Big steps forward

I'm finally ready to write-up the wrap-up for this latest trip to Guatemala. I also recently got a final batch of great photos of White Thunder and the lab, which I've posted below. If you don't want to wade through all my narrative, just scroll down to check 'em out.

In any case, the big news is that the ambulance and the lab are both up and running and looking fantastic. After nearly three years of work, White Thunder is up in the villages and saving lives at this moment!

First, the updates on the laboratory, which I didn't have time to write when I posted from Guatemala last month.

For those who aren't up to speed, here's the back story on the lab. Its been the dream of a lot of people for a long time to increase the diagnostic capabilities of the clinic. A number of past volunteers have all worked to lay down groundwork, especially Rachael Horner who created an incredible bilingual lab manual from scratch (w/ Jacob Jackson and Amanda Delouriero) and inventoried all material.


However, its only been within the past nine months, thanks to the efforts of my classmate Adam Ackerman, that the lab has begun to be used. Last summer, he brought down some really exceptional lab equipment, including a beautiful microscope and several centrifuges.

We spent two months that summer practicing and tinkering with various diagnostic protocols, mostly focusing on peripheral blood smears, rapid antigen tests, and stool wet mounts. By the end of the summer, we had identified a regimen of at least a dozen highest-yield labs the clinic could really benefit from. However, the lab was still short many of the reagents and supplies we'd need. Going out on a limb, we went into Guatemala City the weekend before we left and pickup up nearly $500 of supplies. 


As usual, departure left many things in limbo. The lab was stocked and the staff had started to learn many of the tests. But we were still worried it would more or less gather dust while we were gone.

This trip, our objective was to make the lab so usable and convenient it would never be neglected again. Adam once again returned loaded with more supplies from the UVM Pathology department, including about 20 pounds of frosted and charged glass slides and another 20 pounds of hematology and parasitology diagnostic texts (the densest two materials I've ever encountered). Combined with our purchases from the past year, we had a fully stocked lab from the second we arrived. It was time to get cookin'!

Nevertheless, it seemed we'd still end up struggling with the same shortages that limited the lab's use in the past—space and personnel.

I had no expectation whatsoever that over two weeks we would managed to overcome both of hurdles... but that's exactly what happened.

The laboratory had always been set up on a small table in the back of the pharmacy. Right off the bat, this was one of the smallest and most-utilized rooms in the clinic. As one of the only open surfaces, the lab table was often used for mixing syrups, preparing injections, counting pills, and charting notes. And of course the lab primary worked with blood and feces... which should ideally be kept nowhere close to medications and paperwork. It was far from ideal, but short of building a new room for the lab, however, I couldn't think of a better option.

Over an early meeting with Dr. Sinkinson, he made the best suggestion I'd ever in years. Why not replace the clinic's kitchen with a lab?

It made so much sense I couldn't believe I hadn't thought of it years ago. The kitchen was barely used, with shelves of dusty pots and pans a bulky, unused gas range. Mostly the room just sheltered a sizeable cockroach infestation. Adam spent the entire first weekend working with the clinic's amazing volunteers Laura and Miguel (who are in Santa Cruz for nearly a year) to take the whole room apart, scrub it to sparkling, and build the best lab possible out of the ashes! The result was a complete transformation. The lab now offers meters of bench space, a sink and a fridge, and a beautiful hand-carved wooden desk for the scope.

The next coup of genius involved giving a staff member a serious stake in running the lab. As the clinic's patient load keeps growing, Dr. Sinkinson recently hired another full-time interpreter. Maria, a young woman from the nearby town on San Marcos, turned out to be one of the brightest and most curious individuals I'd ever had the please of meeting. Laura and Miguel were raving about her potential before we even met her. Despite only having a few years of basic education, she would pick up medical tasks and concepts instantly. Laura recalls teaching her to use the ultrasound for prenatal checkups, and before long Maria was asking why we gave folate supplements to women hoping to conceive, which opened off a 20 minute conversation on embryology and neural tube defects. Laura and Miguel had been advocating for her to attend medical school.

