Conclusion at El Hospitalito

I'm now back on the road once again, after a month spent living in Santiago Atitlan and working at El Hospitalito. On the cusp of a new segment of my adventuring, I sit amidst a tangle of emotions. Most superficial (and which is in current contribution to my more introspective, sit-down-at-the-nearest-internet-cafe-and-write mood) is... sad! After a final weekend hurrah spent with my housemates in Panajachel enjoying live music and each other's company, they wooshed away after hurried goodbyes and hugs on the lancha back across the mid afternoon washed lake to return to Santiago. Since the first of this month, I became quite close to them, finagling sublime meals after shopping sprees in the local markets (the British ER doc perpetually insisting on her bottle of red wine to accompany our concoctions), trying so hard to make a disheveled stand for the gringos in regular soccer matches, jumping into the lake, pancakes for breakfast before shift, and fantastic conversation at 3am on call. In many ways they were mentors to me, all older, and being so fully invested into the medical world, tirelessly advised me, encouraged me and explained to me about medical school, the life of a doctor, international medicine, and all their personal convictions. (by virtue of the age diversity, I did have opportunity to have discussions I would never have had with my friends back home -- serious talks about marriage, life partners... and kids!!) I am so grateful for my time with all of them! And I already miss the staff of the Hospitalito, all the Guatemalan nurses so kind, genuinely interesting people. I've now got so many email addresses stacked up in the back of my journal, I wonder if I'll ever see any of these friends again. Such finite and such intense relationships.

The second discernible emotion related to the "tangle" of above is relief! Work at the Hospitalito was intense and emotionally involved, by no stretch of the imagination. I'm going to tell you about the events of last Friday; I have been thinking about them over and over during the past few days, and don't yet feel.. certain, or comfortable, about the day's first encounter in the Hospital. It will take some time. From what I was able to tell, it was nothing wholly rare at this place, but quite affective for me. An opportunity, really, to see such a graphic display of humanity, and of life in almost cosmic proportions. And so informative about the world of medicine in general. Friday was my last shift, the normal day shift of 8am to 5pm. I woke up, made the family oatmeal and banana pancakes, and headed off to the Hospitalito, the ferns and flowers of my morning commute bowing and curtseying in a cool morning breeze. Changed into scrubs, I sauntered into the Emergency Department (two beds and the lack of specialized materials requiring some creativity at times). Leah, the head doctor, and more than the average number of nurses were clustered around "cama A". Not a trivial ER visit, I supposed. I went over with a 4th year NYC med student named Aileen, and pulled the curtains closed behind us. As we arrived, one of the nurses was hastily urging the family, visibly distraught, to refuge out of the ED. I began to sense the energy was weird and tense and elevated in a way I'd not really felt since arriving here. My happy high since morning pancakes was quickly dissolving. On the bed was a boy, maybe one year old, and lying in such a way, slightly abnormal but not for any readily indicatable reason, that anyone's innately human empathy would stand their neck hairs at attention. He was not well; cyanotic, not breathing, approaching rigidity. All stiffened in their respective silences as Leah connected his cool chest to the EKG monitor. After a few grotesquely loud beeps, the machine reported sporadic electrical activity flaring in this rapidly dying body, causing a groan from Leah -- we were obligated to begin resusitation on this clinically dead body. A beat, then activity began in earnest, and as the med student and I looked on shocked, Leah began to bag the boy with O2, simultaneously directing application of epinephrine, and a slew of other drugs. IVs were started, vital signs taken, all so efficient and methodical. Overcoming my stupefaction, I relieved Leah of the bagging as she prepared to intubate the boy. After successful intubation, I resumed bagging as Irene began chest compressions. Anxious, unbelieving, I thumped away at the bag valve mask as my heart beat faster and climbed higher into my throat. I noticed increased resistence through the tube, and muttered that it was getting harder to bag. No one responded, so I kept on. After minutes, the gurgling resistence that I could and did push through gave way to a direct, against-a-wall resistence. I began to get scared when blood started bubbling out of the boy's left nares. Still not coordinated, Irene and I mumbled our disease some more, I guess hoping for either direction or reassurance from Leah running the code. In that moment, I have no idea where she was, what she was doing -- I couldn't take my eyes off the boy's face, pressure in his cheeks contorting his eyelids, forcing his blue lips into a frown. PRESSURE! fuckfuckfuckfuck. His shirt was quickly torn open, letting free that chest, that ripped and broken and horrible chest. In my furious bagging, and without direction, I had distended his abdomen, forcing air out of his lungs and down his esophagus into his bowls. His umbilicus seemed to rise like a mountain above his thorax, straining against the rigidity of his ribs. Leah halted all, and quickly diagnosed a bilateral pneumothorax. After a moment, and with everyone acutely aware of everyone else and of the dead and tortured baby beneath us, Leah called a cease. I quietly asked whether it was a result of forceful bagging, and was granted a firm "yes" and no explanation. Everything started to recede from my awareness, and after hazily noticing the mother tearing through the ranks and collapsing on her son's body and shrieking, I abruptly found myself outside, sitting on the rock stairs heading off the property and towards the lake. My mind writhed for an hour.

