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.
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.
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.