Unfortunately Maria and her family have had a tough run of it. For many years she has been the only breadwinner for her family. At 22, she is the oldest child. Both her parents are too handicapped to work (her father has gone blind from retinitis pigmentosa), and her 18 year-old brother is unemployed. She has another three younger siblings. One time she admitted to only having eaten one meal a day for most of her childhood.

Before we even proposed the idea to her, Adam had put a spider leg on a slide and she proceeded to spend 10 minutes looking at it. It was a no-brainer to ask Craig if we could increase Maria's salary in exchange for taking over responsibility for the lab. Maria herself was delighted when we asked.

Although it does not live up to Laura and Miguel's dreams of sending her to medical school, we hope that it's a good start. We are covering a 25% raise in her salary ($700/yr) for 5 years. Due to her educational background and financial situation, it would be exceedingly difficult for Maria to attend medical school at the moment. As small as her salary is, she is supporting herself as well as her entire family with it. And even if money were not an issue, in Guatemala the playing field for entering medical education is tragically unbalanced. Those living in rural indigenous communities barely learn simple arithmetic and handwriting in their few years of primary education. Entrance into Guatemala's medical, dental or nursing school requires passing a sophisticated entrance exam similar to the MCAT, competing against wealthy Guatemalans who have attended 12 years of private school.

With this position, we hope to be able to offer Maria the opportunity to learn significant amounts of medicine and basic science. She will gain skills that would make her easily employable in a laboratory in a larger town. She'll be able to supplement her current income. She'll assist in the improved diagnostic capabilities that should hopefully lead to better treatment for hundreds of patients. And it already seems like she's loving it!

The first time we showed Maria a peripheral blood smear, I tried explaining to her the "two types of blood cells", all the little reddish ones (RBCs) and the ones with the big purple blotches in them (WBCs). "Wait a minute," she asked me, "aren't there also a type of cell in your blood that help stop bleeding when you get cut?". Well, touché! I guess we won't be oversimplifying concepts for her in the future.

For the next five months, the long-term volunteer Laura will work regularly with Maria to train her in lab techniques. Laura already has a significant background in parasitology herself, and Adam spent our last week working with her to instruct her in all the protocols we had perfected. She has been sending us regular updates of their progress to date!

A lab retrospective: The extremely congested laboratory space (and generally bufoonery) we had to contend with last year.

The kitchen midway through its cleanup and transformation... I wish I'd thought take a photo when it was still a total kitchen

The new lab features more bench space than you can shake a purple-top tube at!

The beautiful desk we found as a throne for the beautiful scope.

Maria! We will be sending her down her own embroidered lab coats soon.

Adam explaining how to work the scope.

If you can get excited about working with poo, you will be an amazing lab tech!

She has come to absolutely love the scope.

Just a little blood draw to run some coagulation tests required by the hospital in Guatemala City to approve Dona Cruz for the cholecystectomy she needs (which was diagnosed by a student on the clinic's ultrasound).

Meanwhile... while Adam was working in the lab, my last few days in Santa Cruz were devoted to the truck. After three years of planning, there was no way I was leaving this time without a finished product... but time was ticking down! There's quite a bit of lead-up in my previous blog posting (which I mostly penned from a shuttle on the way to Antigua to get truck documents signed and notarized with Carmen--a success!) for those interested as well. The next day I met Don Andres (the gentleman from Pajomel elected to be the truck's legal representative) up in Sololá and we spent four hours going from tax office to bank to police station to municipality and back, signing and handing out money at each place. But the paperwork, finally, was completed.

The big steps left on the ambulance were mostly painting—I spent that night and the next morning spray painting the interior ceiling white and applying numerous coats of heavy lacquer to the back to make it as waterproof and cleanable as possible.

