Saman Kamal (Class of 2021)
At the end of May, four first-year LSUHSC medical students went to Antigua, Guatemala to gain clinical skills in a summer experience facilitated by Dr. Patricia Molina (Department Chair, Physiology). The trip was for us to experience the healthcare delivery system, learn the art of practicing medicine in a developing country, and refine our Spanish language abilities. I, along with Alex Molina, Rod Paulsen, and Jason Schroeder spent a week at the San Pedro Hospital, under the guidance of physicians from the local medical school, including Drs. Guillermo Sanchez, Pedro Palacios, Pedro Ayau, Leonel Leon Pineda, and Dominique Jimenez.
When you walk down a cobblestone street in Antigua, Guatemala, it feels like you’ve stepped back in time. The quiet streets are lined with colorful stucco Spanish buildings, the air smells like fresh corn tortillas, and the street vendors sell freshly cut fruit. San Pedro Hospital is a bright yellow Baroque-style church and hospital. In addition to exam rooms, the hospital has a small surgery wing, labor & delivery ward, pharmacy, lab, and an endoscopy/ultrasound suite. Healthcare services are provided at no cost to the patients, many of whom travel hours from rural areas to be seen at San Pedro.
The clinic is staffed by a team of medical students from the Universidad de Francisco Marroquin (UFM), as part of their internal medicine rotation. The students complete the entire history and physical exam for each patient, usually spending over 30 minutes with each person. They present their diagnosis and treatment plan to the supervising physician, who either agrees with their treatment plan or steers the students in the right direction. If students are uncertain or need more clarification about a diagnosis, they will consult the literature. In fact, when we asked questions, the students would often explain the answer and send us a relevant peer-reviewed article with more information.
We met patients between the ages of 11 – 80, with problems varying from ear infections, cervical dysplasia, upper respiratory infections, diabetes, and hypertension. Our patients ranged from women presenting with back pain or right upper quadrant pain, to true Guatemalan ranchers from local cattle farms, to a schoolgirl who was injured at the playground. We were nervous at first, hesitant to speak to patients or examine them. We watched the students with trepidation, wondering if we’d ever be that confident in front of our patients. As our first day progressed, their courage rubbed off on us. By lunchtime, we had started taking histories from our patients. In fact, by Thursday, we went through a mock Step 2 CS exercise, during which we took patient histories, performed a physical exam, and wrote a note, entirely in Spanish. We had become comfortable with physical exam skills that scared us on Monday morning, like checking for a Murphy sign, performing a straight leg raise, or testing reflexes and sensation.
On our last day with UFM, Drs. Leon Pineda and Jimenez met us at an inpatient hospital, tucked away in the mountains outside of Antigua, for patients with neurological problems or developmental delay. Once inside, we each were assigned to one pediatric patient and one adult patient. Many of the pediatric patients suffered from cerebral palsy, often caused by neonatal meningitis infection. My patient was a 10-year-old boy, Angel, with severe microcephaly. He lay in a crib, silent, attached to a feeding tube and oxygen cannula. His head, covered in fuzzy black hair, was still soft as if he was a newborn. His limbs were under-developed, his hands clenched into permanent fists. According to his chart, after giving birth, his mother left Angel at the hospital in Guatemala City. A team of American neurosurgeons operated on Angel. Afterward, he was sent to the hospital, where he will stay for the rest of his life.
I had never taken a history or performed a physical exam with a patient who could not speak. I introduced myself to Angel, explained that I was a medical student from the U.S., and saw no response. I reached down to touch his chest; he immediately started shivering. I found his wrist, feeling his pulse under my fingers, letting Angel become accustomed to my voice and my touch. As the shivering slowed down, I asked him to follow my flashlight with his eyes. Surprisingly, Angel complied, although he could not abduct his left eye. Building up my confidence, I listened to his strong heart and his lungs. I tested his reflexes with a hammer, noting a response in both knees and his left elbow. I tickled the bottom of his feet, asked him to turn his head towards my voice, and performed other maneuvers under the guidance of Dr. Jimenez. As we wrapped up, I realized I had elicited a surprising amount of information, even though my patient couldn’t speak. I was able to tell that Angel was recovering from his previous upper respiratory infection by the diminished crackles in his lung base, able to see that he still had sensation and reflexes in his tiny legs, count his chest rising and falling to find his respiratory rate, and assess his cranial nerve function by watching his eyes.
The free hospital was unlike any place I’ve ever seen, whether in the U.S. or abroad. For a child like Angel, it quite literally saved his life. We are very thankful to the faculty, students, and staff at UFM for allowing us to experience and learn from the patients at San Pedro and the inpatient hospital. We are also very grateful to LSUHSC and Dr. Patricia Molina for facilitating this learning experience.