Orientation for Doctors and Medical Students

Hospitalito Atitlán

Volunteers are expected to attend morning report at 7:30 AM every day.

The first day, please arrive for morning report which will be followed by a
short tour. Usually the volunteer will “shadow” a doctor for a day or two to
learn how the hospital works.
Volunteers are expected to abide by the customs and regulations of the
hospitalito while representing the hospitalito. They are expected to work
approximately 40 hours a week.

Schedule:
Morning report M-F 7:30AM – Everyone is expected to attend unless not available.
Medical staff meeting Tuesday 7:00AM
Clinic (general) (consulta) M-F 8:30-12:30
Follow up Monday 2-5 (scheduled follow-up for ER and inpatients)
General surgery clinic Tuesday 9:00
Ultrasound (non-OB) Wednesday 2-5
Prenatal Clinic Thursday 2-5PM

Lab and Pharmacy open M-F 8-5; lab open Saturday 8-12

LABS available include :Stool O&P Blood glucose, beta HCG, Hgb, HCt, Urine
dipstick, Manual WBC and Diff, Sputum for BK (TB), Urine culture (Use sparingly
please), blood type, rapid syphilis, HIV, hebB Other labs may be drawn and sent to
Panajachel Monday to Friday including cultures. If a long term doc is available, please
call and talk to them about these labs. They are expensive! And will not return till the
next business day. Labs are ordered by filling out a lab request form (found in the
doctors’ area) and putting the form in Pedro’s box on the wall in the lab. If you want the
lab STAT, speak with Pedro as well. We receive the results of send-out labs via e-mail
(long-term doctors). Whoever gets the result first will print it and put it in Pedro’s box.
Pedro will then pull the chart and put the chart with results in the box in the doctors’
work area called “Labs”. Check every morning for labs you might have ordered

Pharmacy The list of meds is on the computer desk top “Farmacia Find it” And there is a
map on the wall in the pharmacy and there is an equivalency list since we have so many
donations. Injectables and pediatrics and adult orals are all a bit separate. The pharmacy
is not necessarily logical. Keep looking!
STASH The ER has an emergency stash for true emergencies, also an overnight stash for
commonest used drugs, ready to go home, and in the desk under the computer a narcotic
stash. The key for the narcotics stash should be around the neck of the doctor on call. All
controlled drugs must be signed out in the book (clipboard now) in the cabinet with the
controlled drugs.
The OR has a stash for anesthesia. Sala de Partos has a stash for OB. Find them and
check them out before you start! (Pharmacy stocking has been a real sticking point. It is
wise to check that whatever you might need is where it belongs in advance so you have
sufficient time to locate it in its back-up area!) During weekdays patients can be sent to
the pharmacy with a prescription (found in the doctors’ work area and in the
consultorios). Nights and weekends, you (the doctor) fill the prescription out of the
pharmacy or out of the ER stash and send the patient home with the prescription as well.

XRAY Nearest X-ray is in San Lucas Toliman, 30 min away by car. Not done by a tech,
not read. Costs the patient money! Nearest real X-ray is Solola, National Hospital. Plain
films are supposed to be free. An IVP will need to pay for the dye, which is the cost of a
private IVP. Patients usually bring the X-rays back with them usually without a reading.

ENT OPTHO BOX there is a box with some ENT and optho equipment in the ER under
the defibrillator on the floor. You can use 2%Lidocaine to anesthetize an eye.

CT, MRI CT and MRI are available only in Xela (Quetzaltenango) and Guatemala City.
To arrange for these, see below in “Referrals”.

Ultrasound We have ultrasound here. Leah can do OB ultrasounds. Jack will do gall
bladders, FAST exams, AAA, renal calculi. He is only learning, and will give an
advisory reading only.

Referral For surgery, ob-gyn (that Leah cannot handle. She can do C sections) ortho,
pediatrics (mild to moderate) Solola is our nearest hospital and “free to all patients”.
That’s the ideal, but patients have to pay for anything the hospital doesn’t have in stock,
which is A LOT.
For Neurosurgery, critical patients, urology, intensive care, cardiology, refer directly to
Hospital Roosevelt in Guatemala City. All referrals need a Hoja de Referencia. If the
Spanish is way beyond you, just write it in your most erudite medicalese. It is probably
almost the same. But you must write it! It is the entrance ticket!. For non-emergency
referrals, write it to the “consulta externa”; for urgent, to “emergencia”. Patients being
referred for X-ray, CT, MRI, etc., also need an Hoja de Referencia filled out.
Concepcion Mendoza, our social worker, can help get CT, MRI, and formal ultrasound
appointments. Appointments are not needed for X-ray.