That Friday afternoon it was time to drive the truck from Santa Cruz up to the villages. The whole crew loaded up into the truck, Noé and the gringos: Adam, Dave, Stacy and Peggy. I will certainly admit to having a few butterflies in my stomach as we started to drive. A few years before, I’d been pretty good behind the wheel of White Thunder… but it had been a while and I wasn't getting much of a warm up... we were going from parked to off-roading in about five minutes.

Things started looking grim as soon as we hit our first serious incline. Despite getting up as much speed as a could, the truck began to spin and stall out. We all got out to assess the damage. First we tried moving rocks around and blocking behind the tires. Soon Noé was on the phone to get a legit local driver up to replace me. That’s when Adam’s buddy Dave noticed the front wheels weren’t spinning at all… when I went to switch from Hi-4WD to Lo-FWD, I’d actually put it back in 2WD.

With that embarrassing fix, White Thunder lurched into action, easily conquering the rest of the rocky switchbacks. We ascending 3000 feet above Santa Cruz, eventually arriving at Sololá for a car wash and a fuel up.

From there, we started on the drive that should soon be White Thunder’s route of choice—from Sololá, where the hospital is, along the winding roads out to Pajomel, Chuitzanchaj, and Laguna Seca. We picked up the Laguna Seca cocodes and made it to Chuitzanhaj by 5PM.

For an hour or so, I mingled around, talking with the village officials from each town. Then our ceremony got under way. The cocodes had set up the loudspeaker to broadcast the words to the entire community.

Mayans are notorious for being long-winded, and this was no exception. Several officials from each town took their turn at the microphone, some of them going on for up to 20 minutes. Finally, well past dark, I got to take the stage. Adam, Stacy, Dave and Noé gave a demonstration of how the backboard on wheels loads and locks into the back of the ambulance. I had a lot of people to thank, of course. I repeated my desires that the ambulance be used for no purpose other than carrying patients, that it always be available, and that its services be completely free of cost. I explained that I now had no further ownership of the vehicle—the responsibility now rested completely with the community for the ambulances upkeep and maintenance. They would need to rehearse rescues, continue negotiating with mayor for gas and maintenance funds, and maintain logs of the ambulance’s usage.

We concluded with a ceremonial handing over of the keys and paperwork, and then we all lined up to sign the handwritten minutes that verified the happenings of the meeting.

And that's that! The next morning we departed for the states. In the three weeks sinceUpdates from Guatemala have been limited, but with Noe looking over the next steps in the ambulance and Laura and Maria in the lab, both projects are in the best hand we could imagine! It will come down to another future posting to details the ways in which both the ambulance and lab are being utilized.

Here are some photos of the truck!

A retrospective: White Thunder outside Zion National Park in 2010.

Upon my return to Santa Cruz this spring, I was rewarded by a nearly unrecognizable vehicle--freshly painted and fully refurbished. There was plenty of work to be done though (note "ambulance" has been written on in magic marker)

Part of the renovations the technical students undertook was removing the partition between the cab and the bed to give more space and allow communication between the driver and patient.

First order was replacing the tires--two of which were frankly flat, and the rest were nearly bald (they were the same I'd driven 5000 miles on for the road trip).

Since there was no way to change or purchase tires in Santa Cruz, I had to remove them two at a time, carry them by boat to Pana, and have the new tires mounted on the metal hubs. Tires are heavy.

It turns out there were limited jobs I was qualified to do... namely cleaning...

While the girls of course got to man the power equipment.

Ah yes, I was also the best man for the job when it came to standing on things! Pictured here is the beautiful CECAP wordworking shop, without whose use we never would have finished the project.

Now we're cooking with gas! To avoid drilling directly into the metal of the truck, Peggy and Stacy's flawless model involved crafting a platform that fit perfectly into the truck bed and building the benches and cot from the floor up.

Most of the work was accomplished by night, after long days in the clinic.

I was finally allowed to handle power tools!

