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Hoa Tran, MD – Global Health Rotation at Hospital General San Juan de Dios

Written by Hoa Tran, MD PGY 3 at Kaiser Permanente Santa Clara Internal Medicine Residency Program on global health rotation at Hospital General San Juan de Dios in Guatemala City, Guatemala.

I did a three-week global health rotation in Guatemala City at San Juan Teaching Hospital in February 2015.  My experience was amazing and definitely unforgettable, and let’s not mention that my Spanish is now much improved! I spent most of my time in the emergency room assisting with triaging, admitting and stabilizing patients. This experience has definitely improved my clinical skills since the hospital has very limited resources, we had to rely heavily on our physical exam to make a diagnosis (rather than labs and imaging as we do in the US).  Additionally, due to its scarcity, we had to learn to ration our medications, ensuring that the sickest and youngest patients receive the medications first. I also had the opportunity to learn how to perform central line placements, thoracentesis and paracentesis without ultrasound guidance. The first time I placed a central line during this rotation, I was taken back by the lack of sterile techniques, which consisted of only sterile gloves and a small sterile sheet that barely covered the patient’s face.  The concept of a “sterile field” did not exist; the central line kit was placed either directly on the patient’s bed or on a nearby non-sterile tray that was not cleaned after each procedure.  However, to my surprise, during my three-week rotation, there was only one reported case of line-related infection.

Due to the high patient flow, the emergency room functioned as a ward, ICU, rapid care and emergency room all in one.  Patients would get triaged and if they were stable, they would go to “La Banca” where they would sit in a chair (sometimes a recliner chair if they were lucky) anywhere from a few hours to a few days while they received IV antibiotics/medications, awaited a bed in the ward, or awaited a procedure.  If the patients were sicker, they were sent to “La Clinica,” which is equivalent to our step-down unit, with more frequent monitoring (but no telemetry). If the patients were in critical conditions, they would be taken from the triage area to “Area Roja,” which is equivalent to our “code rooms,” where they would be coded, intubated or treated for shock with central line placements.  These patients then remain in this area for days until there is an available bed in the ICU. Frequently they would run out of ventilators, so a medical student would have to stand there and bag the patients for hours until there is an available ventilator.  All of these different areas in the emergency room essentially consisted of a large open room with countless gurneys next to each other without curtains or dividers between patients; so the concept of HIPAA also did not exist.  The entire Emergency Department was solely ran by residents; there was one attending per day who showed up for about 30 minutes to check on the sickest patients, then they would leave to work in their private clinics to augment their income; it is very common for doctors to have multiple jobs in Guatemala City in order to make a decent living.

Unfortunately, about four to five patients would enter the “Area Roja” every hour and on any given day, there would be about five to six deaths, most of which were patients under the age of 60 years old with underlying HIV, cirrhosis or ESRD.  The cause of death most often was hemorrhagic shock (due to the lack of blood products and the non-existence of a massive transfusion protocol), septic shock (due to the lack of antibiotics / pressors) and arrhythmias from electrolyte imbalance, namely hyperkalemia (due to the lack of electrolyte repletion supplies and resources for urgent dialysis).

Despite of the lack of resources/medications, I truly do admire the doctors/residents with whom I worked with during my rotation. They are extremely hard working, humble and intelligent.  All the residents work very long hours but never a word of complaint. The residency program has a very strong educational basis and the chief residents and directors are extremely enthusiastic about teaching and keeping the program up to date with new research.

After this experience, I feel very grateful to be practicing medicine in the US, specifically within the Kaiser system, where we have a vast amount of resources and adequate medications to treat both simple and complex diseases.  This experience has also taught me the importance of conserving resources and medications by avoiding unnecessary lab/imaging orders and prescriptions. As chief resident next year, I will definitely encourage all of my residents to take advantage of the global health rotation opportunity. And in my future career, I will continue to be involved in different medical missions to lend a hand to the other countries in need.

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