Transport Transport for emergencies is via bomberos. Ask the guardian to give them a
call to come pick up a patient when you need them to come. If the patient is poor, the
hospital will pay. Beware! One trip will use up all the money earned in a whole day! A
trip to Guatemala City is three times the cost to Solola. Solola is 1.5 hours, G City 3.5
hours. Roads are dangerous at night. Very rich patients or those hurt in car accidents
may be eligible for helicopter transport. (we tried it twice. One survivor, one died) Plus,
are you going along? There are no paramedics. If medically appropriate, patients may
elect to figure out their own transportation. IF the patient can tolerate it, transfer to
Solola and they will pay for the transfer to Guatemala City (if they agree with the
necessity of transfer).

Food Patients or their families provide all their food. Atol (liquid cereal drink) and
mosh (oatmeal or cream of rice or corn) are VERY popular. Many patients will ask
about diet. Grease, chile picante, coffee are the commonest questions. Even after an
ankle sprain.

Water There is pure water in containers in the hospital. Do not drink the sink water.

Conservation of resources We are very short of many things that would ordinarily be
discarded in a US or Canadian hospital. Please ask before discarding almost anything.
(i.e. we reuse disposable staple removers, syringes (after disinfecting) are used for oral
meds for kids, water bottles are used as spacers for MDIs, EKG stickers are reused etc)

Green area We are trying to keep the OR as much of a sterile area as we can. Please try
to avoid going into it, or change shoes and clothes before going in if at all possible.

Pediatric Helps We have Broselow tapes and a Broselow book and a Broselow bag to
help with dosing pediatric patients. Please ask for a brief demo.

Computer--Internet We have a wireless satellite hookup. It is frequently down for

some reason. The desktop is hooked to a printer and is very prized. Family should not
use the hospital computer. Volunteers should be very thoughtful of others. See rules
above it. Clinical needs of course preempt other uses. The doctor on shift has
precedence. There is a great internet cafe in town where long email sessions can take
place. Please print only when really necessary. Use the back side of paper if possible.

Phone The hospital has a land line. You can receive calls on it, and can make patient
related outgoing calls. Please do not use it for personal calls. IT sets a bad example for
our employees. Rental cell phones are available in town. Log all phone calls made on
the hospital phone with the guardian.

Translation The guardians are the first choices for translators from Spanish to Tzutujil.
If the guardian is not available, check to see if one of the nurses is not busy. If there is no
nurse available, ask Maria the laundress to translate. Spanish is a second language for
almost all our patients. If you think there is any problem with the history, ask someone to
translate. It helps immensely! Patients will say that they understand when they really do
not. Jose Reanda can find a translator if you cannot.

Staff of the Hospitalito Atitlán is : Administrator Jose Reanda Director Doctora Irene
Quieju Other long term docs : Leah Abraham (chief of staff), Marly Larrabee, Bernie
and Jack Page. ( John Nelson does 3 month stints for OB-GYN) Diego is the head nurse
(he is a graduate nurse, more or less RN level) (Kathy Roach RN comes down for 2-6
month stints) Luisa, Concepcion, Jacinto, Felipa, Nestor are auxiliar nurses (6th grade
plus 6 weeks) Their math is definitely lacking. If you are asked the same question 5
different ways, it is because they don’t get it. Go over all orders with them. We are not
up to sliding scales or if... then... orders. Pedro is the lab tech. Concepcion Mendoza is
the social worker. Jose Luis is the pharmacist (6 wk course years ago) Maria Elena is the
receptionist. She speaks some English. Maria is the laundress and Rigo, Freddy and
Cristobal are the guardians. If you don’t know something, ask them! Gail is trying
valiantly to sort out our stock.
PLEASE DO NOT GIVE MONEY OR THINGS TO OUR STAFF WITHOUT
DISCUSSING IT WITH A LONG TERM VOLUNTEER FIRST. PLEASE DO NOT
PRESCRIBE ANY CONTROLLED DRUGS TO OUR STAFF WITHOUT
DISCUSSING IT WITH A LONG TERM VOLUNTEER. ALL STAFF RECEIVE
FREE TREATMENT AT THE HOSPITALITO. ALL TREATMENT MUST BE
WRITTEN ON A CHART. And, please do not teach the adorable children to beg by
giving them quetzales or candy.
If you want a hand made article, ask one of the staff about it. Almost all of them or their
families do bead work or weave and would love to sell some. They are not permitted to
conduct that business on hospital grounds however, so you must arrange transactions off
premises.