Flash forward a few days! The benches are nearly complete, and we're working on the tracks and wheels for the removable backboard.

I consider the stickers to be the true moment of transformation

These two little pieces of metal cost about $1000 and took dozens of hours of direct time and over a year of waiting to get.

Here is all the paperwork that we ended up needing to present to the Guatemalan government to get the truck imported, pay all taxes, get a title and license plates, and transfer ownership. Most of them are generally stamped, embossed, signed, or highlighted.

My favorite two documents--my forged bills of sale! They are actually quite superb quality... but I was still afraid I'd be detained at any given time for the months these were being scrutinized by the Guatemalan vehicle tax folks.

Unfortunately, this is the best photo we seem to have taken of the finished interior of the ambulance. This is prior to the mounting of the oxygen tank in the interior, which lies horizontally behind the driver and passenger seats.

Setting up the switchbacks to ascend 3000ft from Santa Cruz to Solola.

Although the ride was bumpy, it was encouraging to learn the backboard was the most comfortable seat in the ride.

Vrooom!

Noe put superhuman efforts into making the ambulance a reality, especially while I was out of the country. Its completion is now more his accomplishment than anyone's. Here we are, finally arrived in Chuitzanchaj.

At long last, the ambulancia has arrived in the hill communities that it will serve!

The cocodes (village elders) start lining up in preparation for the formal presentation of the truck

By the time I finally was invited to the stage for my turn at public speaking, it was nearly two hours later.

Having finally brought the ambulance project to a point of transition after two and a half years of work and planning, I would like to acknowledge the vast amounts of assistance I've benefited from along the way. I am indebted to the donations and financial support from many amazing individuals. Their contributions to the projects my friends and I have undertaken or to the clinic itself have made these accomplishments possible. Thank you Ernie and Kim Parizeau, Marj and Jim Matthews, Betty Edson, DeRoss Kellogg and Imogen Corcoran, Zac and Dr. Sarah Morgan-Edwards, Sylvia Burrows, John and Rachi Farrow, Dick and Marjorie Drysdale, The Blanchard Foundation, Dr. Mary Tang and the Fletcher Allen Pathology Department, Rhonda and Dr. Steve Karl, ViAnn Oden, Paul Kendall and Sharon Rives, Genie Robbins, Judith Wechsler, and Sandy and Tom Cooch. In addition, I’m grateful for the support from the Avera McKennan Hospital, UVM COM alumni and the student travel award committee, and the Arnold P. Gold Foundation.

For their donations of top-notch medical and lab supplies, I’d like to thank Dr. Aliyah Sohani and the MGH Department of Pathology, Blessings International, Heart to Heart, medic Jan Larsen , Penny Maxfield and Joe Woodin of the Gifford Hospital Administration, Brian Behn, Wanda and Dr. Chris Wilson, and Dr. Steve Karl.

For their encouragement, company, letters of support, and much more, I’d like to thank Dr. Jean Szilva, Dr. Patti O’Brien, Liz Huen, Rick Oden and the Stowe Rotary, Jessica Eve Rattner, Mitch Denburg, Caroline Lamar Pihl, Jimmy and Kelsey Heilman, Dave Kraut and Jan Hillson.

Para sus esfuerzos y dedicación incesante, quiro darle las gracias a Noé Rafael Simon. For their contributions to the laboratory, we are grateful to Dr. Carlos “Nito” Hermes, Teracita, Rachael Horner and future amazing doc Laura Greisman, For the generous use of their expertise, manpower, and facilities, I’d like to thank Pat Torpe and Amigos de Santa Cruz. And for years of support, guidance, and mentorship (and for not disowning me when I left them to deal with Walter and the tramitadores), I’d like to thank Dr. Craig Sinkinson and Dra. Carmen Cerezo.

