Hospital de la Familia – Alexander Rivero

Written by Alexander Rivero, MD PGY2 at Kaiser Permanente Oakland Otolaryngology Residency Program while on a global health rotation at Hospital de la Familia in San Marcos, Guatemala in March 2015.

Rooster crows followed by the slow wave of rumbling voices as our patients slowly begin to fill the halls of the clinic. They sit patiently, waiting. However, this is not the beginning of their waiting game. This began in some cases up to two years ago when the prior mission folks left. During this time, our patients returned home with some living as close as 10 minutes away and others crossing the Mexican-Guatemalan border over 4 hours away. But it is now 6 am and the line has only begun to form yet it already has expanded to occupy half of the quiet block on which Hospital de la Familia (HDLF) sits. Located in a small, sleepy town in San Marcos, Guatemala, HDLF stands as a bastion of health for not just its home town, but also of the many surrounding villages, towns and cities.

The waiting continues – our patients are then individually called by name to collect numbers that identify their place in line. They will see the local doctors first for triage – all 1200 of them seen over 7 days. Several hours later, they will collect a second number; this time to see the surgical specialist. Four hours seems like nothing when you have waited over two years to have your neck mass examined. To add to the misery of the waiting, our patients are advised to remain NPO (nothing by mouth) since midnight prior to their visit, in the event that their possible surgical intervention will happen the day of their visit. It is clear, the rumbling heard earlier is not just of voices.

They continue to wait. The word “patient” would have lost meaning for some of our American counterparts in the U.S. I can only imagine the types of complaints we will hear when our patient is finally able to sit on the examination table. The room is crowded with several other otolaryngology evaluations happening concomitantly. And then a smile – our patients are happy to hear a familiar language, not expected from the American doctors. Having grown up in Costa Rica, my heart is not far from where we currently are. They tell their histories with incredible attention to detail with mannerisms and sayings unique to their culture. I work diligently to collect the information and process a diagnosis. We hope to provide them with a physical benefit – surgery, medication, etc. This only seems the most fair given the amount of time they have patiently waited.  And then we deliver the news – no surgery is needed. In fact, no medications are needed. For this particular diagnosis, lifestyle modifications are the standard of care. They smile in what I think is disbelief – minutes, hours, weeks, months, years waiting and all I have to do is change my diet? I wait for what will be the complaint of the century. They speak… “Thank you” or “Thank God”. I was amazed that their gut reaction was not annoyance or desire for surgery but sincere gratitude to be seen by a specialist who was able to calm their worries, provide guidance and reassurance. After over six hours of waiting their day is over and their burning questions have been answered.

For others, their patience is about to be tested. “We think surgical intervention is appropriate and should be performed”. After hours of waiting, they have only several minutes to decide if they will proceed with surgery. This is due to the unfortunate nature of the medical mission. More patients need to be seen and more patients will likely require surgery but there are a limited number of slots that time will permit. And so, what in the U.S. can at times take months, a surgery is scheduled for the following days. Our patients proceed to take a third round of numbers now identifying their place in cue for hospital admission the night prior to surgery. When the surgery cannot be performed the day of or the following days, our patients stay in local B&B’s that have established themselves prior to our arrival. In this way, they wait once more.

At last, the day of surgery. Mothers anxiously hold their child tight and it is difficult to separate them. There is no pre-medication in the pre-operative area to ease the separation as is the case in the U.S. Instead, donated beany-babies are used to lure our patients into what can only be described as an operative suite. Four beds, side-by-side with no dividers or separation. It can be daunting for a child (and even a mature adult) to walk into a room full of strangers in masks and gowns, only to see a man fist deep in someone’s abdomen only three steps away from the operating table he/she will lay down in. The surgery is performed with equal attention to detail as would be the case in any other sophisticated surgical center. The exception lies in the step back in time where all instruments are recycled and re-sterilized and cloth gowns are employed. All of our supplies are donated and brought in by the team. For this reason, simple surgery becomes complex. As we delve into historical techniques using dated instruments, we are reminded of how lucky we are to live and work in an environment with the latest technology and advancements.

With the surgery complete, our patients are sent to recover in the post-anesthesia care unit. Family members are anxiously awaiting their son, daughter, father or mother to exit the black box that is the operating room in safe manner. I exit the operating room with a child in my arms carrying him to the PACU across the hall. Mom sees me and bursts into tears. Once the patient is settled into monitored care, we address the family. Mom gives me and my attending a hug as she continues to cry. “Thank you” she says between tears, “thank you and God bless you”. With our hearts full, we walk across the street to our overflowing clinic where the wait for others has only just begun.