Notes from the field: Jackie Candido

As part of a special series, I’ll be posting updates from Jackie Candido, RN, BSN, who is spending three weeks volunteering through Saving Mothers at the Hospitalito Atitlan in Santiago, Guatemala. Jackie has worked for the past two years on the Labor and Delivery floor at Mount Sinai hospital in NYC, though just relocated to the west coast this month.  She received her BSN from UPenn in 2009. This is her first time volunteering abroad.

Buenos dias and greetings from Santiago, Guatemala, where I am volunteering for the next three weeks as an RN at the Hospitalito Atitlan! I arrived in Guatemala City Sunday morning and was met at the airport by Aclax, a driver sent from Atitlan and undoubtedly the friendliest man in Guatemala (and possibly the Western Hemisphere).

Driving through the mountains en route to Atitlan, I was reminded of Jerry Seinfeld’s musings on how we tend to feel invincible when riding in NYC taxi cabs (“Doing 50 mph the wrong way down a one-way? I’d never do that in my car ha-ha.”)  It was only when I managed to peel my eyes away from the fantastic mountain vistas that I realized my knuckles had turned white from clutching the seat. Seat belts? None to be found. Passing on the right on a narrow curvy dirt road? Sure, por que no? But Aclax could not have made me feel more comfortable, and his 18-year-old son Silven kept me entertained with conversation (of note, Silven is a big fan of Jack Johnson and The Beatles, but finds Lady Gaga “un poca loca, no?”  Es verdad, Silven, but if you spent more time at the discotecas, you may come to appreciate her appeal.) 

We arrived about three hours later at Las Milpas, the Hospitalito volunteer housing I am sharing with Janet, a Canadian fundraiser who has been here for two months, and Matt, a mid-Western ER doctor who arrived this morning.

Las Milpas is a charming complex that consists of a main house with kitchen, living room, bathroom, four bedrooms, and four separate one-room cabins.  My room is upstairs in the main house and has the most breathtaking view of San Pedro, one of the dormant volcanoes overlooking Lake Atitlan (to do list: hike San Pedro). 

I was pleased to find that our shower not only gets hot water, but has even better water pressure than my shower in Seattle (to do list: call Seattle landlord and complain).

Las Milpas is only about a five minute walk down the main road from the Hospitalito, which brings me to the part of this blog that all of you health care people actually want to read: My first impressions of providing healthcare in the developing world — and the blatant cultural differences between Guatemala and the U.S.

The Hospitalito is a private nonprofit care center located on Lake Atitlan (I won’t go into the whole history, see for that). Basically, it consists of a four-bed ER, two two-bed labor and delivery rooms, four three-bed inpatient rooms, and an outpatient clinic. While there are two ORs, they are not currently being used because there are no surgeons in house. This also means that anyone requiring surgery is transferred via ambulance (the bomberos) to the nearest city hospital, which is about two horus away. 

We also transfer anyone requiring more complicated treatment than we are equipped to administer. Just this morning, we transferred an 87-year old man with cardiac failure. He felt chest pain when working out in the fields that morning at 6 a.m. I don´t think that requires further comentary — mull that one over on your own time. 

As far as I know, there is no concept of health insurance in Guatemala, and as the Hospitalito is not a free clinic, its patients pay out-of-pocket for all the care they receive here.

This brings me to “Jackie’s Culture Shock of the Day”:The ER nurses keep track of every supply used in caring for each patient. Medications and IVs yes, but also syringes, needles, gauze pads, and GLOVES (one pair of gloves costs one Quetzal). This is a separate page in the patient’s chart, and when he or she is discharged or transferred, the nurse totals the charges and presents the patient with
a bill.

My mouth was hanging open in shock as I watched one patient’s son take 130Q out of his wallet and hand it to the nurse,who then removed a locked cash box from under her desk and counted out change. WHAT?  Actual cold hard cash handed over for medical treatment? Is this the Gap or a hospital? This transaction has been on my mind all night, and I’m going to try not to ramble as I share some of my thoughts on this issue. 

First of all, the penny-pincher in me sees one huge pro to this system,which is that it absolutely makes you, as a health care provider, consider what supplies you use, and discourages wastefulness. It’s no secret that administering health care in the U.S. is hugely expensive. While there are many factors contributing to this, wouldn’t it help some if we reduced waste in the system? I want to kick myself now thinking of all the syringes I’ve wasted, extra gauze pads I’ve used unnecessarily, whole vaginal delivery sets I’ve opened too soon and then had to throw away (a thousand apologies Mt. Sinai).

Having to keep a list of literally everything you use really makes you think about what you’re doing. But it’s not just supplies. How many labor patients get a full lab work up for having one elevated blood pressure incident? Elective inductions of labor?  What if you had to pull cash out of your purse for every Misoprostol or for every hour you’re given Pitocin? Don’t even get me started on the cost of elective C sections (75% of the patient’s chart would consist of the charges sheet).

Granted, there are always going to be patients rich enough to not care what their care costs. And there will always be docs ordering extra tests to cover themselves should the lawyers come calling. I think it would be an enlightening exercise to have a day where we in the U.S. keep these “charge lists” for each patient.

Of course there are obvious cons to this system too. Mainly, are we at risk of taking dangerous short cuts if we’re too focused on cutting costs?  I saw some instances today where nurses weren’t wearing gloves when they definitely should have been. And some supplies are reused that shouldn’t be, such as suction tubing and nasal cannulas.

One more thing I feel merits a comment before I end this novel of a blog post (I’m typing this on a Kindle fyi…).

We had a patient come in today who Dr. Susana diagnosed wth a bowel obstruction. She needed surgery or she would likely die. Seems straightforward, no? But before you call the bomberos, consider the whole story: This woman is 85 years old. She is extremely frail, I doubt she weighs more than 90 pounds soaking wet. Given her body’s lack of reserves, she may not even survive this surgery/recovery.

To top it all off, paying for surgery will effectively wipe out her family’s savings.  All things considered, she opted to reject Dr. Susana’s recommendation for surgery and was taken home by her family. Once again, I was sort of in shock. I discussed the issue with Isabel, a American RN spending the year here serving as the Hospitalito nurse educator.

Isabel said, ”It’s just a different cuture here. In the U.S., our mentality is ‘save everyone,’ and while that is obviously good a lot of the time, here they place much more value on quality over quantity of life.”

Isabel reminded me of a study done a while back in the U.S. that found that while 80% of peple reported preferring to die at home over a hospital, about 80% of us will experience the latter. Clearly there is a disconnect there.

But I wonder, is there a role for Hospice-type services in Guatemala? Is there a way we ould help that lady and others suffer less as they come to the end of their lives? Comida for thought.

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