Mid-Shuttle Update

Hey folks! I’m back in Guatemala for my shortest trip to date. I arrived here two weeks ago, after taking my step 1 exams in the states. It is down to the last three days here to wrap everything up before returning to Vermont to start third year rotations (I fly in midnight Sunday night, starting on Monday). During that time, I hope to accomplish… well, the same thing I’ve hoped to accomplish the last two times I’ve been here, which is finally getting the truck up in the villages. I’ve been thwarted twice before, and the stakes feel higher than ever. I have no idea when the next time I can return to Guatemala will be… perhaps not for over a year. And after all the time and money I (and my incredible benefactors) have invested in this endeavor, there’s no way I can put off any longer.

This time, however, I feel I have a lot going in my favor! For the start, I’m getting a LOT of help from my friends. I’m fortunate enough to be joined by my classmate Adam Ackerman, who spent last summer at the clinic has well. Adam’s area of expertise is diagnostics and microbiology, and he is working around the clock just like me to bring the lab to completion before he leaves. Adam is also incredibly adept at communicating his enthusiasm for the ambulance and the lab to others. It is thanks to him and the incredible generosity of the FAHC pathology department and the Blanchard Foundation that we have funding for all the infrastructure we’re presently setting up.

The next humongous advantage is that truck is actually in my possession—which is a big step up from last summer. Last May, I took up an offer by a vocational autobody center to completely refurbish the truck for only the cost of materials. Although I’d been told the truck would just spend a few months in the shop, done in plenty of time for me to work on it during the two months I was here… that was of course not the case. After uncovering many deeper structural flaws (they took the entire truck apart down to the chassis), the repairs lasted until last December.

For another, the paperwork has managed to come along. It became clear that the Guatemalan “tramitadores” (experts in navigating the bureaucracy and greasing the right palms) I’d hired to last summer were less than trustworthy. I’d been promised completed documents back in two to four weeks, but after over six months they had nothing to show for it, despite holding the identification of our pediatrician and the future guardian of the truck locked away in the capital the entire time (obviously at enormous inconvenience to them).

I spent the last week hassling them on a daily basis, and on Monday my efforts were rewarded when they returned the last of the paperwork. We now have Guatemalan license plates! As I am writing this, I am sitting on a shuttle to Antigua, where I will rendezvous with our pediatrician (who is grant writing from the city) to notorize the title, and tomorrow I will go with the cocodes (village elders) to the Solola tax office to finalize the transfer. Although it is highly exasperating to spend seven hours winding along the Pan-American highway for a few signatures, it is at least giving me a little time to catch up on the blog—otherwise there’s simply been too much to do to take time to write about doing it.

My ace in the hole are two fourth year medical students from Ohio who have become my construction geniuses. Peggy was a mechanical engineer and rebuilt her house and Stacy is a rock climber who has lived out of the back of similarly tricked out pickups. They came up with a stunning design for the truck bed. And they’ve been working with me over the weekend and every day after the clinic lets out until nine or ten at night to build it. Today the benches (which double as storage space) are going in, as well as the rollable and locking backboard. All that will be left to do is paint and shellac everything to make it washable, and mount the oxygen tank, and we will be in business!

In addition, with the ambulance lettered on the side, and the back more or less occupies with storage space, the cot, and medical supplies, I hope to pre-empt possible abuses of the truck by those who will take ownership. That will be a principle objective of presenting the truck to the people of the villages as well. Although I will no longer have any legal say in how the truck is used, I believe with three different communities all feeling ownership of the truck, lots of eyes keeping watch on it, and no room in back for cinderblocks or chickens… it should only be used as it was intended to.

Another hurdle that I had to clear involved getting new tires for the truck… as it still had the same ones as when I bought it in 2008 in Montana, now barely showing any tread. To complete the construction work in the bed, my Guatemalan friend and go-to Noé had the truck driven down from Sololá to Santa Cruz. The road is a switch-backed, steeply pitched talus slope that is riddled with landslides. It has been known to break many an axle in the past, and worse. On the decent into Santa Cruz, the truck got two flat tires and barely limped into town. It was an expenditure I’d hoped to avoid, but the quality of the road between the villages and the hospital is nearly as bad (if not as steep)… and the last thing I want is for the truck to get a flat while transporting a woman in labor in the pouring rain in the middle of the night. Plus, I’ve got to admit the truck looks pretty badass perched up on its new all-terrain tires.

