Post from the Field: Rashmi Kudesia

Happy Monday, folks! We have a new post from the field for you today, this time from volunteer Rashmi Kudesia, a resident in obstetrics and gynecology at New York Presbyterian Hospital. We hope you’re enjoying these posts from our volunteers in Guatemala and that they give you a flavor of what Saving Mothers is trying to accomplish in terms of improving maternal health in local settings.

I’m now over a week into my trip to Guatemala and words cannot describe how content I feel down here. This trip seems to be exactly what I needed and I wanted to share with you all some of the experiences I’ve had.

Logistically, I’m living in Santiago Atitlán, in the Department (kind of like a state, Guatemala has 22) of Sololá. I came down here through an amazing NPO, Saving Mothers, which has worked out fantastically because it has given me access not only to the Hospitalito Atitlán, where I’m ostensibly working, but also many of the other amazing maternal health efforts down here (more on that later).

Santiago is a beautiful place (Google Map it to get an idea). It’s on the shore of Lake Atitlán and nestled among a series of (mostly inactive) volcanoes, creating a beautiful natural backdrop. The local history is significantly influenced by a bad mudslide that happened in 2005 as a result of Hurricane Stan, and that destroyed what was previously the site of the Hospitalito. Luckily the lake is no longer toxic and all, but I still haven’t had the interest to go swimming in it, as some of my more adventurous (and less toxin-fearing) colleagues have. Nonetheless there is plenty of exercise since it’s a hilly terrain. I’m living up by the hospital’s current site, which is a 15-minute walk from town, so I’ve been on my feet a lot going back and forth.

The Hospitalito is a short 5-minute walk away, and a great resource for the community and I’ve had some new experiences since being down here. The first was getting used to the idea of an ob/gyn being such a rare commodity in town. For the past week, I’ve theoretically been “on call”, in case of any ob/gyn emergencies, but so far no middle-of-the-night Cesareans (actually no Cesareans since I’ve been here), only some ultrasounds and a complete abortion who came in bleeding. 

I essentially have been running the ob/gyn clinic alongside the local ob/gyn, Dr Recinos. All visits are in Spanish or translated by a nurse into the local Mayan language, Tz’utujil. It’s not surprising but still interesting how little preventative care goes on here. Women really resist pelvic exams, and pretty much refuse them during pregnancy because they’re convinced, no matter what you tell them, that it will cause a miscarriage. All that aside, though, the most interesting part has been actually preparing Pap slides (like on a real slide, no ThinPreps here!) from a kit that consists of a WOODEN spatula and an endocervical brush - that’s in the hospital; in the community, they only have the wooden spatulas, which at the other end have a triangular portion (still wooden) that you’re supposed to use for the endocervical portion. So different!

The other patients have been a mix of pelvic pain (tough to manage no matter which country you’re in!) and prenatals. The latter has been the other exciting thing, because it’s offered me a great opportunity to work on my ultrasound skills. This is the first time I’ve really had to do a full anatomy scan, and so far, I’ve had success with finding nasal bones and 4-chamber hearts, but I’ve found it motivating me to spend some quality time in our sono unit when I come back! I’ve also been able to work with some of the other family medicine and general medicine doctors, reinforcing their skills at EFW, etc, and that’s more comfortable territory.

We’ve had two more complex antepartum patients, and that’s been very interesting. The first is a pregestational diabetic, a 41yo G16P10-0-5-10, who is now coming up on 37 weeks. Because she has no mechanism for storing insulin at home, etc, she COMES TO THE HOSPITAL TWICE A DAY for her insulin shots. She’s been on a NPH/regular regimen that’s drastically improved her control. The plan is to induce her next week. The wrinkle in all this is that the fetus has gone back and forth between being breech and cephalic, so I’m hoping and praying that when she comes in for admission, that kid is head first! I feel it would be such a travesty to section a P10 with every risk factor for a bad wound infection (diabetic, poor hygiene, etc). It really did surprise me that they don’t do breech vaginal deliveries here, but I guess the fingers of the Term Breech Trial are long and insidious. There are some comadronas that do versions out in the community, but a number of them also send their breech patients to the hospital for Cesarean.

The other antepartum patient was one I admitted who came in at 6w with a poor OB history (2 preterm CS due to preeclampsia and a 4-month demise) with a BP of 240/130! Yes, you read that right. I took it myself. It was the weirdest sensation, because I don’t usually inflate the cuff all the way to 300 and when I inflated it the usual amount, turned the dial and immediately heard pumping (at around 230mmHg), I almost had a heart attack myself. So we admitted her for BP control and she responded really well to anti-hypertensives. I hope she can continue with her meds and have a better outcome this time. 

There has been some down time, and so I’ve had some other opportunities as well. I spent one afternoon at the Centro de Salud, which was fun, and a few hours attending a hospital-organized training/meeting with the comadronas, but the highlight was working with a new friend, and a woman I have grown to admire deeply over the past week. Her name is Kathy, and she’s a 70+ yo nurse from Virginia. I adore her. She’s been down to Guatemala probably around 8 or 9 times now, for a few months each time, and literally knows everyone down here. These days, she works for the local outreach effort and yesterday, I did home visits with her. The local district has a list of pregnant women floating around, and basically, we went with a local worker (who helped us with the patients who speak only Tz’utujil) and sought out these women. It was a totally different side of things to see their 100-200 sq ft shacks, jam-packed with multi-generational families and many without chimneys (and hence smoke and fumes creating lots of chronic lung disease), and do prenatal visits. We carried around a scale, so we weighed them, took their BP, did a fundal height and Leopold’s and answered their questions, made sure they had vitamins and a birth plan, and went on our way. Occasionally, we came across one that had already delivered, so we took a look at the baby, made sure they were breastfeeding well, and so on.

Anyways, it’s been a great experience so far, and I’m looking forward to the next week’s adventures!

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