anything bothered her. She was completely receptive and seemed to get some relief from the support. Her Grandmother was helpful too in convincing the patient to get up out of bed and move into different positions. The Grandmother told me that she had given birth to 10 children, and she certainly never got those babies out by laying down.
The power was down that day in the clinic and didn’t come back until after the delivery, so when the baby came, we used head lamps and flashlights to see. Around noon, she delivered a beautiful 7lb baby girl. She had perineal and labial tears, so I did my first repair since being here (by head lamp). The power of course came back on shortly after we finished. The patient and her giant family were thrilled and lots of hugs and thanks were exchanged. It felt incredibly fulfilling for this line of family members to thank me for the care. After the birth, the midwives served the entire extended family lunch (see the photo below).
I spent the rest of the day glowing from the birth. I am so lucky to do this sacred work. It feels especially wonderful when things go smoothly! However, the next day at our weekly mobile clinic, we found ourselves in a scary and frustrating situation.
This week’s mobile clinic was in a community called Toj Rincón, located about an hour from Concepción Chiquirichapa in the municipality of San Martín. It’s a remote community down the rocky and steep jungle road that I liken to Jurassic park. This week we saw 13 patients. One of the first women to arrive came in for her first prenatal visit. Her current pregnancy will be her 7th child and she was about 30 weeks along (7 months) by our ultrasound measurements. She didn’t know her own age, which is common, but she thinks she is about 33 years old. When she arrived, the midwives checked her blood pressure and it was very elevated: 165/105. They rechecked the other arm and got a similar number. She complained of headache and blurry vision. I lifted up her long skirt to see swollen feet and ankles. It was an obvious case of preeclampsia and this patient needed a higher level of care than we could provide. Unfortunately, we did not have anti-hypertensive medication with us (something that will change as of next week’s mobile clinic). We did a quick assessment of the baby’s well-being by doppler and ultrasound and began to explain to the patient how serious preeclampsia is. We explained that it often gets worse very quickly and that she could seize and die if not treated. We explained that she could lose both the baby and her own life and we urged her to come with us so we could take her to the health center and from there the hospital. Fortunately, she agreed to come with us, but first insisted on walking home to let her family members know before returning.
I phoned the doctor at the county health center to let her know we would be coming. Last month, we also transported a patient to the same health center who had a 3rd trimester fetal demise and that doctor was helpful in that she arranged for the health center’s ambulance to take that patient straight to the hospital in Xela. I was hopeful that she would be similarly helpful with this case and arrange for the patient to be taken straight to the hospital for further evaluation and treatment. When we got there, she was waiting for us and we gave her the full report on the patient. What happened next was a shocking display of negligence and incompetence by this doctor. She laid the patient down, scolded her in Spanish for having too many children, and hastily checked her blood pressure, which she called 140/90. She then asked our mobile clinic doctor, Valeria, to recheck. Valeria rechecked it and got 150/90, still very elevated. The doctor then felt the patient’s feet and ankles and told us she wasn’t swollen. Valeria and I suggested that we give the patient Nifedipine right away to bring down her blood pressure. This is the safest and quickest-acting oral medication used to treat severe blood pressures in pregnancy. The doctor said that it was too expensive and not available. Then I asked if the patient could get labs drawn to check her platelets, liver, and kidney function. The answer was no, the health center doesn’t have a lab. Then, the doctor decided that the best plan of care would be to give the patient a prescription for ½ a tab of Lasix per day to bring down her blood pressure (a diuretic that we do NOT use to treat preeclampsia) and she wanted to send her home!!!
Valeria and I eyed each other very uncomfortably from across the room. This was a crazy plan of care that would likely result in the patient dying at home. The doctor also wanted to give the patient a muscle relaxant called methocarbamol to “calm her down”, which is also not considered a safe medication in pregnancy and again, would not help treat preeclampsia in any way. I asked the doctor if she didn’t agree that the patient should be sent to the hospital and admitted for treatment and evaluation. “No no no, the hospital is wayyyyy too full and saturated with people for them to take a patient like this”, she said. I stood there with my insides churning, wanting to scream at this doctor for her ineptitude. But I knew that if we severed the relationship with this woman, we could have a big problem and lose all future support from her. Plus, the patient and her sister were there and I thought better of criticizing the doctor in front of the patients.
The doctor handed us the Lasix and Methocarbamol prescriptions and asked us to take the patient to the pharmacy to pick them up. Once we got outside we ripped up the prescriptions and Dr. Valeria wrote up an rx for Nifedipine, which is what we really wanted. We went and looked for it in 3 different pharmacies in the town, but nobody was stocking it. There were no beta-blockers either, which would have been our second choice. At that point, we told the patient we really needed to take her to the hospital and explained that we would go in with her and give the team there a full report.
The patient refused.
More begging and convincing ensued. The ACAM midwives rapidly translated our Spanish into Mam. She could have a seizure, a stroke. Her other six children needed her. She needed to be treated promptly.
She agreed that she would go tomorrow morning, first thing. Her husband would drive her as they had their own vehicle. She agreed that she would go to the next town over, which is bigger, and take her Nifedipine prescription and try to pick it up before heading home.
Frustrated, worried, and fearful for this patient’s life, we watched her walk away. We think that the patient would have gone with us to the hospital if we had taken her straight there, but after hearing the local community health center doctor minimize the situation, she seemed to lose her trust in our recommendation and felt that if the doctor wanted to send her home, it was safe.
Later that evening, I called the phone number that the patient had left with us, which belonged to her Father (she didn’t have her own phone). She hadn’t found the medication. I couldn’t get a clear answer about her plans to go to the hospital.
The next morning Dr. Valeria called again and the patient still hadn’t gone to the hospital.
I called the auxiliary nurse that works out in that community and asked her to go check in on the patient and urge her to go to the hospital. As of today (now 2 days after seeing the patient) she is still at home and won’t go to the hospital. She did manage to get the correct medication and is taking it. Her pressure is less severe but still elevated. She needs lab work, a long-term care plan, and likely early delivery of her baby, which is truly the only cure for preeclampsia.
This case was eye-opening. It goes to show how deeply fearful and resistant many indigenous Maya people are of going to the hospital. At the hospital they are not treated well, they are discriminated against, they are not given explanations of what is happening to them, they are not provided with translators, and they are not included in any healthcare decision-making. This situation is literally costing indigenous lives.
So that was a rough one. The lesson learned is that we need to be more prepared to deal with preeclampsia on the spot at the mobile clinics. This week I’ll go to Xela with the midwife in charge of all our medication ordering and see what kind of pricing we can get for Nifedipine and start stocking it in the mobile clinic medication bins.
The next day I was exhausted, but had planned to do a workshop on neonatal resuscitation during our Thursday morning all team meeting, which I think went well. The midwives are learning so much and I want to share every last piece of information I can possibly leave them with before the end of my six months here.
Later that day, feeling preoccupied and tired, I went for a walk and stumbled upon an entire pack of puppies that looked like they were about 7 weeks old. I silently thanked the universe for that patch of grass where I sat down and got crawled on by an entire litter of puppies, because that may as well be the best thing in the world. My favorite one is pictured below.
Thank you for reading and sending love to you all!
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