The tires will get their first test on Friday morning when the truck takes the journey from Santa Cruz up to be presented to the villages. I think I’ve recently decided that I’ll take the wheel myself instead of hiring a local go to do it. I ran the road the other morning and felt fairly confident on the way up, but rather terrified seeing the same conditions on the way back (it was far too steep and loose to run down). Four-wheel drive should be the trick.

Alright, gotta run, but more updates to come soon.

Trip Summary--Summer 2011

Once again, I find myself reflecting over another great stay in Santa Cruz. It was my fourth time in Guatemala, and I've now spent over twelve months of time volunteering at the clinic! By this point it truly feels like a second home. Whenever I have more than a few weeks off, I find I now take it for granted that I'll return.

At only two months, this was the shortest period time I've been able to stay for a while (the downside of being back in school). Fortunately, by this point I benefit from ever-increasing groundwork, connections, and momentum from previous visits. Although it felt far too short, it is still incredibly encouraging to hit the ground running each time I return. Thanks to help from so many friends, supporters, classmates, and the support of those who live in Santa Cruz, the trip proved among the most successful and productive to date!

I was able to start the trip off on the right foot thanks to the wealth of incredibly donations that were bestowed on the clinic. In February, I received a 400lbs shipping pallet of top-notch diagnostic equipment and medications from an organization called Heart to Heart. I’d been able to check all the supplies off of a list that I thought would vitally serve the clinic, and they only charge the cost of shipping. I received several additional boxes full of supplies from Gifford Medical Center, my hometown hospital. For most of last spring, a quarter of my little apartment bedroom was stacked floor-to-ceiling with boxes ranging from Vitamins to procedure lights.

All told, I’d assembled a total of ten 50 pound suitcases filled with donated medical gear. At first, I was absolutely flummoxed as to how I’d get them across the border, especially without a truck to drive this time. Shipping the supplies might have cost thousands in fees and taxes, and it probably would have been lost in transit anyway. Fortunately, I had two friends from medical school that decided to join me as volunteers at the clinic this summer. The little brother of a third friend from Dartmouth also happened to be traveling through Guatemala this summer, along with four of his classmates. With everyone taking one or two suitcases as checked luggage, we successfully muled tens of thousands of dollars worth of new materials to Guatemala for just a handful of extra baggage fees.

Unfortunately, once we showed up in Santa Cruz, it looked like these supplies would push the clinic’s storage problem to the breaking point. All but one of the clinic bathrooms had been converted to ad-hoc storage spaces. You could barely open some of the doors due to without triggering a landslide of cardboard boxes, trash and inaccessible yet essential supplies. The l stacks of suitcases and boxes in the pharmacy had become home to a bustling metropolis of cockroaches and spiders.

My friends and I ended up devoting nearly the entire first week to a massive cleaning, exterminating, sorting, and organizing effort. At some point we determined that we had no choice other than to construct new shelving in several closets if we wanted materials to be accessible. My carpentry skills are limited to say the least, but we were fortunate to have the engineering genius of my friend Chad Cosby in mix. After he’d drawn up a blueprint, we got to work (often by headlight, as several had no functioning lights). It took another few days and multiple trips across the lake to the hardware store, but I’d say the final result is sturdy enough to hold up for years to come and has perhaps doubled the clinic’s storage capacity.

With the working space cleared out, we were able to focus on one of this trip’s major goals—to get the clinic’s laboratory up and running. We’ve had several extremely competent volunteers in the past that had brought some supplies and implemented testing protocols. However, the efforts would usually cease once they left the clinic. Our goal became to not only significantly expand the scope of our testing, but make the use of the lab a regular fixture in clinic life.

