Don't panic!

Both Douglas Adams, in The Hitchhiker's Guide to the Galaxy, and a doctor friend of mine, who helped arrange my current elective at the Roosevelt Hospital in Guatemala City, Guatemala, said these ever-helpful words.  Don't Panic!  My friend said this several times, as well as "don't worry", when she took me to see the Roosevelt Hospital for the first time, the day before last Christmas.

I knew that I was going to a hospital, which would be different to the ones I've already been in, seen and trained in Europe, yet how different I did not know.  This quickly became apparent as we entered the area and then the hospital itself.

As with so many businesses and institutions here in Guatemala, everywhere there are armed guards, barbed-wire fences and walls, and a lot of people.  All of this a applies to Roosevelt.  On entering the area, a guard lets one in.  When walking from the car park, I could see the 5 storey building, which seemed about 50 years old.  When standing in front of the main entrance, the emergency ward is somewhat to the right, and to the left are first paediatrics and then further left, the maternity ward, everything else was right in front of me in the old main building.

When entering, one is encountered with a lot of people.  If early in the morning, there will be hundreds of people waiting in lines or sitting on benches, to have an appointment with a medical professional.  I was taken to the day-care hospital, where I've been for the past 2 weeks in elective surgery.  Everything was nicely decorated before Christmas, i.e. everything apart from the operating theatres.
Nothing was going on, as there were no elective surgeries because of Christmas holidays.  We said hi to the nurses, who were packing surgical equipment, cleaning equipment and beds, oiling tires of the beds and even painting the walls.  Yet, this ward didn't seem a lot different from old European hospitals, but then I found out, that this is probably one of the better kept areas.

When walking through other areas, the poverty and the deprived healthcare system became apparent.  Very old beds, little equipment, maintenance lacking, many patients in limited space, no isolation between patients in intensive care, whilst in the air a mixed scent of disinfectant and bacteria (mainly pseudomonas).  This isn't surprising in a hospital built 60 years ago, after the US Roosevelt era (hence the name) and the amount of patients which pass through per day.  The hospital has 800 beds, has all specialities, and seems very short of cash.

The real shock though came when entering the emergency departent (A&E / ER).  There, a long corridor from the aft to the front door is immediately apparent, and on one side are ophthalmology, X-rays, operating theatres and a shock room.  On the other side, rooms for patients.  Then in the middle of it all, people and more people.  Patients on stretchers or sitting on a bench between the stretchers, whilst awating further care.  In the inspection and treatment areas there are usually 3 patients at any given time, and a lot of residents and medical students.  Nurses are scarce.  I was thrown back decades when witnessing this area for the first time.  Coming from a background mixed of Northern and Western Europe, this seemed like something one sees in movies or documentaries.  I was somewhat taken aback.

Still, this was just my first impression, and still it didn't quite prepare me for my first shift.

Up to now, the surgery in the laparoscopic day care facility has been very good.  I think I can say that the surgeons here are competent and the equipment is good.  The operating theatres are not the newest, nor are the lights and operating tables, but they suffice.  The anaesthesia is also good, although they are somewhat lacking in equipment and drugs.  Still, they have what's necessary.  I've mostly witnessed cholescystectomies up to now, but also hernia repairs and some appendicectomies.  Then, in A & E (Accidents and Emergencies) things are somewhat different.

During a shift, the residents (and the medical students), mainly take care of the emergency ward and As & Es.  The shift starts after a normal day, continues until next morning, when the residents go back to their posts, usually not having slept the whole night.  Everything imaginable and unimaginable can be witnessed on the shifts.  A lot of acute abdomens come in, some needing surgery because of severe cholecystitis or appendicitis, as well as gun-shot wounds, sports accidents, fights and infections, just to mention a few.

My first shift consisted mainly of observing, as just about everything was new to me.  I encountered somewhat of a cultural shock whilst observing, trying to follow what was going on, as well as the way patient-doctor interactions were conducted.  A the day (and night wore on)  I got the chance to assist in a appendicectomy, then I observed a laparotomy after a gun-shot wound, which penetrated at least 4 organs, and then again another appendix was resected.  Also, lots of acute abdomens of all ages, gangrenic feet, cuts of various bodily parts being sewn, I saw a man who had been shot in the side, and had an entry and exit wound, which thankfully didn't penetrate his thorax, only the subcutis, as well some motor-vehicle accident victims.

All in all, I probably saw more in one evening, than I did during my 2 weeks of emergency medicine in Iceland.  Yet, despite the amount of patients, I am still not in the clear how things work.  There seems to be a sever lack of just about everything, except doctors.  The residents do the work-up, whilst the medical students do the work.  I did not see a qualified specialist on my first shift, yet the most senior residents take charge, and seem very competent.  However, the work-load on each residence seems immense, and the infrastructure is seriously lacking.  Medcine is scarce, space is little, there are no telephones nor computers, nurses are few and general infrastructure seems to be about 50 years old.

All this said, this was just my first shift, yet coming from Europe, this was a medical cultural shock.  At 3 in the morning I was shown a room where I could sleep until the next morning, and the bed with 2 pillows and a sheet was very welcoming, compared to what the patients had to endure downstairs in the ER.  Thanks to some sleep, the next morning wasn't that bad, yet I felt the drain when returning home.

After that shift, I told my instructor that I would not be doing shifts every 3 days like they do, as this would undoubtably be too much, taking into account that I do not know the system, do not speak the language well enough, and am definitely not yet accustomed to the practice of Guatemalan medicine, which truly is different from what I already know.

When thinking of this difference, it became apparent to me, that it is truly based on WHERE, rather than WHAT one learns.  Even though the medical community might have the same books, the same sources of knowledge and a similar academic background, this does not account for each country, or even each medical centre within a country, to offer the same standard of care.  It has become apparent to me, that even standard drugs are different depending on where one works, i.e. medicine is not just science, it is also culture, a culture based on where one practices and the resources, knowledge traditions, which reside there.

My next shift is in 3 days' time.  It will without doubt be another grand experience and a very informative one.  I will do my best to continue my comparisons and thoughts on my current elective in the coming weeks, and also try to travel back in time to the advent of Dr. Gunther von Bergweinstrom, which is actually a few internships ago.  Whilst comparing, I will not hesistate to go back in time and recollect some of my previous travels, which should have been documented at that time, yet connections and computers are not always available, and sometimes enjoying the ride is more important than documenting it :-).