After a while, when the shellshock emotions of guilt, of grief, of complete bewilderment and of acute anger for falling into such a position while so naive and lacking in experience slowed their rages, I looked up. I watched the lake for a while, in that mind-emptied way, looked at birds cheeping and chirping around in branches nearby. I went to get up three or four times before I set my feet beneath me and walked back to the ED. Quiet, somber, I avoided eye contact. After aimlessly lapping the familiar halls in search of some distraction, but only met by more patients, eagerly looking up to me, reverently and ingenuously calling me "doctor" -- Leah caught me. She told me what I knew I needed to hear, and explained the baby's death. The boy had been brought to the ED clinically dead, and finding some remnants of electrical activity, we were obliged to begin resucitation attempts, to Leah's chagrin. Yes, my bagging had been the impetus for the blown lungs and gastric distention, but she readily and sincerely told me she had provided me no instruction for pediatric bagging, and noted she never responded to my mumbled announcements of increased resistence. "That baby's death is in no way your fault", she said. I frowned. She continued that she should have called it earlier, and she was happy for a reason to stop, such as it was -- an albeit improbable resusitation would have resulted in a life of mental retardation and years of grief for the family. She unwaveringly took all responsibility for what happened that morning. I thanked her and went for a walk to think.

Upon my return to the hospital, I was assigned vital signs of all inpatients. I cannot explain to you how strange it was and how fearful I was to again attend to a patient, even just taking vitals. It lasted a split moment only, but that feeling of fear, that knowledge of the monstrous power in my own hands, will stay with my for long. It was a good way to work back into the shift. At 10am, one of our laboring patients began bearing down, and I stood by with two other nurses to help the OB deliver the baby. It's surreal, to see and hear that blue baby suck its first breath of air, its lungs ballooning open for the first time since its aqueous life. We cleaned, dressed, and measured the baby, administered the routine Vitamin K and antibacterial eyedrops, and turned to receive the placenta. Mom, exhausted, and baby, in wonder, and so happy the whole family was. The sheer profundity of my two opposite experiences within the space of two hours set me a deeply introspective mood for the rest of the day. (In order to finish me completely, Chac the mayan rain god threw down the hardest storm I have ever seen in my life. It started so fast that I, running about 20 feet behind my housemate Will, was soaked as I panted into the covered veranda, while he was completely dry. The sound on the roof was so thundrous that I could not hear Will's words when he sat 3 feet from me. We didn't speak for two hours.)

Wow... I don't know how you're doing, but that was exhausting to write. I'm going to take a bathroom break...

One other wild hospital story. I've also now seen an emergency cesarean section operation. I didn't scrub in this time, but I can tell you, it was absolutely wild to see! It's a fast paced operation, since the anesthesia can compromise the baby, so after about two minutes, the surgeon had sliced through the abdomen, through the bottom of the uterus, and was forcing the baby out. Anyone seen the movie "Alien"? It was fantastically bizarre to see a healthy, wriggling baby pulled from the belly of a healthy, babbling woman. The baby was full term, cleaned up well, and I turned my attention back to the surgery. By now the OBGYN had pulled the uterus out of the incision and sewed it shut, it just sitting there flopped onto the woman's stomach. Bizarre, just crazy!

As of now, I'm a little too drained, and it's still a little to early to draw any substantial conclusions about my time spent in Santiago. But you could all reason the impact it's already had on me. And not surprisingly, I'm now significantly interested in medicine and admittedly have, of late, fantasized about being a doctor. I like it -- analytical yet creative, personable yet uncompromising in its goals to sustain health. It's an expertise, an art, and the be-here-now, the impetus into the active present... I'll do some sitting with it for the next few months.

That's all I've got for now. Next time I write, I've got to tell a little about my thoughts re: returning to Vassar in the fall. This is another major area where I've been spending a lot of mental time and energy (and wouldn't mind learning your opinion!). But that's for down the road.

Speaking of road, I'm heading out again! I've got to go back to the house right now and pay penance to my guide book, but I'm fairly certain I'll be leaving the country tomorrow. My gut tells me to head to Copan ruins, just over the border into Honduras. I'll likely continue up to the Bay Islands for some diving and beach relaxation, then do the travel thing down through Nicaragua on my way to Panama!

Love to all. Grab hold of what you've got. Thinking about each and every one of you, Ty