Emergency numbers: The administrator is Jose Reanda house 7721 7014 cell 5977
1259The director is Doctora Irene. Her number is house 7721 7424 cell 5415 5391 These
numbers are posted on the ER wall.

Patients 95% of the population of Santiago is Tzutujil. Many are unable to read and
unable to speak Spanish. Many have no understanding of anatomy or physiology. (“You
don’t need an antibiotic. You have a pulled muscle.” OK, Should I take amoxicillin?”
“NO, it is not an infection.” “OK, I have some injections of gentamycin left over from the
last time I had this, I restarted them yesterday. Should I continue them?” “No, you need a
pain medicine” OK, for my pneumonia, I should take a shot of vitamins? I really need a
shot!” “No, you need acetaminophen pills” “Great, How do I take it?”....

Medical decisions Medical decisions are made on a family and economic basis. An
appendicitis may choose to wait for a day till her husband can be reached. A family often
chooses to take a patient home to die rather than transfer to Solola. Be patient. If you are
frustrated with the decisions the family or patient seem to be making, ask Concepcion
Mendoza to come down and talk with them. She may be able to help explain why we’re
recommending what we are, and she may also be able to get insight into their resistance.

Temperature history Patients frequently will say that they have had a fever when they
mean that they think their hot and cold parts are unbalanced. Take a “fever” history with
a grain of salt. They will also ask what temperature of shower or bath they can take.
Pick frio or tibia or caliente.

Common diagnoses Our most frequent patients are pregnant women and sick children.
Diarrhea and respiratory illnesses including asthma, pneumonia, COPD, and bronchiolitis
are our most frequent diagnoses. The ever popular abdominal pain of unknown etiology
is also a frequent diagnosis. Our most common positive stools are: ascaris, giardia,
trichuria, and amoeba. There is reportedly (partly due to our altitude of 5,000ft) no
malaria, no Chagas, no Dengue ,no leishmaniasis, no oncocercosis (whoops, we just
diagnosed one of those)

Post op activity Patients here are not used to surgery. They will think they NEED to
stay in bed for weeks (also post partum) Underline many times that they must get up.

Home remedies Remember that almost any drug is available without a prescription and
that the pharmacists in Santiago do not have ANY understanding of pharmacy. Babies
take adult aspirin, adults take steroid injections. Ask carefully for full current drug
history.

Equipment and Supplies You should be able to find all the basic things you need for
patient care in the clinic rooms, ER, and Labor and Delivery. If you run out of something
or can’t find what you need, look in the back-up supply area located on the second floor
in the multi-purpose room at the end of the hall. If you can’t find what you need there
and it’s an emergency, call one of the long-term docs. Also, please let us know if there
are supplies you feel should be available that aren’t.
Trash Please put biohazard (bloody) trash in the RED bags. All other garbage should
go in non-red bags. Hospitalito pays a lot per pound for disposal of the red bags. Please
help us keep down the cost by using them only when needed.

Past history Patients are reluctant to give past medical history. When they say they
have none, ask again if they have stayed in a hospital overnight or if they have seen
another doctor or had studies. Take all outside study reports with a grain of salt,
however. Ask again specifically about a disease if you are really suspicious. One patient
reluctantly went home to get a head CT scan, and when I referred the patient on to
Roosevelt, said they were going to hide the head CT so the doctors at Roosevelt would
start fresh, without preconceived ideas.

Fat and Exercise To be fat is considered a sign of wealth. A generation ago, most of the
work was hard exercise. Now most women have very sedentary jobs. 25% of middle
aged Guatemalans have hypertension or diabetes. Remember to talk about exercise and
diet! You are the elite foreign experts.

Abortion is illegal. Babies are occasionally “given away” thru a process with the city
government.

Accident victims will have care paid for by the person who caused the accident. For that
reason, they can afford care that otherwise they would not.

Visitor policy There is a visitor policy. Please abide by it. If you want to make
exceptions, please discuss the exceptions with the guardian and nurse on duty.
Social Psychological Support is scarce. Our social worker will aid you, but give her
direction. There are psychologists at rare times at the Centro de Salud. Ask Concepcion
Mendoza to call and make arrangements at the Centro de Salud for patients that need
psychological counseling.

The Centro de Salud will give vaccines and also treatment for HIV patients and TB
patients and at times has free birth control and prenatal vitamins.

Vaccinations The Centro de Salud has vaccinations. We have adult tetanus, a few
hepatitis A. A patient who needs rabies needs to be referred the next working day to the
health department who will refer him to Solola.