I have no a background in microbiology. However, I was fortunate enough to be joined for the summer by my friend Adam Ackerman, who spent many years working in a pathology lab before medical school. Adam started by reaching out to his former colleagues and soon had acquired a donated centrifuge from Fletcher Allen and high-end refurbished light microscope from Mass General. He introduced me to faculty in the pathology department at FAHC, letting me arrange several afternoon tutorials. In that way, I was able to learn protocols for many simple techniques, such as gram staining, preparing wet points, centrifuging blood and feces, and making peripheral blood smears.

After setting up the microscope and centrifuge and assessing the available materials, it was clear we were short a lot of critical elements. There wasn’t much other choice than one of the always-avoided errand trips to Guatemala City. After purchasing another $500 of supplies and reagents in Guatemala City, we had everything we needed for a simple but functional laboratory.

It soon proved that creating a physical laboratory was the easy part. Becoming proficient in the protocols ourselves was the first hurdle. Adam and I taught the clinic’s medical assistants phlebotomy, and had numerous vacutainers of own blood drawn to practiced preparing, staining, and reading smears. I’d collect fecal samples of anyone with diarrhea for closer examination. As my comfort increased, I worked to integrate the lab testing into everyday life at the clinic.

I am quite proud of what we were able to accomplish in the end. The clinic now uses a hematocrit centrifuge to screen for anemia in all prenatal check-ups. The staff can quickly prepare peripheral blood smears, helping to differentiate between various subtypes of anemia. It may also prove a powerful diagnostic tool for intracellular parasites such as malaria. Our providers run rapid antigen assays on patients in for H pylori, rotavirus and adenovirus. Stool samples can also be prepped as ova and parasite exams under the microscope. Skin scrapings can help diagnose scabies and fungal infections. The clinic now has occult blood tests and urinalysis in its arsenal as well. In the past, the clinic lost valuable funds paying for necessary laboratory tests to be run by private labs in nearby cities, often an hour away. The clinic is now both saving money and providing better care to patients thanks to the new in-house diagnostic capabilities. Most excitingly, having a laboratory has sparked a curiosity among the clinic staff, most of whom are indigenous Mayans. It’s been so gratifying and exciting to show our nurse practitioner white blood cells under the microscope, or help one of the assistants perfect her venous blood draw.

Of course, one of the big objectives for the summer was to complete the truck ambulance. On that front, there were both breakthroughs and hold-ups. As it stood, I had to leave before being able to witness the final results. However, the parts are all in motion. Barring further roadblocks, the truck should be in place and functional later this month.

As it happened, last spring, I decided to take advantage of an offer extended by the government university in the department capital of Sololá. The Universidad del Valle runs a technical training program in automobile body repair. Although it appeared primarily superficial, they truck had considerable body damage from an unknown past accident.

I accepted the university’s offer and had the truck delivered. The technical program offered to completely refurbish the truck’s exterior as a training project for its students. They are only charging for materials, and at a steep discount. After talking about it for years, the truck is being completely repainted white, with “Ambulancia” and the names of the three communities stenciled on the side. I’ve always believed that clearly distinguishing the ambulance is vital to deter non-medical abuses of the truck by the drivers or community officials.

The technical program is bestowing many additional practical improvements as well. The partition between the cab and the truck bed is being removed to allow for free communication between the driver and the patient. The height of the camper that covers the back is being raised to allow the medics space to work and sit.

Unfortunately, as you might guess, the refurbishing process has lasted far longer than I expected. The labor is all provided by students, and there proved to be many unforeseen repairs along the way (it turned out parts of the chassis were badly warped and needed to be reworked). As a result, the truck was in the garage for the entire summer. The last time I visited, all the seats and non-metal components were still completely disassembled, and they were hammering out the body. However, I’ve been assured that the truck is less than a month from completion.