Orders After writing a new order in an inpatient chart, put a pink clothes pin on the
chart (the signal that there’s a new order) and put it in the chart rack mounted on the wall
by the door. Be aware, however, that our nurses don’t always check the orders in a
timely fashion. If it’s something you want done soon or something you’re worried might
not get done right, speak to the nurse about it.

Chart forms Extra forms needed for inpatient charts are found in the doctors’ work area.
If you can’t find it downstairs, you should be able to find what you need upstairs in
medical records.

Finding old charts Old charts are available. The nurse should be able to locate them by
using the computerized system.

Discharging patients When finished with a patient in clinic, finish the chart, write the
prescription, and give both to Jose Luis, the pharmacist. When finished with a patient in
the ER, give the patient the prescription and meds (or send them upstairs with the
prescription if it’s during the day) and put the completed chart into the red decorated
cardboard box near the door to the ER. When discharging an inpatient, complete the
front sheet, write the discharge order, write the prescriptions and fill them( if not during
the weekday). On weekdays, write the prescriptions and leave them with the chart, and
give the completed chart (with or without meds/prescriptions) to the nurse. It takes a
long time for the nurse to complete all her paper work.
There is an AMA form on the back of the Front sheet. Use it if a patient leaves AMA. IF
really serious, have patient and family sign (or put thumbprint)

Public Health Teaching Perhaps the most important thing you will do for a patient and
his/her family is give very basic public health advice. Give it to EVERY patient. Give it
EVERY time. (Wash your hands before eating after bathroom if pt has diarrhea, and
pure water, and clean food ; breast feed and vaccinations if a delivery etc)
13-2-2006

Research Currently the hospitalito does not have anyone on staff experienced in
research. All research that a volunteer intends to do must be cleared first through the
chief of staff to ensure that it is in accord with hospitalito and Santiago goals and culture.
Supervision must be done from an experienced researcher at the home institution.

Surgery Any procedures more than minor office procedures must be discussed with the
Chief of Staff prior to starting the procedure. The hospitalito has limited resources and
we of course want all care to be safely done within the capabilities of the hospitalito.

Medical Students are expected to work approximately 40 hours a week. We would

expect this to be a mix of shifts (covering ER, OB, and inpatient) and clinics. If desired,
surgery/anesthesia or clinics in town with a doctor can be a part if they occur. Med
students are requested to make up their own schedules and post them in the doctor part of
the ER. Many students make up a schedule to have blocks of time off to sight see. Med
student s are asked to present one interesting patient with a discussion of the case per
month.

Doctors are expected to work their fingers to the bone. Only joking. Most doctors will
be expected to work a 24 hour shift every 4th night. If desired, additional clinics can be
done. Specialists should make up a schedule with Dr. Leah, the chief of staff. There will
almost always be an OB backup doctor (most often Leah). And feel free to call the long
term doctors if needed

Housing, Transportation and Food for Volunteers: Please contact the volunteer
coordinator (Violeta Luz [email protected] ) for help with locating housing and
transportation to the Hospitalito. There is no food available at the hospitalito. Please
bring your own when you are on duty.

Common diagnoses (different from US) Stool specimens often are positive for ascaris,
trichuria, giardia, entamoeba histolytica. We think we have a lot of neurocysticercosis
also.

Common medical terms: MC=motivo de consulta (CC)

DS= datos subjetivos (HPI)
Antecedentes = PMH
R x S = revisión por sistemas
DO= datos objetivos (PE)
IC = impresión clínica
ND= nuevos datos (labs etc)
Efectos secundarios = side effects

Arrival info for volunteers coming to Santiago

Transportation and housing can be arranged by Violeta Luz. Please contact her if you
need assistance with either. Violeta Luz <[email protected]>,
Please keep these phone numbers handy in case questions on arrival:
Violeta Luz house: 7721-7328 cel: 5963 8546
Aclash (van driver) 5611 5291
Bernie 5688-0104
Hospitalito 7721-7683

If you are arriving by chicken bus, ask to get off at the Hospitalito. (If the driver seems
confused, ask to get off at the Hotel Bambu. You should see the Hospitalito sign when
you get off).
If you arrive by boat, you will be surrounded by a cloud of tuc-tucs (golf cart type
vehicle) that will cost 5-10 quetzales to take you to the hospitalito (or almost any other
place in town).
If you arrive by van, Aclash (Nicolas) should of course drop you at your lodging.
Consider buying “special” food at “Paiz” or “HiperPaiz” when you are still in Guatemala
if you want: cheeses, fresh milk, wine, nuts, pop corn, olive oil, balsamic vinegar.

If you are coming for an extended time, bring your music CDs, books to read, soccer
shoes if you play soccer. Ear plugs are a good idea. 29-3-06