Another hurdle which I had to take on this summer involved transferring ownership of the truck from me to the collective ownership of the three villages. It’s a prerequisite step in order to receive Guatemalan license plates and registration. Unfortunately, it’s been the most ghastly round of red tape I’ve seen to date. To file the paperwork, I had to relinquish possession of my passport to the Guatemalan tax agency for an undisclosed period of time (I’d been told around a month). For that reason I’d been unable to complete the transaction the year before. As a result, the truck had been forced into inaction over the past year since it wasn’t technically legal to drive yet.

With limited time this summer I knew I had to act fast. I found a business that specialized in greasing the wheels with taxes and paperwork. Reluctantly, I handed over my passport and a good stack of cash. For the next month, I remained undocumented. Delay and complication stacked up one after another. The entire time I was sweating bullets as significant parts of my paperwork were forgeries I had to have made at the Guatemalan/Mexican border last spring when paying truck import taxes. In the end, I had to force the agency to do a document “hostage exchange” with only a week to spare before my departure. They took possession of our Guatemalan pediatrician’s driver’s license, as well as the documents for Don Andres, the village elder who’s the spokesperson for accepting the ambulance. As of now, the paperwork is still stuck in the pipeline somewhere. Most recently, I’ve been informed I need to pay another fine “for taking so long to complete the paperwork”. All in all, it makes tax time in the US seem like a breeze. Anyway, I am pressing hard (from abroad, with emails and skype calls) to wrap this up. It will be such a relief to complete the long, very expensive chain of bureaucratic maneuvering I’ve undertook since bringing the truck in a year before.

In any case, if all goes to plan, the truck will be in the communities where it belongs within the next month. I am already planning a return trip for several weeks in February. A top priority will be to formally present the vehicle to the towns and convene the community educational forums I intended to this summer. However, it should be transporting those in need long before that.

To be continued...

Doña Paulina

Some photos from summer 2011

Here are some photos highlighting some of the chief activities of this summer--establishing the microbiology lab, organizing the clinic, and seeing patients.

I am not feeling so comfortable about the thought of riding up to Solola to check on the truck without a helmet. Luckily, I was too heavy to drive around so I ended up taking a chicken bus.

The clinic was absolutely in a state of disarray when we arrived

Initial cleaning and sorting at the clinic

Shelf construction by headlight!

Some of the completed shelves we constructed.

Another set of shelves which I built during an all-nighter the day before I departed the clinic.

An array of top-of-the-line medical donations, mounted on the wall of our nurse practitioner's office.

The ulcer on Dona Paulina's leg has completely healed!

Preparing an injection of antibiotics on a path in the village Pajomel for a woman with a large peritonsilar abscess. We were able to arrange for a truck to transport her to the hospital later that day--but it would have been an ideal case for the ambulance.

Domingo has had a sizable inguinal hernia for five years. The cost of surgery is more than he can afford, but it prevents him from working on the land he owns.

Polydactyly (multiple toes) combined with a slowly-healing wound from a tuk-tuk accident

Adam Ackerman, my classmate in medical school, brought his years of laboratory expertise toward helping us establish or microbiology lab.

Teaching Eliza and Martita to do fecal occult blood tests, under the watchful eye of an ambercrombie and fitch shopping bag we converted into a poster.

Adam acquired a top of the line $2000 scope from the MGH Pathology lab where he used to work. Here, Nohemi is learning basic microscopy with wet mounts of stool samples and peripheral blood smears.

Here's an example of many red blood cells (donut shapes), one white blood cell (large with the purple nucleus) and several platelets (dark blue) on a slide of my blood. Peripheral blood smears like this can help diagnose a large variety of anemias and intracellular parasites like Malaria, among many others.

A gorgeous photo of a mysterious object we found in vast quantities in a sample of diarrhea. It turned out to be some sort of plant matter, but we thought we'd discovered a new pathogen.

Nohemi practicing drawing blood on me for practice tests in the lab. She ended up being a natural at phlebotomy.